Recovery Of Dysphagia Research Articles

The Role of White Matter in the Neural Control of Swallowing: A Systematic Review

Background: Swallowing disorders (dysphagia) can negatively impact quality of life and health. For clinicians and researchers seeking to improve outcomes for patients with dysphagia, understanding the neural control of swallowing is critical. The role of gray matter in swallowing control has been extensively documented, but knowledge is limited regarding the contributions of white matter. Our aim was to identify, evaluate, and summarize the populations, methods, and results of published articles describing the role of white matter in neural control of swallowing.Methods: We completed a systematic review with a multi-engine search following PRISMA-P 2015 standards. Two authors screened articles and completed blind full-text review and quality assessments using an adapted U.S. National Institute of Health's Quality Assessment. The senior author resolved any disagreements. Qualitative synthesis of evidence was completed.Results: The search yielded 105 non-duplicate articles, twenty-two of which met inclusion criteria. Twenty were rated as Good (5/22; 23%) or Fair (15/22; 68%) quality. Stroke was the most represented diagnosis (n = 20; 91%). All studies were observational, and half were retrospective cohort design. The majority of studies (13/22; 59%) quantified white matter damage with lesion-based methods, whereas 7/22 (32%) described intrinsic characteristics of white matter using methods like fractional anisotropy. Fifteen studies (68%) used instrumental methods for swallowing evaluations. White matter areas commonly implicated in swallowing control included the pyramidal tract, internal capsule, corona radiata, superior longitudinal fasciculus, external capsule, and corpus callosum. Additional noteworthy themes included: severity of white matter damage is related to dysphagia severity; bilateral white matter lesions appear particularly disruptive to swallowing; and white matter adaptation can facilitate dysphagia recovery. Gaps in the literature included limited sample size and populations, lack of in-depth evaluations, and issues with research design.Conclusion: Although traditionally understudied, there is sufficient evidence to conclude that white matter is critical in the neural control of swallowing. The reviewed studies indicated that white matter damage can be directly tied to swallowing deficits, and several white matter structures were implicated across studies. Further well-designed interdisciplinary research is needed to understand white matter's role in neural control of normal swallowing and in dysphagia recovery and rehabilitation.

Nomogram for predicting swallowing recovery in patients after dysphagic stroke.

To date, variables predicting the recovery of dysphagia in patients after dysphagic stroke have not been well defined. However, despite the difficulties in predicting and understanding the dysphagia recovery trajectory, its significance for stroke care cannot be understated. This study aims to identify the factors for functional swallowing recovery and develop nomograms that predict dysphagia recovery after stroke. The demographic, neurological, and swallowing characteristics were compared between patients who recovered from dysphagia and those who did not. Then, the factors with P <.1 through comparison were enrolled in the multivariable logistic regression analysis to build a prediction model. A nomogram was also built to provide a quantitative tool. Discrimination, calibration, and clinical usefulness of the prediction model were assessed by using the C index, calibration plot, and decision curve analysis. Predictors in the early-phase (T7) prediction nomogram included age, Functional Oral Intake Scale (FOIS), National Institutes of Health Stroke Scale (NHISS), hemispheric stroke, and brainstem stroke on admission. In the middle phase (T14), predictors included age, FOIS, and NHISS on admission. In the late phase (T30), predictors included age, FOIS, NHISS, bilateral stroke, and body mass index on admission. The C index for the day 7, day 14, and day 30 prediction nomograms were 0.847 (95% CI, 0.804-0.884), 0.817 (95% CI, 0.772-0.857), and 0.786 (95% CI, 0.739-0.829). These novel nomograms predicting dysphagia recovery after ischemic stroke are discriminative and well calibrated and could be used to guide enteralnutrition decision making, rehabilitation plans, and individualized care.

How demographic and clinical characteristics contribute to the recovery of post-stroke dysphagia?

According to the analysis to find out how demographic and clinical characteristics influent the dysphagia outcome after stroke, furthermore, giving some insights to clinical treatment.One hundred eighty post-stroke dysphagia (PSD) patients were enrolled in this retrospective study at the stroke rehabilitation department. The outcome measurements are beside water swallow test at discharge and length of stay at hospital. Twenty-five demographic and clinical variables were collected for this study. Logistic regression and multilinear regression were utilized to estimate models to identify the risk and protect predictors of PSD outcome.Mouth-opening degree, drooling severity scale (DSS) level, mini-mental state exam (MMSE) level, Barthel index and Berg balance scale were significant different between recovered and unrecovered group. Type of stroke, MMSE degree, DSS and hemoglobin level shown significant predictive value for PSD outcome in logistic regression. In addition, obstructive sleep apnea (OSA) and DSS degree were important risk factors for PSD outcome. Gender, body mass index, drinking, hypertension, recurrent stroke, water swallow test level on admission, Berg balance scale, DSS and days between onset to admission shown significant predictive value for length of stay of PSD patients.PSD outcome was influenced by type of stroke, MMSE degree, DSS and hemoglobin level significantly and obstructive sleep apnea act as an important risk role for PSD recovery.

A Prospective Observational Study of Short-term Mortality Indicators in Acute Stroke Patients

Introduction: Stroke is the second leading cause of death worldwide, causing 6.2 million deaths in 2011. There is a lack of uniform consensus regarding the predicting factors for mortality associated with stroke. Aim: To determine the various factors which influence the mortality in acute stroke. Materials and Methods: This was a prospective study conducted between November 2017 to February 2020 at the hospitals attached to Bangalore Medical College and Research Institute, Bangalore, Karnataka, India. All the patients diagnosed with Cerebrovascular Accident (CVA) using neuroimaging of brain within 24 hours of a symptoms were enrolled and followed-up for 28 days. After obtaining informed consent, demographic, clinical, laboratory and radiological data was recorded. Patients were assessed using standardised data sheet containing different variables and treated appropriately for ischaemic and haemorrhagic stroke. Results: The study included 100 patients; 33 died during follow- up. The mean age of the patients was 55.35±15.78 years; there were 54 males and 46 females. Male gender (p-value &lt;0.001), poor Glasgow Coma Scale (GCS) (p-value &lt;0.001), severe neurodeficit (p-value &lt;0.001), raised intracranial pressure (p-value &lt;0.001) and complication like delayed recovery of GCS (p-value &lt;0.001), aspiration pneumonia (p-value&lt;0.001), Acute Kidney Injury (AKI) (p-value &lt;0.001), fever (p-value &lt;0.001), dysphagia (p-value &lt;0.001), bedsore (p-value &lt;0.001) and seizure (p-value &lt;0.001) were the predictors of mortality in acute stroke. Conclusion: The factors like poor GCS, severe neurodeficit, raised intracranial pressure at the time presentation of patient and occurrence of complication like delayed recovery of GCS, aspiration pneumonia, AKI, fever, dysphagia, bedsore and seizure can be used as prognostic marker in acute stroke. Comprehensive neurological care wherever feasible involving neurologist, neurosurgeon, interventional radiologist, physiotherapist which take care of the immediate need and to prevent the long term complication would help to decrease mortality in acute stroke.

Assessment of Nurses'''' Knowledge and Practice Regarding Patients with Postextubation Dysphagia in Trauma Intensive Care Unit

Abstract Nearly 60% of patients who are intubated in intensive care units (ICUs) experience dysphagia after extubation, and approximately 50% of them aspirate. Little is known about dysphagia recovery time after patients are discharged from the hospital. Aim of the study was to assessment of nurses' knowledge and practice regarding patients with postextubation dysphagia in trauma intensive care unit. Subjects and methods: Descriptive design was utilized in this study on a convenient sample of 50 nurses'. The study was conducted in the trauma intensive care unit. Data was collected using a self-administered questionnaire with closed-ended questions which was developed by the researcher. The assessment was performed by using a questionnaire for knowledge and check list for practice assessment. Results: The study found that 40.0% of nurses' were more 30 years. Regarding to educational qualifications, more than 50% of nurses' had diploma nursing. The findings of study show that nurses have low overall knowledge and practice level. In conclusion: the overall knowledge of participants was found to be low knowledge about postextubation dysphagia. Regarding the overall practice of nurses' was found to be low practice. Recommendations: Nurses in need for in-service training programs and refreshing courses to improve their knowledge, which will reflect into their practice while working with patients.

Transcranial direct current stimulation for post-stroke dysphagia: a systematic review and meta-analysis of randomized controlled trials.

Transcranial direct current stimulation (tDCS) has been investigated as a tool for dysphagia recovery after stroke in several single-center randomized controlled trials (RCT). The aim of this investigation was to quantitatively evaluate the effect of tDCS on dysphagia recovery after a stroke utilizing a systematic review and meta-analysis. Major databases were searched through October 2019 using a pre-defined set of criteria. Any RCT investigating the efficacy of tDCS in post-stroke dysphagia using a standardized dysphagia scale as outcome measure was included. Studies were assessed for risk of bias and quality using the Physiotherapy Evidence Database (PEDro) scale. Effect sizes were calculated from extracted data and entered into a random effects analysis to obtain pooled estimates of the effect. Seven RCTs with a total sample size of 217 patients fulfilled the criteria and were included in the analysis. The overall results revealed a small but statistically significant pooled effect size (0.31; CI 0.03, 0.59; p = 0.03). The subgroup which explored the stimulation intensity yielded a moderately significant effect size for the low-intensity stimulation group (g = 0.44; CI = 0.08, 0.81 vs. g = 0.15, CI -0.30, 0.61). For the other subgroup analyses, neither comparisons of affected vs. unaffected hemisphere or acute vs. chronic stroke phase revealed a significant result. This meta-analysis demonstrates a modest but significant beneficial effect of tDCS on improving post-stroke dysphagia. Whether benefits from this intervention are more pronounced in certain patient subgroups and with specific stimulation protocols requires further investigation.

Cortical and Subcortical Control of Swallowing-Can We Use Information From Lesion Locations to Improve Diagnosis and Treatment for Patients With Stroke?

Purpose Swallowing is a complex process, mediated by a broad bilateral neural network that spans from the brainstem to subcortical and cortical brain structures. Although the cortex's role in swallowing was historically neglected, we now understand, especially through clinical observations and research of patients with stroke, that it substantially contributes to swallowing control. Neuroimaging techniques (e.g., magnetic resonance imaging) have helped significantly to elucidate the role of cortical and subcortical brain areas, in general, and the importance of specific areas in swallowing control in healthy individuals and patients with stroke. We will review recent discoveries in cortical and subcortical neuroimaging research studies and their generalizability across patients to discuss their potential implications and translation to dysphagia diagnosis and treatment in clinical practice. Conclusions Stroke lesion locations have been identified that are commonly associated across patients with the occurrence and recovery of dysphagia, suggesting that clinical brain scans provide useful information for improving the diagnosis and treatment of patients with stroke. However, individual differences in brain structure and function limit the generalizability of these relationships and emphasize that the extent of the motor and sensory pathology in swallowing, and how the patient recovers, also depends on a patient's individual brain constitution. The involvement of the damaged brain tissue in swallowing control before the stroke and the health of the residual, undamaged brain tissue are crucial factors that can differ between individuals.

Dysphagia and disability in minor strokes – An institutional study

BackgroundMinor strokes, defined as NIHSS ≤5 are considered non-disabling, associated with a favourable outcome. AimOur aim was to study prevalence and predictors of dysphagia in patients with minor stroke and its impact on functional outcome. MethodsSingle centre retrospective study of all minor strokes admitted to Comprehensive Stroke care centre with 1 year completed follow-up were recruited. Clinical and imaging details and follow-up data were extracted from medical records. ResultsWe had 147 patients with minor stroke, 72.1% men with median age 61 years. 71% presented within 24 h of symptom onset. Most common etiology was lacunar .Median NIHSS at admission was 3(IQR 2). 85 patients had anterior circulation strokes and 34 had chronic infarcts in imaging.19 had significant dysphagia and 10 were discharged with nasogastric feeding tube. Admission NIHSS and white mater changes in imaging were predictive of post stroke dysphagia. Excellent recovery of dysphagia was found within 1 month post stroke in all, except one who required percutaneous gastrostomy. At 3 months 76% had excellent outcome. Presence of dysphagia and diabetes were found to be predictive of short term outcome, independent of admission stroke severity. At 12 months, post stroke dysphagia, female gender and white mater changes in imaging were predictive of unfavourable outcome. ConclusionsMinor strokes are disabling in a small fraction of patients. Over 10% of them can have significant post stroke dysphagia necessitating nasogastric feeding short term. This patient subgroup tend to have less favourable outcome on short and long term follow-up.

Epiglottic Retroflexion is a Key Indicator of Functional Recovery of Post-stroke Dysphagia.

ObjectiveTo evaluate the longitudinal changes of swallowing kinematics based on videofluoroscopic swallowing studies (VFSSs) in subacute stroke patients grouped according to the method of dietary intake.MethodsSixty-nine subacute stroke patients who had taken at least 2 successive VFSSs were included. Subjects were allocated into 3 groups according to the degree of swallowing function recovery—not improved group (tube feeding recommended to patients at both studies), improved group (tube feedings recommended initially to patients and oral feeding recommended at follow-up study), and well-maintained group (oral feeding at both studies recommended to patients). Initial VFSS was performed during the subacute stage of stroke, 1 to 12 weeks after the onset of stroke, and follow-up VFSS was performed at least once. Kinematic variables were calculated by two-dimensional motion analysis of multiple structures, including the hyoid bone, epiglottis, and vocal cord. Changes of kinematic variables were analyzed in serial VFSSs.ResultsAt the initial VFSS, the well-maintained group showed significantly larger angles of epiglottic folding than the not improved group, while at the follow-up VFSS, the improved and the well-maintained groups showed significantly larger epiglottic folding angles than the not improved group. The distribution of epiglottic folding angles was in a dichotomous pattern, and each cluster was related to the swallowing function.ConclusionThis study showed that improved epiglottic folding angles are associated with the recovery of the swallowing process and suitability for oral feeding among various kinematic variables in subacute stroke patients.

Influence of Inhalation Injury on Incidence, Clinical Profile and Recovery Pattern of Dysphagia Following Burn Injury.

Inhalation injury is predictive of dysphagia post burns; however, the nature of dysphagia associated with inhalation burns is not well understood. This study describes the clinical profile and recovery pattern of swallowing following inhalation burn injury. All patients admitted 2008–2017 with confirmed inhalation burns on laryngoscopy and managed by speech-language pathology (SLP) were included. Initial dysphagia presentation and dysphagia recovery pattern were documented using the FOIS. Co-presence of dysphonia was determined clinically and rated present/absent. Persistent laryngeal/pharyngeal injury at 6 months was documented using laryngoscopy. Data were compared to published data from a large adult burn cohort. All patients with confirmed inhalation burns during the study period received SLP input, enabling review of 38 patients (68% male; m = 40.8 years). Percent Total Body Surface Area burn ranged 1–90%, 100% had head and neck burns, 97% required mechanical ventilation (mean 9.4 days), 18% required tracheostomy and 100% had dysphonia. Comparing to non-inhalation burn patients, the inhalation cohort had significantly (p < 0.01) higher dysphagia incidence (89.47% vs 5.6%); more with severe dysphagia at presentation (78.9% vs 1.7%); increased duration to initiate oral intake (m = 24.69 vs 0.089 days); longer duration of enteral feeding (m = 45.03 vs 1.96 days); and longer duration to resolution of dysphagia (m = 29.79 vs 1.67 days). Persistent laryngeal pathology was present in 47.37% at 6 months. This study shows dysphagia incidence in burn patients with inhalation injury is 16 times greater than for those without inhalation injury. Laryngeal pathology due to inhalation injury increases dysphagia severity and duration to dysphagia recovery.

Abstract TMP46: Fostering Eating After Stroke (FEAST) Trial: A Randomized Controlled Trial of Non-Invasive Brain Stimulation for Improving Dysphagia After Stroke

Background: Effective therapy for dysphagia recovery after stroke is currently lacking. We conducted a phase-2 RCT to investigate the effects of anodal transcranial direct current stimulation (atDCS) in reducing aspiration risk, improving diet, and analyzed its safety in the acute-subacute stroke phase. Hypothesis: Since swallowing has bi-hemispheric representation targeted atDCS to the unaffected hemisphere combined with swallowing exercises may improve dysphagia from a unilateral hemispheric infarction [UHI]. Methods: This phase-2, double-blind, RCT enrolled subjects with dysphagia [penetration and aspiration (PAS) score ≥ 4], from an acute-subacute UHI [day 2-day 6 after stroke onset] and randomized them into 3 groups: low-dose atDCS [2 mA atDCS alternating with sham twice daily], high-dose atDCS [2 mA atDCS twice daily] or sham [twice daily]. All sessions were performed with standardized swallowing exercises for 20 minutes over 5 days. Major safety outcomes were incidence of seizures, worsening of neurological and swallowing functions and mortality; primary efficacy outcome was a change in PAS scores between day 1 and 5 of intervention; main dietary outcome was a change in dietary intake at 1 month using the Functional Oral Intake scale (FOIS). Results: Of the planned 99 subjects, 42 could be enrolled in the funding period. No group differences in pre-defined safety outcomes were observed. Mean (SD) change in PAS score from baseline to final session was -0.8 (±1.6) in sham, -0.8 (±1.5) in low-dose and -0.4 (±1.2) in high dose groups. Adjusting for baseline PAS, NIHSS scores and age, means (SE) were -0.96 (0.33) in sham, -0.81 (0.36) in low-dose and -0.34 (0.35) in high dose; there were no significant pairwise differences (p&gt;0.40). Mean (SD) changes in FOIS scores from baseline to 1 month were: 2.1 (±1.7) in sham, 2.5 (±1.7) in low-dose and 2.9 (±1.2) in high dose. Adjusted means (SE) were 2.07 (0.35) in sham, 2.46 (0.38) in low dose and 3.05 (0.38) in high dose (pairwise p &gt; 0.15). Conclusion: Application of atDCS to the unaffected hemisphere is safe in the acute-subacute stroke phase but did not decrease aspiration risk in this phase-2 RCT. Higher doses of atDCS were associated with better dietary scores but group differences were not statistically significant.

Anodal transcranial direct current stimulation and intermittent theta-burst stimulation improve deglutition and swallowing reproducibility in elderly patients with dysphagia.

Dysphagia in the elderly, known as presbydysphagia, has become a relevant public health problem in several countries. Swallowing disorders may be a consequence of different neurological disorders (secondary presbydysphagia) or the expression of the aging process itself (primary presbydysphagia). We aimed to test the therapeutic potential of two different non-invasive brain stimulation (NIBS) techniques in subjects with primary or secondary presbydysphagia. A blinded randomized controlled trial with crossover design was carried out in 42 patients, randomly assigned to anodal transcranial direct current stimulation (tDCS) or intermittent theta-burst stimulation (TBS) group. Both tDCS and TBS were applied for 5 consecutive days over the right swallowing motor cortex. The swallowing function was assessed before and 1 and 3months after the stimulation using the Dysphagia Outcome and Severity Scale (DOSS), scored based on clinical assessment and fiberoptic endoscopic evaluation of swallowing. An electrophysiological method was also applied to evaluate changes in the reproducibility of the swallowing behavior. Both real tDCS and TBS had beneficial effects on the swallowing function in patients with primary and secondary presbydysphagia. Anodal tDCS resulted in an improvement of 0.5 points in DOSS at 1-month follow-up (P=.014), whereas intermittent TBS induced an increase of 0.7 and 0.6 points at 1- and 3-month follow-up evaluations, respectively (P=.0001 and P=.005, respectively). Reproducibility of both the oral and pharyngeal phases of swallowing significantly increased at 1-month follow-up. Our results suggest that non-invasive cortical stimulation may be useful for dysphagia recovery in elderly patients.

Dose to swallowing structures and dysphagia in head and neck Intensity Modulated Radiation Therapy - A long term prospective analysis.

To analyse the long term swallowing function in head and neck cancer patients and correlate with the dose to midline swallowing structures. The use of concurrent chemo radiation (CRT) as the present standard of care resulted in high rates of early and late toxicities. Dysphagia, aspiration, and xerostomia are early as well as late effects of radiation. Not many studies on the dysphagia scores during radiation and follow-up period have correlated dose to the swallowing structures, hence this study. Histologically proven head and neck cancer patients treated with intensity modulated radiation therapy were accrued in this study. The pharyngeal constrictors, larynx and cervical oesophagus were contoured and labelled as midline swallowing structures. The volume of the midline swallowing structures which were outside the PTV was delineated separately and was given a mean dose constraint of 45Gy. Dysphagia was assessed at baseline, weekly intervals during irradiation and follow-up at six years. The dose to the structures for swallowing was correlated with degree of dysphagia. There was a gradual increase in the dysphagia grade during the course of radiation. There was a significant recovery of late dysphagia compared to dysphagia during the completion of radiation therapy in patients who received <45Gy to the swallowing structures (p<0.0001). Giving a constraint to the swallowing structure and limiting it to <45Gy resulted in earlier recovery of swallowing function resulted in good physical, mental and social well being of the patients when compared to those who received >45Gy.

Post stroke dysphagia and disability in minor strokes

Minor strokes, defined as NIHSS ≤5 are considered non-disabling, associated with a favorable outcome. Our aim was to study patients presenting with minor stroke in the acute phase to see their medical complications and functional outcome on follow-up. Retrospective study design,where all minor strokes admitted to Stroke care centre, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum between January 2016-June 2017, with 1 year completed followup were selected from medical records. Clinical and imaging details and follow-up data were collected. We had 147 patients with minor stroke during the study period with median age 61 years. 71% presented within 24 hours of symptom onset.Median NIHSS at admission was 3 (IQR 2). 85 patients had anterior circulation strokes and 34 had chronic infarcts in imaging. At discharge, 19 had significant dysphagia, with 10 requiring nasogastric feeding. Admission NIHSS and white mater changes in imaging were predictive of post stroke dysphagia.Excellant recovery of dysphagia was found within 1 month post stroke in all, except one who required percutaneous gastrostomy. At 3 months, 76% had excellent outcome. In multivariate logistic regression analysis, presence of dysphagia and DM were found to be statistically significant predictors of short term outcome, ie at 3 months. At 12 months,post stroke dysphagia, females and those with white mater changes had a less favourable stroke outcome. Minor strokes are disabling in a small fraction of patients.Over 10% of them tend to have significant dysphagia necessitating nasogastric feeding short term.This patient subgroup tend to have less favourable outcome on short and long term followup.

Clinical progression and outcome of individuals with and without swallowing impairment following non-traumatic subarachnoid haemorrhage: A retrospective cohort study

Purpose: To establish the clinical profiles of individuals with and without dysphagia following non-traumatic subarachnoid haemorrhage (SAH), and to further describe the clinical progression and outcome of dysphagia within the acute phase for those individuals with dysphagia.Method: Retrospective chart review of 250 patients consecutively admitted with non-traumatic SAH to a major, tertiary neurosurgery referral centre in Australia over a three-year period. Clinical information associated with usual clinical care was collected for the duration of the acute hospital admission. Characteristics of participants with dysphagia (n = 73/250) were further analysed to evaluate dysphagia progression and recovery.Result: Participants with dysphagia took 10.93 times longer to commence oral intake following admission than those without dysphagia (p < 0.01). Those with dysphagia took approximately 12.86 times longer to reach total oral feeding than those without dysphagia (p < 0.01). There was no statistically significant difference between groups for time to SLP referral (p = 0.549) or commencement of supplemental feeding (p = 0.256). Safe management of thin fluids occurred for >50% of participants by weeks 2 and 3 following admission, with 75.34% of participants with dysphagia resuming thin fluids by discharge. Safe management of full diet took slightly longer with 32.88% of participants resuming unmodified diet by week 3. By discharge, only 53.42% of participants resumed a full diet.Conclusion: The clinical progression and recovery of dysphagia within the acute phase following non-traumatic SAH can be protracted for some patients, necessitating ongoing speech-language pathology (SLP) input after discharge. The study findings will enhance SLP assessment processes, management focuses and guide prognostic decision making for this population.

Functional limitations and cognitive impairment predict the outcome of dysphagia in older patients after an acute neurologic event.

Dysphagia prevalence increases with age and a significant contribution is given by stroke survivors; its treatment is mainly based on rehabilitation, but outcome cannot be easily predicted. The aim of this study is to detect possible predictors of the outcome of dysphagia in patients beginning rehabilitation after a major Central Nervous System injury. Dysphagia severity was measured in 95 consecutive patients (71 with ischemic or hemorrhagic stroke) upon admission to our neurorehabilitation unit and at discharge, during the year 2017. The initial evaluation included also demographic data, functional and geriatric multidimensional assessment, laboratory test results and comorbidities. Their possible predictive value on the degree of recovery of the swallowing process at discharge has been analyzed. Poor functional conditions and the presence of cognitive impairment on admission appear to be associated with a worse outcome of dysphagia at discharge. A significant correlation exists between scores at functional scales at the beginning of rehabilitation and dysphagia score at discharge. Patients with cognitive impairment at the beginning (n = 60) showed a significantly lower degree of recovery of dysphagia at discharge. Other factors, beside the degree of dysphagia itself, are important to predict its outcome. Their knowledge not only allows an initial prognostic assessment; it can also be useful to decide which aspects should receive greater attention when treating patients with dysphagia.

Association Between Duration of Dysphagia Recovery and Lesion Location on Magnetic Resonance Imaging in Patients With Middle Cerebral Artery Infarction.

ObjectiveTo investigate association between lesion location on magnetic resonance imaging (MRI) performed after an infarction and the duration of dysphagia in middle cerebral artery (MCA) infarction.MethodsA videofluoroscopic swallowing study was performed for 59 patients with dysphagia who were diagnosed as cerebral infarction of the MCA territory confirmed by brain MRI. Lesions were divided into 11 regions of interest: primary somatosensory cortex, primary motor cortex, supplementary motor cortex, anterior cingulate cortex, orbitofrontal cortex, parieto-occipital cortex, insular cortex, posterior limb of the internal capsule (PLIC), thalamus, basal ganglia (caudate nucleus), and basal ganglia (putamen). Recovery time was defined as the period from the first day of L-tube feeding to the day that rice porridge with thickening agent was prescribed. Recovery time and brain lesion patterns were compared and analyzed.ResultsThe mean recovery time of all patients was 26.71±16.39 days. The mean recovery time was 36.65±15.83 days in patients with PLIC lesions and 32.6±17.27 days in patients with caudate nucleus lesions. Only these two groups showed longer recovery time than the average recovery time for all patients. One-way analysis of variance for recovery time showed significant differences between patients with and without lesions in PLIC and caudate (p<0.001).ConclusionInjury to both PLIC and caudate nucleus is associated with longer recovery time from dysphagia.

The possible role of repetitive transcranial magnetic stimulation in dysphagia following brain stem infarctions

Background Dysphagia is a very common manifestation of brain stem infarctions, which is usually severe enough to need special feeding programs including nasogastric tube application. Repetitive transcranial magnetic stimulation (rTMS) can modulate the cortical excitability and enhance the recovery of swallowing dysfunctions. Aim To evaluate the possible therapeutic role of rTMS in accelerating recovery of dysphagia following brain stem infarctions. Patients and methods This study was conducted on 30 dysphagic patients following brain stem infarctions; 15 received real rTMS and 15 received sham rTMS on bilateral supratentorial cortical swallowing areas. Every patient underwent 10 rTMS sessions repeated five times per week for 2 successive weeks. Scheduled dysphagia severity was evaluated using The Dysphagia Outcome and Severity Scale at stroke onset, after the first rTMS session, and then at 7, 30, and 60 days after the last rTMS session (visits 0, 1, 2, 3, and 4, respectively). Results There was significant improvement of dysphagia in patients who received real rTMS compared with those who received sham rTMS during visits 1 and 2. The improvement was maintained through visits 3 and 4, but without significant difference. Conclusion Bilateral application of real rTMS on cortical swallowing areas for patients with dysphagia following brain stem infarctions has a potential rapid maintained improving effect of swallowing functions with decreased burden of aspiration in the early poststroke period until recovery takes place.

Sarcopenia is associated with worse recovery of physical function and dysphagia and a lower rate of home discharge in Japanese hospitalized adults undergoing convalescent rehabilitation

The aim of this study was to evaluate the effect of sarcopenia on functional outcomes, including activities of daily living (ADLs); dysphagia status; and the rate of home discharge, among hospitalized adults receiving convalescent rehabilitation. A retrospective cohort study was conducted with 898 patients newly admitted to in-hospital convalescent rehabilitation wards at a single rehabilitation hospital in Japan. Baseline sarcopenia was diagnosed using muscle mass index and handgrip strength according to the criteria of the European Working Group on Sarcopenia in Older People, with the cutoff values of the Asian Working Group for Sarcopenia. The primary outcome was ADLs, assessed by Functional Independence Measure motor (FIM-motor) score at hospital discharge. The secondary outcomes included dysphagia, assessed by the Food Intake Level Scale (FILS), at discharge, and the rate of home discharge. Three multivariate analyses revealed an association between sarcopenia and the clinical outcomes. Each analysis adjusted for the following confounders: age, sex, time from onset, premorbid ADLs, comorbidities, cognitive level, nutritional status, major drugs, and admission diagnoses. After enrollment, 795 patients (mean age 74.9 ± 13.2 y; 59% women) were included in the final analysis. Admission diagnoses included stroke (n = 276; 34.7%), musculoskeletal disorders (n = 382; 48.1%), and hospital-associated deconditioning (n = 137; 17.2%). Of the 795 patients examined, 402 (50.6%) had sarcopenia. The multiple linear regression analysis showed that sarcopenia was independently associated with FIM motor score at discharge in patients with all disease types (β = -0.189 [stroke], -0.240 [musculoskeletal disorders], -0.230 [hospital-associated deconditioning]; all P < 0.05), with FILS score at discharge only in patients with musculoskeletal disorders (β = -0.271, P < 0.001), but not in patients with stroke (β = -0.061, P = 0.375) or those with hospital-associated deconditioning (β = -0.131, P = 0.070). The multiple logistic regression analysis showed that sarcopenia was associated with rate of home discharge in all disease types (odds ratio [OR], 0.201; 95% confidence interval [CI], 0.067-0.597 for stroke; OR, 0.242; 95% CI, 0.076-0.772 for musculoskeletal disorders; OR, 0.121; 95% CI, 0.110-0.347 for hospital-associated deconditioning; all P < 0.05). Sarcopenia is associated with worse recovery of ADLs and dysphagia and a lower rate of home discharge in hospitalized adults undergoing convalescent rehabilitation. Early detection of sarcopenia and treatment by rehabilitation nutrition should be implemented in this population.

Repetitive transcranial magnetic stimulation in combination with neuromuscular electrical stimulation for treatment of post-stroke dysphagia.

ObjectiveThis study was performed to determine whether repetitive transcranial magnetic stimulation (rTMS) combined with neuromuscular electrical stimulation (NMES) effectively ameliorates dysphagia and how rTMS protocols (bilateral vs. unilateral) combined with NMES can be optimized.MethodsSixty-four patients were randomly divided into four groups using a random distribution table: the sham rTMS plus NMES (Sham-rTMS/NMES), ipsilesional 10-Hz rTMS plus NMES (Ipsi-rTMS/NMES), contralesional 1-Hz rTMS plus NMES (Contra-rTMS/NMES), and bilateral rTMS plus NMES (Bi-rTMS/NMES) groups. Cortical excitability as measured by the amplitude of the motor evoked potential at the mylohyoid muscle cortical representative area, swallowing function as measured by the Standardized Swallowing Assessment, and the degree of dysphagia were evaluated at baseline, after the stimulation course, and at the 1-month follow-up.ResultsBi-rTMS/NMES produced higher cortical excitability and better swallowing function recovery. Compared with NMES alone, unilateral rTMS plus NMES had additional effects on cortical excitability and rehabilitation of dysphagia, but there were no differences between the Contra-rTMS/NMES and Ipsi-rTMS/NMES groups. No adverse events occurred.ConclusionThe combination of rTMS with NMES was superior to NMES alone in improving the recovery of post-stroke dysphagia, and the combination of bilateral rTMS with NMES was more effective than unilateral rTMS combined with NMES.