Treatment Of Post-stroke Dysphagia Research Articles

Repetitive Transcranial Magnetic Stimulation on Individualized Spots Based on Task functional Magnetic Resonance Imaging Improves Swallowing Function in Poststroke Dysphagia.

Background: Functional magnetic resonance imaging (fMRI) has not previously been used to localize the swallowing functional area in repetitive transcranial magnetic stimulation (rTMS) treatment for poststroke dysphagia; Traditionally, the target area for rTMS is the hotspot, which is defined as the specific region of the brain identified as the optimal location for transcranial magnetic stimulation (TMS). This study aims to compare the network differences between the TMS hotspot and the saliva swallowing fMRI activation to determine the better rTMS treatment site and investigate changes in functional connectivity related to poststroke dysphagia using resting-state fMRI. Methods: Using an information-based approach, we conducted a single case study to explore neural functional connectivity in a patient with poststroke dysphagia before, immediately after rTMS, and 4 weeks after rTMS intervention. A total of 20 healthy participants underwent fMRI and TMS hotspot localization as a control group. Neural network alterations were assessed, and functional connections related to poststroke dysphagia were examined using resting-state fMRI. Results: Compared to the TMS-induced hotspots, the fMRI activation peaks were located significantly more posteriorly and exhibited stronger functional connectivity with bilateral postcentral gyri. Following rTMS treatment, this patient developed functional connection between the brainstem and the bilateral insula, caudate, anterior cingulate cortex, and cerebellum. Conclusion: The saliva swallowing fMRI activation peaks show more intense functional connectivity with bilateral postcentral gyri compared to the TMS hotspots. Activation peak-guided rTMS treatment improves swallowing function in poststroke dysphagia. This study proposes a novel and potentially more efficacious therapeutic target for rTMS, expanding its therapeutic options for treating poststroke dysphagia.

The neural plasticity and efficacy of acupuncture for post-stroke dysphagia: protocol for a randomized controlled trial with fMRI and DTI

BackgroundDysphagia, a common complication of acute stroke, is associated with increased mortality and morbidity. Acupuncture, a widely used swallowing therapy in China, has been suggested as an effective therapy for treating Post-Stroke Dysphagia (PSD) by recent meta-analyses and guidelines. The use of resting-state functional Magnetic Resonance Imaging (rs-fMRI) and Diffusion Tensor Imaging (DTI) could explore the change of regional spontaneous neural activity, functional relationships between brain regions, and white matter connectivity patterns after acupuncture intervention for PSD. This trial aims to evaluate the efficacy of acupuncture treatment for PSD and explore its central mechanism by neuroimaging.Methods/designThis randomized controlled trial will recruit 40 PSD patients. All patients will be randomized to either the Real Acupuncture (RA) or Sham Acupuncture (SA) group by a ratio of 1:1. All patients will receive immediate acupuncture treatment in the MRI scanning room, followed by four weeks of long-term acupuncture treatment. The primary outcomes are the rs-fMRI and DTI indicators, which will be evaluated after the immediate and long-term acupuncture treatment. The secondary outcomes are the scales that assess the efficacy, including the Functional Oral Intake Scale (FOIS), Water Swallowing Test (WST), Swallowing Quality Of Life Questionnaire (SWAL-QOL), and National Institute of Health Stroke Scale (NIHSS). The modified version of the Massachusetts General Hospital Acupuncture Sensation Scale (M-MASS) and fMRI sensation record table will also be evaluated.DiscussionThis protocol presents the design of a randomized, single-blind trial that will evaluate the efficacy and explore the neural plasticity of acupuncture treatment for PSD. This trial will deepen our insight into the clinical value of acupuncture for PSD and initially probe into the time-dosage-effect mechanism of acupuncture.Trial registration numbersChinese Clinical Trial Registry (www.chictr.org.cn) ChiCTR2300067480. This study was registered on 9th January 2023.

Exploring the rules of related parameters in acupuncture for post-stroke dysphagia based on data mining

BackgroundPost-stroke dysphagia (PSD) affects the efficacy and safety of swallowing, causing serious complications. Acupuncture is a promising and cost-effective treatment for PSD; however, as the number of randomized controlled trials increases, scientific analysis of the parameters and acupoint prescription is required. Therefore, this study aimed to explore the effects of acupuncture on parameters related to post-stroke dysphagia (PSD).MethodsWe searched the Cochrane Library, PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang Database, Chinese Biomedical Literature, and Chongqing VIP Database for randomized controlled trials of acupuncture for PSD in the last 15 years and relevant parameters were analyzed using data mining techniques.ResultsIn total, 3,205 records were identified, of which 3,507 patients with PSD were included in 39 studies. The comprehensive analysis demonstrated that the closest parameter combinations of acupuncture on PSD were 0.25 mm × 40 mm needle size, 30 min retention time, five treatments per week, and a 4-week total course of treatment. Additionally, the gallbladder and nontraditional meridians, crossing points, and head and neck sites are the most commonly used acupoint parameters. The core acupoints identified were GB20, RN23, EX-HN14, Gongxue, MS6, SJ17, EX-HN12, EX-HN13, and the commonly used combination of EX-HN12, EX-HN13, GB20, and RN23.ConclusionThis study analyzed the patterns of PSD-related needling and acupoint parameters to provide evidence-based guidelines for clinical acupuncturists in treating PSD, potentially benefitting affected patients.

Research hotspot and frontiers in post-stroke dysphagia: A bibliometric study and visualisation analysis.

Dysphagia, a common complication after stroke, significantly hampers the recovery process of patients, both due to dysphagia itself and the additional complications it causes. Although a large number of articles have been published on post-stroke dysphagia (PSD), bibliometric analysis in this field is still lacking. This study aimed to provide a comprehensive understanding of the research hotspots and trends in PSD, thereby guiding future research efforts. The Web of Science Core Collection (WoSCC) database was searched for articles related to PSD from 2003 to 2022. Data were visualised and analysed using CiteSpace and VOSviewer. A total of 3102 publications were included in the scientometric analysis, with a gradual increase in the number of papers published each year. The United States emerged as the country with the highest number of publications (625 articles), while the University of Manchester led with the most publications among institutions (67 articles). Notably, Dysphagia was both the most published (254 articles) and the most cited journal (11,141 citations). Among authors, Hamdy S emerged as the most prolific (52 articles), with Martino R being the most cited (1042 citations). Based on our findings, we anticipate that research hotspots in PSD will mainly focus on complications due to PSD such as stroke-associated pneumonia, stroke-related sarcopenia. Additionally, exploration into the mechanisms and parameters of noninvasive brain stimulation techniques for the treatment of PSD, as well as the rehabilitation needs of patients with PSD, are expected to be key focal points in future research endeavours.

Current state of research on acupuncture for the treatment of post-stroke dysphagia: a scoping review.

Post-stroke dysphagia (PSD) is a common complication of stroke. Acupuncture as one of the traditional therapies in traditional Chinese medicine (TCM), can change the excitability of cerebral cortical nerve cells, and promote the recovery of neurological and swallowing functions. Several clinical primary studies (including RCTs, cohort studies, etc.) and systematic reviews have demonstrated its efficacy and safety in patients with PSD. The positive effects of acupuncture on PSD are also mentioned in international clinical and treatment guidelines, while there is no synthesis of this evidence. This scoping review aims to summarize the evidence from clinical primary studies, reviews, systematic reviews, and guidelines on acupuncture for the treatment of PSD and explore the breadth of this evidence, provide an overview of the range and characteristics of existing evidence, research gaps, and future research priorities in treating PSD with acupuncture. PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, SinoMed, Wan Fang Data, and VIP databases were searched from inception until June 12, 2024. The relevant data were presented through bubble diagrams, line graphs, and structured tables along with descriptive statistics and analysis. This scoping review was conducted based on the PRISMA-ScR Checklist. A total of 1,130 studies were included. Most of the studies were conducted in China, with the number increasing over time. The studies included 254 reviews, 815 clinical studies (678 RCTs,107 nRCTs, 12 case reports, 14 cohort studies, and four case series), 51 systematic reviews, and 10 guidelines. Acupuncture interventions included manual acupuncture (MA), electroacupuncture (EA), and MA/EA combined with acupuncture-related methods (such as scalp acupuncture, auricular acupuncture, warm acupuncture, etc.). The most frequently used acupoint was RN23. Acupuncture is often applied in combination with other treatments, such as herbal medicine, Western medicine, rehabilitation training, swallowing training, or catheter balloon dilatation. Effective rates and WTS were the most frequently used outcomes. Most studies reported significant efficacy and only a few studies explicitly reported adverse events. Acupuncture received positive recommendations in nine guidelines for the treatment of PSD. As a convenient and safe traditional Chinese medicine therapy with its characteristics, acupuncture can improve different stages and types of dysphagia without causing serious adverse reactions. In the future, more standardized international cooperative clinical research is needed to identify the influence of different acupuncture intervention times on the curative effect and dose-effect relationship of acupuncture; standardize the clinical acupoint selection scheme of acupuncture; develop a COS with TCM characteristics to improve the quality of outcome reporting, This will enable different research data to be summarized and compared, reduce resource waste, and provide more high-quality evidence.

Pharyngeal Cavity Electrical Stimulation-Assisted Swallowing for Post-stroke Dysphagia: A Systematic Review and Meta-analysis of Randomized Controlled Studies.

Stroke is the leading cause of death and disability among adults. The incidence of stroke per 100, 000 patient-years was 2875. As many as 37% to 78% of patients with acute strokes suffer dysphagia. Dysphagia can easily lead to inhalation pneumonia, dehydration, malnutrition, and other serious complications, affecting the quality of life of stroke patients and increasing their mortality. Effective prevention and treatment of post-stroke dysphagia are of great significance to improving the prognosis and quality of life of patients. Some studies have shown that Pharyngeal cavity electrical stimulation-assisted swallowing (PCES-assisted swallowing) has a positive effect on patients with post-stroke dysphagia. This study will evaluate the effects of PCES-assisted swallowing on post-stroke dysphagia, including swallowing function, withdrawal rate of nasal feeding tubes, duration of hospitalization, and so on. Randomized controlled trials (RCTs) of PCES-assisted swallowing in the treatment of post-stroke dysphagia were searched in eight databases, including Cochrane Library, Embase, PubMed, Web of Science, Chinese Biomedical Literature Database, VIP Information Resource System, CNKI, and Wanfang Medical Science. The retrieval time was from the database establishment to June 2022. Rayyan was used to screen the retrieved literature risk of bias for included studies and was calculated using ROB2.0. The RevMan 5.3 software was used for the meta-analysis with the standard mean difference (SMD) and 95% confidence interval (CI). The model type was a random effect model, The risk ratio (RR) was used as the effect size for the two categorical variables. The swallowing function scores, withdrawal rate of nasal feeding tubes, and Length of stay (LOS) of the intervention and control groups were extracted, and the results of the meta-analysis were presented using a forest plot. Six studies from 2010 to 2018 with a total of 341 people were included in the meta-analysis. All studies reported quantitative outcome measures for the severity of dysphagia, and some reported the withdrawal rate of nasal feeding tubes, LOS, and penetration-aspiration-scale (PAS). The overall swallowing function of the PCES group was better than that of the control group (SMD = -0.20, 95%CI -0.38 to -0.03, P = 0.02). In terms of the severity of dysphagia, there was a statistically significant difference in the Dysphagia Severity Rating scale (DSRS) between the Pharyngeal cavity electrical stimulation (PCES) group and the control group (SMD = -0.24, 95%CI -0.48 to 0, P = 0.05). The PCES group nasal feeding withdrawal rate of nasal feeding tubes was higher than the control group (RR = 2.88, 95% CI 1.15 to 7.26, P = 0.02). There was no significant difference in the LOS between the PCES group and the control group (SMD = -0.19, 95%CI -0.44 to 0.07, P = 0.15). This systematic review and meta-analysis provide reasonably reliable evidence that PCES-assisted swallowing can improve nasogastric feeding swallowing function and the withdrawal rate of nasal feeding tubes in patients with post-stroke dysphagia. However, the evidence for reducing oral feeding, aspiration, and length of hospitalization stay is lacking, and further studies are needed.

Participation of the nucleus tractus solitarius in the therapeutic effect of electroacupuncture on post-stroke dysphagia through the primary motor cortex.

Post-stroke dysphagia (PSD), a common and serious disease, affects the quality of life of many patients and their families. Electroacupuncture (EA) has been commonly used effectively in the treatment of PSD, but the therapeutic mechanism is still under exploration at present. We aim to investigate the effect of the nucleus tractus solitarus (NTS) on the treatment of PSD by EA at Lianquan (CV23) through the primary motor cortex (M1). C57 male mice were used to construct a PSD mouse model using photothrombotic technique, and the swallowing function was evaluated by electromyography (EMG) recording. C-Fos-positive neurons and types of neurons in the NTS were detected by immunofluorescence. Optogenetics and chemical genetics were used to regulate the NTS, and the firing rate of neurons was recorded via multichannel recording. The results showed that most of the activated neurons in the NTS were excitatory neurons, and multichannel recording indicated that the activity levels of both pyramidal neurons and interneurons in the NTS were regulated by M1. This process was involved in the EA treatment. Furthermore, while chemogenetic inhibition of the NTS reduced the EMG signal associated with the swallowing response induced by activation of M1 in PSD mice, EA rescued this signal. Overall, the NTS was shown to participate in the regulation of PSD by EA at CV23 through M1.

Diagnostics and treatment of post-stroke dysphagia

Post-stroke dysphagia is highly prevalent and leads to severe complications, such as aspiration pneumonia and malnutrition. Despite the high clinical relevance dysphagia management is heterogeneous and often inadequate. The aim of this review article is to provide an overview of the diagnostic and treatment strategies for post-stroke dysphagia based on recent studies. Narrative literature review. Dysphagia screening should be performed as early as possible in every stroke patient, e.g., with asimple water swallowing test or amulticonsistency protocol. Subsequently, flexible endoscopic evaluation of swallowing (FEES) is indicated in patients with abnormal screening results or existing risk factors for dysphagia. Dietary modifications, oral hygiene measures, and nutritional therapy can help reduce complications. Behavioral swallowing therapy or experimental therapies, such as neurostimulation procedures and pharmacological approaches aim to improve swallowing function and have shown promising results in studies. Timely management of dysphagia is necessary to reduce complications.

Treatment of Post-Stroke Dysphagia with Repetitive Transcranial Magnetic Stimulation Based on the Bimodal Balance Recovery Model: A Pilot Study.

Brain plasticity and functional reorganization are the main mechanisms of stroke rehabilitation and the theoretical basis for transcranial magnetic therapy. Bimodal balance recovery model suggests that the structural integrity of neural pathways affects the functional reorganization mode of brain recovery after stroke. The principal neural pathway that innervates swallowing is the corticobulbar tract (CBT). The goal is to investigate the impact of corticobulbar tract integrity on swallowing function recovery in post-stroke dysphagia (PSD) patients treated with repetitive transcranial magnetic stimulation (rTMS). Thirty-five patients with high CBT integrity (relative fractional anisotropy (rFA) >0.5) and 32 patients with low CBT integrity (rFA ≤0.5) were respectively assigned to three subgroups through a random number table: 5 Hz frequency rTMS group, 1 Hz frequency rTMS group, and Sham rTMS group. The Standardized Swallowing Assessment (SSA), Penetration Aspiration Scale (PAS), and Dysphagia Outcome Severity Scale (DOSS) were analyzed before and after therapy. Significant improvements in SSA (p < 0.05), PAS (p < 0.05), and DOSS scores (p < 0.05) were seen in the high frequency (HF) and low frequency (LF) groups compared with the Sham group for patients with high CBT integrity. Increased SSA (p < 0.05), PAS (p < 0.05), and DOSS scores (p < 0.05) demonstrated that the HF group achieved greater remediation than the LF and Sham groups for patients with low CBT integrity. Both 5 Hz and 1 Hz rTMS over the contralateral hemisphere are effective for the treatment of swallowing disorders for patients with high CBT integrity after stroke; 5 Hz rTMS over the contralateral hemisphere is more effective than 1 Hz and sham stimulation for patients with low CBT integrity.

The effect of acupuncture on the correction of post-stroke dysphagia compared to methods of physical influence

Background. Dysphagia is a problematic field in the clinical work of neurologists, resuscitation experts and therapists due to the high percentage of secondary complications caused by aspiration pneumonia, nutritional deficiency, which affect the recovery process. This ultimately affects the main socio-medical indicators such as mortality, lethality, disability in structure of cerebrovascular diseases. Neurogenic dysphagia occurs in 25–65 % of patients with stroke, while mortality among patients with post-stroke dysphagia receiving tube feeding varies from 20 to 24 %.The aim. To evaluate the impact of reflexology in the treatment of post-stroke dysphagia in comparison with the methods of physical impact. Materials and methods. An open clinical comparative study was conducted in two clinical bases: Republican Hospital named after N.A. Semashko (Ulan-Ude) and Bokhan District Hospital.In this clinical trial, 53 patients with swallowing disorders during the acute period of ischemic stroke were tested. When diagnosing dysphagia, a point scale of the Clinic of the Institute of the Brain was used, which assesses the degree of swallowing disorders before and after treatment. The comparative group receiving standard therapy in combination with physiotherapy (VOCASTIM) included 27 patients, the study group was comprised of 26 patients, who underwent basic therapy in combination with acupuncture (1 course – 10 sessions). In the course of the comparative clinical trial, statistical data were obtained that indicate the positive role of acupuncture in restoring the function of swallowing in patients with acute impairment of cerebral circulation.Results. During the current clinical study, on the background of a 10-day course of reflexology with an exposure of 10–15 minutes and VOCASTIM physiotherapy for 10–15 minutes, the majority of patients experienced regression of post-stroke dysphagia.Conclusion. According to the results of this study, the method of reflexology as a result of physiotherapy showed a faster recovery of swallowing function in the correction of neurogenic swallowing diseases, which causes cerebral infarction.

Manual Acupuncture or Combination of Rehabilitation Therapy to Treat Poststroke Dysphagia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Backgroundand Objective. Poststroke dysphagia is one of the most common stroke complications with high morbidity and long course, while acupuncture treatment is easily accepted by patients due to its reliability, feasibility, simple operation, low price, and quick effect. Our objective was to evaluate the efficacy of manual acupuncture in poststroke dysphagia patients. Methods. Databases including Medline, Web of Science, PubMed, Cochrane Library databases, EMBASE, CNKI (China National Knowledge Infrastructure), WanFang (WanFang Database), and VIP (Chongqing VIP) were searched from inception until Aug 19, 2022. Data were analyzed using Revman 5.3, Stata 14.0, and TSA 0.9.5.10 Beta software. Evidence quality evaluation was performed by using GRADE profiler 3.6. Results. A total of 33 randomized control trials (RCTs) enrolled 2680 patients. Meta-analysis results revealed that compared to rehabilitation, acupuncture decreased water swallow test (WST) and standard swallowing assessment (SSA) scores. Meanwhile, in contrast to rehabilitation alone, integration of acupuncture with rehabilitation effectively decreased WST and SSA scores; improved swallowing scores of videofluoroscopic swallowing study (VFSS), swallowing scores of Fujishima Ichiro, Barthel index (BI), and swallowing quality of life questionnaire (SWAL-QOL); reduced the aspiration rates as well as aspiration pneumonia; and shortened the duration of empty swallowing and the duration of 5 mL water swallowing. Pooled analysis did not reveal any significant differences in dysphagia outcome severity scores (DOSS) (p=0.15 > 0.05p) between the acupuncture group combined with rehabilitation group and the rehabilitation group alone. After the risk-of-bias assessment, these studies were not of low quality, except in terms of allocation concealment and blindness. Evidence quality evaluation showed that allocation concealment and blindness led to a downgrade and primary outcomes' evaluation of acupuncture combined with rehabilitation were ranked as moderate-quality evidence while acupuncture alone was ranked as low-quality. Conclusion. This meta-analysis provided positive pieces of evidences that acupuncture and acupuncture combined with rehabilitation were better than using rehabilitation alone in the treatment of poststroke dysphagia.

Effects of Insular Cortex on Post-Stroke Dysphagia: A Systematic Review and Meta Analysis.

Objective: To investigate the relationship of lobar and deep brain regions with post-stroke dysphagia (PSD). Method: The databases of Medline, Embase, Web of Science, and Cochrane Library were searched from the establishment to May 2022. Studies that investigated the effects of lesions in lobar and deep brain regions on swallowing function after stroke were screened. The primary outcomes were PSD-related brain regions (including aspiration-related and oral transit time-related brain regions). The secondary outcomes were the incidence rate of PSD. The brain regions with the most overlap in the included studies were considered to be most relevant to PSD, and were presented as percentages. Data were compared utilizing the t-tests for continuous variables and χ2 for frequency-based variables. Result: A total of 24 studies and 2306 patients were included. The PSD-related lobar and deep brain regions included the insular cortex, frontal lobe, temporal gyrus, basal ganglia, postcentral, precentral, precuneus, corona radiate, etc. Among these brain regions, the insular cortex was most frequently reported (taking up 54.2%) in the included studies. Furthermore, the total incidence rate of PSD was around 40.4%, and the incidence of male was nearly 2.57 times as much as that of female (χ2 = 196.17, p < 0.001). Conclusions: In lobar and deep brain regions, the insular cortex may be most relevant to PSD and aspiration, which may be a potentially promising target in the treatment of PSD.

Research progress on transcranial magnetic stimulation for post-stroke dysphagia.

Dysphagia is one of the most common manifestations of stroke, which can affect as many as 50-81% of acute stroke patients. Despite the development of diverse treatment approaches, the precise mechanisms underlying therapeutic efficacy remain controversial. Earlier studies have revealed that the onset of dysphagia is associated with neurological damage. Neuroplasticity-based transcranial magnetic stimulation (TMS), a recently introduced technique, is widely used in the treatment of post-stroke dysphagia (PSD) by increasing changes in neurological pathways through synaptogenesis, reorganization, network strengthening, and inhibition. The main objective of this review is to discuss the effectiveness, mechanisms, potential limitations, and prospects of TMS for clinical application in PSD rehabilitation, with a view to provide a reference for future research and clinical practice.

Research progress of clinical intervention and nursing for patients with post-stroke dysphagia.

Post-stroke dysphagia (PSD) is a common and costly complication of stroke and is associated with increased mortality, morbidity, and hospitalization. Although most patients can spontaneously resume swallowing, there are still many patients who do not recover and even die. Despite multiple advances in the acute treatment and secondary prevention of stroke, the effective treatment of PSD remains a neglected area. Studies have shown that repair mechanisms of neurostimulation techniques and increased cortical activity play an important role in the treatment of PSD. In addition, nutritional interventions are also crucial for the treatment of malnutrition in PSD patients. Therefore, this article reviews the effects of the current main clinical treatment methods and nutritional interventions on the treatment and rehabilitation of PSD patients. It also emphasized the necessity of developing an individualized care plan for PSD patients, which is of great significance to promote the clinical treatment, nutritional status, prognosis, and quality of life of PSD patients.

Safety and performance of oropharyngeal muscle strength training in the treatment of post-stroke dysphagia during oral feeding: protocol for a systematic review and meta-analysis

IntroductionDysphagia is a common functional disorder after stroke. Most patients post-stroke are incapable of oral feeding, which often leads to complications such as malnutrition, aspiration pneumonia and dehydration that seriously...

Nutrition in acute stroke management: food for thought

Nutrition is crucial in the management of patients with acute stroke. 1 Dziewas R Michou E Trapl-Grundschober M et al. European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia. Eur Stroke J. 2021; 6: LXXXIX-LXXCXV Crossref PubMed Scopus (0) Google Scholar Clinical features putting patients at risk of malnutrition include dysphagia, impaired consciousness, perception deficits, and cognitive dysfunction. Being malnourished or at risk of malnutrition on admission to hospital after stroke is linked with poor functional outcomes and mortality, and worsening of nutritional status during the acute stage post-stroke is associated with similar adverse outcomes. 2 Dennis M Poor nutritional status on admission predicts poor outcomes after stroke: observational data from the FOOD trial. Stroke. 2003; 34: 1450-1456 Crossref PubMed Scopus (0) Google Scholar Therefore, guidelines dedicated to acute stroke care generally include nutritional management. 1 Dziewas R Michou E Trapl-Grundschober M et al. European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia. Eur Stroke J. 2021; 6: LXXXIX-LXXCXV Crossref PubMed Scopus (0) Google Scholar , 3 Powers WJ Rabinstein AA Ackerson T et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019; 50: e344-e418 Crossref PubMed Scopus (1816) Google Scholar , 4 Boulanger JM Lindsay MP Gubitz G et al. Canadian stroke best practice recommendations for acute stroke management: prehospital, emergency department, and acute inpatient stroke care, 6th edition, update 2018. Int J Stroke. 2018; 13: 949-984 Crossref PubMed Scopus (154) Google Scholar , 5 Burgos R Bretón I Cereda E et al. ESPEN guideline clinical nutrition in neurology. Clin Nutr. 2018; 37: 354-396 Summary Full Text Full Text PDF PubMed Scopus (175) Google Scholar The guideline for the diagnosis and treatment of post-stroke dysphagia from the European Stroke Organization and European Society for Swallowing Disorders, for example, recommends early enteral nutrition via a nasogastric tube if sufficient oral nutrition is not possible. 1 Dziewas R Michou E Trapl-Grundschober M et al. European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia. Eur Stroke J. 2021; 6: LXXXIX-LXXCXV Crossref PubMed Scopus (0) Google Scholar This recommendation relies mainly on the second substudy of the Feed or Ordinary Diet (FOOD) trial, in which 859 patients with dysphagia after stroke were randomly assigned to either early tube feeding or delayed feeding starting later than 7 days after random assignment. Allocation to early tube feeding was associated with a non-significant reduction in mortality by 5·8% (there were 182 deaths in 429 patients randomly assigned to early tube feeding vs 207 deaths in 430 patients in the delayed feeding group; p=0·09). There were no differences in other outcomes, including severe disability or death (339 of 429 patients in the early-feeding group vs 344 of 430 patients in the delayed feeding group; p=0·7), pneumonia (132 of 429 patients in the early-feeding group vs 133 of 430 patients in the delayed feeding group; p>0·9), and percutaneous endoscopic gastrostomy placement at follow-up (30 of 429 patients in the early-feeding group vs 23 of 430 patients in the delayed feeding group). 6 Dennis M Lewis S Cranswick G Forbes J FOOD: a multicentre randomised trial evaluating feeding policies in patients admitted to hospital with a recent stroke. Health Technol Assess. 2006; 10: 1-120 Crossref Google Scholar Safety and efficacy of three enteral feeding strategies in patients with severe stroke in China (OPENS): a multicentre, prospective, randomised, open-label, blinded-endpoint trialIn the early phase of severe stroke, modified full enteral nutrition or hypocaloric enteral nutrition did not significantly reduce the risk of a poor outcomes compared with full enteral nutrition over a 90-day period. Hypocaloric enteral nutrition might be associated with increased mortality compared with modified full enteral nutrition. Further studies are needed to investigate whether modified full enteral nutrition might be the optimal strategy. Full-Text PDF

Clinical trials of Xingnao Kaiqiao needling combined with respiratory training for post-stroke dysphagia

To observe the clinical effect of Xingnao Kaiqiao needling combined with respiratory training on swallowing function, quality of life and throat surface muscle function in patients with post-stroke dysphagia. A total of 124 patients with post-stroke dysphagia were randomized into an observation group and a control group, 62 cases in each group. On the basis of conventional western medication treatment, respiratory training was applied in the control group, once daily, 5 times a week for 4 weeks. On the base of the treatment as the control group, Xingnao Kaiqiao needling was applied at Neiguan (PC6), Sanyinjiao (SP6), Fengchi (GB20), Wangu (GB12), Yifeng (SJ17), posterior pharyngeal wall, Shuigou (GV26) and Lianquan (CV23) in the observation group, once daily, 6 times a week for 4 weeks. Before and after treatment, the Kubota water swallowing test (KWST) scale, swallowing function, swallowing-quality of life (SWAL-QOL) scale, maximum amplitude of pharyngeal surface electromyography (sEMG), and complications of dysphagia were observed and recorded. After the treatment, self-comparison showed that the KWST and swallowing function scores were significantly decreased (P<0.05), the SWAL-QOL score and sEMG were notably increased in both groups (P<0.05) in comparison with their own pre-treatment. The KWST and swallowing function scores were obviously lower in the observation group than in the control group (P<0.05), whereas the SWAL-QOL score and sEMG were evidently higher in the observation group than in the control group (P<0.05). The total effective rate of the observation group was 95.16% (59/62), which was higher than 80.65% (50/62) of the control group (P<0.05). The incidence of dysphagia complications in the observation group was 24.19% (15/62), which was lower than 50.00% (31/62) of the control group (P<0.01). Xingnao Kaiqiao needling combined with respiratory training in the treatment of post-stroke dysphagia can increase the activity of throat muscles, promote the swallowing function, improve the quality of life, and reduce the incidence of dysphagia related complications.

Current perspectives on the benefits, risks, and limitations of noninvasive brain stimulation (NIBS) for post-stroke dysphagia

ABSTRACT Introduction Studies have shown that noninvasive brain stimulation (NIBS), including repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), can promote neuroplasticity, which is considered important for functional recovery of swallowing after stroke. Despite extensive studies on NIBS, there remains a gap between research and clinical practice. Areas covered In this article, we update the current knowledge on the benefits and challenges of rTMS and tDCS for post-stroke dysphagia. We identify some key limitations of these techniques that hinder the translation from clinical trials to routine practice. Finally, we discuss the future of NIBS as a treatment for post-stroke dysphagia in real-world settings. Expert opinion Current evidence suggests that rTMS and tDCS show promise as a treatment for post-stroke dysphagia. However, these techniques are limited by the response variability, uncertainty on the safety in patients with comorbidities and difficulties in clinical study designs. Such limitations call for further work to enhance their utility through individualized approaches. Despite this, the last decade has seen a growing acceptance toward these techniques among clinical personnel. As such, we advocate caution but support optimism that NIBS will gradually be recognized as a mainstream treatment approach for post-stroke dysphagia in the future.

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.

Clinical effect of Liyan Tongqiao acupuncture in treatment of post-stroke dysphagia: an analysis based on diffusion tensor imaging

To investigate the clinical change of post-stroke dysphagia after the intervention of Liyan Tongqiao （relieving sore-throat and dredging orifices）acupuncture using cranial diffusion tensor imaging (DTI). A total of 60 patients with post-stroke dysphagia were enrolled and randomly divided into Liyan Tongqiao acupuncture group and neurology treatment group, with 30 patients in each group. The patients in the neurology treatment group were given routine neurology treatment and swallowing rehabilitation training, and those in the Liyan Tongqiao acupuncture group received acupuncture at Sishencong (EX-HN1), Baihui (GV20), bilateral Tai-yang (EX-HN5), and bilateral Fengchi (GB20) and tongue triple acupuncture, with an electroacupuncture apparatus for EX-HN1, bilateral GB20, and tongue triple acupuncture, for a needle retaining time of 30 minutes each time, once a day and 5 times a week, in addition to the treatment in the neurology treatment group. Each course of treatment was 3 weeks, and both groups were treated for 2 courses. Swallowing function assessment and cranial DTI were performed after treatment. After 6 weeks of treatment, both groups had a marked improvement in swallowing function, a significantly greater change in video fluoroscopic swallowing study (VFSS) score and a higher mean FA value (P<0.05). Compared with the neurology treatment group, the Liyan Tongqiao acupuncture group had a marked improvement in swallowing function, a significantly greater change in VFSS score in the pharyngeal phase and a higher mean FA value (P<0.05). Liyan Tongqiao acupuncture can improve dysphagia and swallowing function in the pharyngeal phase in VFSS, possibly by promoting the remodeling of cerebral cortex and increasing the FA value of infarct zone through the stimulation of related acupoint signals.