Treatment Of Post-stroke Dysphagia Research Articles

Avoiding the Downward Spiral After Stroke: Early Identification and Treatment of Dysphagia

This paper reviews recent evidence concerning the epidemiology, evaluation, and treatment of post-stroke dysphagia. The large variability in dysphagia severity and outcomes after stroke warrant a comprehensive evaluation and treatment approach. Screening, bedside evaluation, and instrumental assessments should be systematically and consistently used based on clinical presentation and available resources. In addition to traditional methods of diet modification and implementation of strategies and exercises, the use of novel treatments such as biofeedback and noninvasive brain stimulation may be effective in treatment, though further research is warranted. Oral hygiene regimens may be instrumental in reducing the incidence of swallowing-related respiratory compromise in patients with dysphagia. Dysphagia after stroke is optimally assessed by timely and appropriately selected screening and evaluation. Treatment depends on pathophysiology, with more research needed to assess the effectiveness of interventions as a part of an individualized treatment plan.

Electroacupuncture for post-stroke dysphagia: A protocol for systematic review and meta-analysis of randomized controlled trials.

Background:Post-stroke dysphagia (PSD) requires effective treatment as it may cause aspiration pneumonia, dehydration, or malnutritution, which can increase the length of hospital stay as well as mortality. In the field of stroke, electroacupuncture (EA) has been widely used, and a number of clinical research papers have been published regarding its effects. This systematic review aims to evaluate the effectiveness of EA for the treatment of PSD.Methods:Randomized controlled trials evaluating the use of EA in PSD will be included in this meta-analysis. The following electronic databases will be searched from inception to July 31, 2020, using terms relating to EA and PSD: PubMed, the Cochrane Library, the Excerpta Medica Database, China National Knowledge Infrastructure, the Korean Medical Database, KoreaMed, the National Digital Science Library, and the Oriental Medicine Advanced Searching Integrated System. Two reviewers will independently search these databases, select studies for inclusion, and evaluate the quality of the studies. Methodological quality will be assessed using the Cochrane Handbook for Systematic Reviews of Interventions (version 6.0). The primary outcome will be the total effective rate; secondary outcomes will include results of other assessments of dysphagia such as the water drinking test scale and videofluoroscopic swallowing study. We will also investigate the number and severity of adverse events. The Cochrane Review Manager (RevMan) software (version 5.3.5) will be employed to assess bias risk, data integration risk, and meta-analysis risk. Mean difference and standardized mean difference will be used to represent continuous data, while risk ratios will be used for pooled binary data.Results:This study will provide a comprehensive review and evaluation of the available evidence regarding the efficacy and safety of EA as a treatment for PSD.Conclusion:This study will clarify whether EA could be an effective and safe treatment for PSD.

The effects of tongue pressure resistance feedback training on post-stroke dysphagia

Objective To explore the clinical utility of tongue pressure resistance feedback training in the treatment of post-stroke dysphagia. Methods Twenty stroke survivors with dysphagia were randomly divided into an experimental group and a control group. Both groups were given conventional swallowing rehabilitation training, while the experimental group was additionally provided with tongue pressure resistance feedback training. Before and after the treatment, MBSImp analysis and the Rosenbek penetration aspiration scale were used to quantify the control of the tongue, food delivery, oral residue, laryngeal elevation, hyoid bone movement, epiglottis turnover, larynx closure, vestibular larynx closure, pharyngal peristalsis and contraction, opening of the upper esophageal sphincter UES, contraction of the base of the tongue, pharyngeal residue and aspiration. Results No significant differences were observed between the two groups before the intervention. Afterward the average pharyngeal period and aspiration score of the experimental group had decreased significantly compared with the control group′s values. Conclusions Tongue pressure resistance feedback training is effective in improving pharyngeal swallowing and reducing the risk of aspiration after swallowing. Key words: Tongue pressure resistance feedback training; Stroke; Dysphagia

Exercise-based swallowing intervention (McNeill Dysphagia Therapy) with adjunctive NMES to treat dysphagia post-stroke: A double-blind placebo-controlled trial.

Dysphagia following stroke is prevalent; however, dysphagia treatment is often applied haphazardly and outcomes unclear. Neuromuscular electrical stimulation (NMES) has received increased attention as a treatment for post-stroke dysphagia; but application data remain conflicted. This study investigated effectiveness and safety of an exercise-based swallowing therapy (McNeill Dysphagia Therapy: MDTP) +NMES for dysphagia rehabilitation following stroke. Stroke patients (n=53, x̅ age: 66 [13.2], 47.2% male) with dysphagia admitted to sub-acute rehabilitation hospital were randomised to MDTP+NMES [NMES], MDTP+sham NMES [MDTP] or usual care [UC] swallowing therapy groups. Patients were treated for 1hour per day for 3weeks and monitored to 3months by a blinded evaluator. Outcomes included clinical swallowing ability, oral intake, weight, patient perception of swallow and occurrence of dysphagia-related complications. Post-treatment dysphagia severity and treatment response were significantly different between groups (P≤.0001). MDTP demonstrated greater positive change than either NMES or UC arms, including increase in oral intake (χ2 =5, P≤.022) and improved functional outcome by 3months post-stroke (RR=1.72, 1.04-2.84). Exploratory Cox regression revealed the MDTP group conferred the greatest benefit in time to "return to pre-stroke diet" of 4.317 [95% CI: 1.08- 17.2, P< .03]. Greater benefit (eg reduction in dysphagia severity, improved oral intake and earlier return to pre-stroke diet) resulted from a programme of MDTP alone vs NMES or UC.

An Exploration of the Application of Noninvasive Cerebellar Stimulation in the Neuro-rehabilitation of Dysphagia after Stroke (EXCITES) Protocol

Background: Poststroke dysphagia is common, associated with a poor outcome and has no definitive treatments. Repetitive transcranial magnetic stimulation (rTMS) targeting the cerebellum is a noninvasive technique requiring minimal physical or cognitive input from the patient, and has been shown to induce positive swallow-related brain changes in physiological studies as measured by increased cortical excitability. Aim: To explore in patients with acute/sub-acute poststroke dysphagia: (1) the feasibility and immediate effect; and (2) the optimal dose for long-term benefit, of cerebellar rTMS in patients with dysphagia in acute/sub-acute stroke. Methods: Two double-blind sham-controlled randomized phase II trials. Participants will be recruited from stroke units in Nottingham and Greater Manchester. Dysphagia will be confirmed via baseline videofluoroscopy (VFS). Participants will be blinded to treatment and receive cerebellar rTMS or sham stimulation: (1) single treatment of (10Hz, 250 pulse) in 24 participants; (2) daily for 3 days, twice-daily for 5 days, or twice-daily sham treatment for 5 days, in 48 participants. Results: The severity of dysphagia will be assessed with VFS, using the penetration aspiration scale (PAS) at: (1) 1-hour, (2) 2-weeks, post-treatment. Additional comparative measures will be taken from: (1) pharyngeal motor evoked potential (MEP) amplitudes, (2) the functional oral intake score and dysphagia severity rating scale. Conclusions: If these studies demonstrate feasibility and identify optimal dosing, further trials to assess the safety and efficacy of cerebellar rTMS as a treatment for poststroke dysphagia will be warranted.

Clinical observation of acupoint injection combined with nerve electrical stimulation in the treatment of post-stroke dysphagia

Clinical observation of acupoint injection combined with nerve electrical stimulation in the treatment of post-stroke dysphagia

Clinical Effects and Safety of Electroacupuncture for the Treatment of Poststroke Dysphagia: A Comprehensive Systematic Review and Meta‐Analysis

Objectives Electroacupuncture (EA), an extension of acupuncture, which is based on traditional acupuncture combined with modern electrotherapy, is commonly used for poststroke dysphagia (PSD) in clinical treatment and research. However, there is still a lack of sufficient evidence to recommend the routine use of EA for PSD. The aim of this study was to assess the efficacy and safety of EA in the treatment of PSD. Methods Randomized controlled trials (RCTs) evaluating the effects of EA on PSD were identified through a comprehensive literature search of the PubMed, Embase, Cochrane Library, Web of Science, Chinese National Knowledge Infrastructure, Chinese Biomedical Database, and VIP databases from their inception to July 2020. The quality assessment of the included trials was performed based on the guidance of the Cochrane Reviewers' Handbook, and meta-analysis (MA) was performed by using the RevMan 5.3 software. Results Sixteen trials were identified, and these included 1,216 patients with PSD. The results demonstrated that EA in combination with swallowing rehabilitation training (SRT) was significantly superior to SRT alone with regard to effective rate (OR 5.40, 95% CI [3.78, 7.72], P < 0.00001, water swallow test (WST) (MD −0.78, 95% CI [−1.07, −0.50], P < 0.00001), the video fluoroscopic swallowing study (VFSS) (MD 1.47, 95% CI [1.11, 1.84], P < 0.00001), the Ichiro Fujishima Rating Scale (IFRS) (MD 1.94, 95% CI [1.67, 2.22], P < 0.00001), and the incidence of aspiration pneumonia (IAP) (OR 0.20, 95% CI [0.06, 0.61], P=0.005). Conclusions The results showed that EA was better than the control treatment in terms of the effective rate, WST, VFSS, IFRS, and IAP of dysphagia after stroke. Strict evaluation standards and high-quality RCT designs are necessary for further exploration.

Professor LI Xiao-ning's experience for post-stroke dysphagia treated with penetrating-needling and swallowing technique of acupuncture

Professor LI Xiaoning's experience for post-stroke dysphagia treated with penetrating-needling and swallowing technique of acupuncture is summarized in this paper. The key pathogenesis of this disease is dysfunction of zangfu organs, impairment of the house of mental activity and dysfunction of meridian sinew. Innovatively, the anatomic structure related to swallowing is divided into three zones. Based on the distributions of heart, kidney and stomach meridians on the neck, three lines are determined. Hence, the theory of "three-zone and three-line" as well as the penetrating-needling and swallowing technique of acupuncture are put forward. In this paper, the theoretic evidences of penetrating-needling and swallowing technique of acupuncture, point selection and manipulation in treatment of post-stroke dysphagia are introduced.

Cerebellar repetitive transcranial magnetic stimulation restores pharyngeal brain activity and swallowing behaviour after disruption by a cortical virtual lesion.

Key points Despite evidence that the human cerebellum has an important role in swallowing neurophysiology, the effects of cerebellar stimulation on swallowing in the disrupted brain have not been explored.In this study, for the first time, the application of cerebellar neurostimulation is characterized in a human model of disrupted swallowing (using a cortical virtual lesion).It is demonstrated that cerebellar stimulation can reverse the suppressed activity in the cortical swallowing system and restore swallowing function in a challenging behavioural task, suggesting the findings may have important therapeutic implications. Repetitive transcranial magnetic stimulation (rTMS) can alter neuronal activity within the brain with therapeutic potential. Low frequency stimulation to the ‘dominant’ cortical swallowing projection induces a ‘virtual‐lesion’ transiently suppressing cortical excitability and disrupting swallowing behaviour. Here, we compared the ability of ipsi‐lesional, contra‐lesional and sham cerebellar rTMS to reverse the effects of a ‘virtual‐lesion’ in health. Two groups of healthy participants (n = 15/group) were intubated with pharyngeal catheters. Baseline pharyngeal motor evoked potentials (PMEPs) and swallowing performance (reaction task) were measured. Participants received 10 min of 1 Hz rTMS to the pharyngeal motor cortex which elicited the largest PMEPs to suppress cortical activity and disrupt swallowing behaviour. Over six visits, participants were randomized to receive 250 pulses of 10 Hz cerebellar rTMS to the ipsi‐lesional side, contra‐lesional side or sham while assessing PMEP amplitude or swallowing performance for an hour afterwards. Compared to sham, active cerebellar rTMS, whether administered ipsi‐lesionally (P = 0.011) or contra‐lesionally (P = 0.005), reversed the inhibitory effects of the cortical ‘virtual‐lesion’ on PMEPs and swallowing accuracy (ipsi‐lesional, P < 0.001, contra‐lesional, P < 0.001). Cerebellar rTMS was able to reverse the disruptive effects of a ‘virtual lesion’. These findings provide evidence for developing cerebellar rTMS into a treatment for post‐stroke dysphagia.

Versatility of Repetitive Transcranial Magnetic Stimulation in the Treatment of Poststroke Dysphagia.

Various techniques and courses of treatment have been researched, proposed, and implemented to evaluate and treat poststroke dysphagia (PSD) which is one of the main medical conditions affecting not only elderly people, as previously assumed, but also in recent years younger populations as well. The effectiveness of therapeutic methods depends mainly on the expertise of an interdisciplinary team of therapists, as well as on the timely application of the treatment. The present review discusses the therapeutic benefits of repetitive transcranial magnetic stimulation (rTMS) in patients suffering from PSD regardless of the location of the lesion. The use of rTMS directly manipulates cortical brain stimulation to restore neuroplasticity in the affected brain areas. This review presents a synopsis of the available literature on the patient along with a discussion on the effectiveness of rTMS as a safe and easy to use promising technique in the rehabilitation of dysphagic patients. Although the results from the studies so far have been largely positive in that direction, the question still remains whether larger scale and longitudinal studies will be able to corroborate the aspiring future of rTMS. Therefore, research questions to advance further investigation on the application and future of this technique are much in need.

The effectiveness of surface neuromuscular electrical stimulation for relieving post-stroke dysphagia: A meta-analysis of randomized and controlled trials

Objective To evaluate the effectiveness of swallowing training supplemented with neuromuscular electrical stimulation to provide a reference for clinical treatment and further study. Methods Reports of randomized and controlled trials of surface neuromuscular electrical stimulation in treating post-stroke dysphagia were sought in the Cochrane library, the PubMed and Embase databases, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and also in the ProQuest, PsycARTICLES, CBMdisc, China National Knowledge Infrastructure (CNKI), CQVIP database and Wanfang databases. All of the literature found was evaluated by 2 researchers according to predefined inclusion and exclusion criteria and the data were extracted and combined. Then meta-analysis was performed using version 5.3 of the RevMan software package. Results Eleven randomized and controlled trials involving 576 patients were included in the meta-analysis. Together, the data showed that swallowing training supplemented by neuromuscular electrical stimulation is significantly more effective than swallowing training alone in improving swallowing function. It reduces the risk of aspiration and improves quality of life. It does not, however, generally shorten the pharyngeal transmit time. Conclusions Swallowing training supplemented with neuromuscular electrical stimulation is a promising approach for treatment of post-stroke dysphagia and warrants further study. Key words: Dysphagia; Neuromuscular electrical stimulation; Swallowing training; Meta-analyses

Repetitive Transcranial Magnetic Stimulation for Post-stroke Dysphagia: a Meta-analysis

Background. Dysphagia is common among post-stroke patients, causing disability due to malnutrition and pneumonia. Repetitive transcranial magnetic stimulation (rTMS) is a novel treatment modality to address this complication. Objective. The study aimed to compare real versus sham rTMS in treating post-stroke dysphagia. Methods. PubMed, Ovid, ClinicalKey, Herdin, and Google Scholar databases were searched from their earliest record to 31 July 2015 for randomized controlled trials that used rTMS to treat post-stroke dysphagia. The Jadad scale was used to assess the quality of the studies. The weighted mean difference (WMD) between baseline and post-treatment mean for Penetration Aspiration Scores (PAS) measured in the experimental and control groups were extracted for subsequent meta-analyses. Results. Three studies were analyzed. The WMD in PAS score between rTMS and control using liquid bolus two weeks after treatment in two good quality studies was -1.14 (95% confidence interval (CI) = -1.80 – -0.48, P = 0.001, I2 = 0.0%), and after four weeks was -1.83 (CI = -3.22 – -0.44, P = 0.010, I2 = 0.0%). Conclusion. Treatment of post-stroke dysphagia with rTMS improved PAS on subgroup analyses of studies using liquid bolus after two weeks, and between real and sham treatment after four weeks.

Effectiveness and Safety of Acupuncture for Poststroke Dysphagia: Study Protocol for a Pragmatic Multicenter Nonrandomized Controlled Trial.

Background. Dysphagia is one of the most common complications of stroke. Acupuncture is widely employed to treat poststroke dysphagia in East Asia. No evidence is established to support such treatment approach. This proposed study aims to evaluate the effectiveness and safety of acupuncture for the treatment of poststroke dysphagia. Methods and Design. This is a multicenter, pragmatic, single-blinded, nonrandomized controlled clinical trial. A total of 140 eligible patients will be enrolled in the study. Subjects who are eligible in study but refuse to have acupuncture treatment will be put on the no-acupuncture control arm. Both groups of patients will receive standard routine care, while the patients of intervention group will receive add-on standardized acupuncture treatment. Each participant in intervention group will receive a total of 24 sessions of acupuncture treatment (three times per week). The primary outcome measure is the Royal Brisbane Hospital Outcome Measure for Swallowing (RBHOMS). Secondary outcome measures include functional oral intake scale, swallow quality-of-life questionnaire in Chinese version, BMI of the participant, and adverse events. All outcome measures will be assessed at baseline, at the end of acupuncture treatment (month 2), and at two months after treatment (month 4). Ethics and Dissemination. The ethics approval of clinical research study was granted by the Research Ethics Committee of both New Territories East and West Cluster of Hong Kong. Written informed consent will be obtained from all participants and the study will be undertaken according to the ICH-GCP Guidelines. Trial Registration. This trial is registered with chictr.org (registration number: ChiCTR-TRC-12002621 and registration date: 2012-10-26).

Transcranial direct current stimulation in post-stroke dysphagia: a systematic review of randomized controlled trials

Introduction: The aim of this research was to systematically review all the randomized controlled trials that have evaluated the effect of transcranial direct current stimulation (tDCS) on post-stroke dysphagia. Methods: Three electronic databases were searched for relevant articles that were uploaded from their inception to March 2015: PubMed, Cochrane Library (Cochrane Central Register of Controlled Trials), and Scopus. All data was that was related to the location of the cerebrovascular accident (CVA), the parameters of tDCS, post-stroke time to commencement of tDCS, the stimulated hemisphere, stimulation dose, any outcome measurements, and follow-up duration were extracted and assessed. Finally, a number of observations were generated through a qualitative synthesis of the extracted data.Result: Three eligible randomized controlled trials were included in the systematic review. All three trials reported that, in comparison to a placebo, tDCS had a statistically significant effect on post-stroke dysphagia.Discussion: The results of our systematic review suggest that tDCS may represent a promising novel treatment for post-stroke dysphagia. However, to date, little is known about the optimal parameters of tDCS for relieving post-stroke dysphagia. Further studies are warranted to refine this promising intervention by exploring the optimal parameters of tDCS.Conclusion: Since brainstem swallowing centers have bilateral cortical innervations, measures that enhance cortical input and sensorimotor control of brainstem swallowing may facilitate recovery from dysphagia.

Pharyngeal Electrical Stimulation for Treatment of Dysphagia in Subacute Stroke: A Randomized Controlled Trial.

Dysphagia is common after stroke, associated with increased death and dependency, and treatment options are limited. Pharyngeal electric stimulation (PES) is a novel treatment for poststroke dysphagia that has shown promise in 3 pilot randomized controlled trials. We randomly assigned 162 patients with a recent ischemic or hemorrhagic stroke and dysphagia, defined as a penetration aspiration score (PAS) of ≥3 on video fluoroscopy, to PES or sham treatment given on 3 consecutive days. The primary outcome was swallowing safety, assessed using the PAS, at 2 weeks. Secondary outcomes included dysphagia severity, function, quality of life, and serious adverse events at 6 and 12 weeks. In randomized patients, the mean age was 74 years, male 58%, ischemic stroke 89%, and PAS 4.8. The mean treatment current was 14.8 (7.9) mA and duration 9.9 (1.2) minutes per session. On the basis of previous data, 45 patients (58.4%) randomized to PES seemed to receive suboptimal stimulation. The PAS at 2 weeks, adjusted for baseline, did not differ between the randomized groups: PES 3.7 (2.0) versus sham 3.6 (1.9), P=0.60. Similarly, the secondary outcomes did not differ, including clinical swallowing and functional outcome. No serious adverse device-related events occurred. In patients with subacute stroke and dysphagia, PES was safe but did not improve dysphagia. Undertreatment of patients receiving PES may have contributed to the neutral result. URL: http://www.controlled-trials.com. Unique identifier: ISRCTN25681641.

Electrical pharyngeal stimulation for dysphagia treatment in tracheotomized stroke patients: a randomized controlled trial.

Treatment of post-stroke dysphagia is notoriously difficult with different neurostimulation strategies having been employed with a variable degree of success. Recently, electrical pharyngeal stimulation (EPS) has been shown to improve swallowing function and in particular decrease airway aspiration in acute stroke. We performed a randomized controlled trial to assess EPS effectiveness on swallowing function in severely dysphagic tracheotomized patients. All consecutive stroke patients successfully weaned from the respirator but with severe dysphagia precluding decannulation were screened for eligibility. Eligible patients were randomized to receive either EPS (N = 20) or sham stimulation (N = 10) over three consecutive days. Primary endpoint was ability to decannulate the patient. Swallowing function was assessed using fiberoptic endoscopy. Patients having received sham stimulation were offered EPS treatment during unblinded follow-up if required. Investigators were blinded to the patient's study group allocation. Both groups were well matched for age, stroke severity, and lesion location. Decannulation after study intervention was possible in 75% of patients of the treatment group and in 20% of patients of the sham group (p < 0.01). Secondary outcome parameters did not differ. No adverse events occurred. In this pilot study, EPS enhanced remission of dysphagia as assessed with fiberoptic endoscopic evaluation of swallowing (FEES), thereby enabling decannulation in 75% of patients.

Manifestations of stroke

The book is divided into two parts namely “Neurologic and Other Disorders” and “Topographic Syndromes”. The first section begins with the motor syndromes, the most common stroke clinical syndrome. The authors have elaborated the various motor manifestations in a simple way. The stroke sensory syndromes are dealt with in a concise manner. The chapter on eye movement abnormalities is very informative. However, inclusion of a few images showing the neuroanatomical pathway would have made it easy to understand. The chapter on visual dysfunctions deals with the visual symptoms in relation to the optic nerve pathway and also covers various visual phenomena. One of the important aspects of stroke clinical diagnosis is differentiating between anterior and posterior circulation strokes. The chapter on dizziness and vertigo explains the clinical clues in localising posterior circulation strokes in relation to the presence of dizziness and vertigo. The chapter “Impaired Consciousness”, covers the various types of disturbances in consciousness. Also, the coma like states which are important in the prediction of prognosis in stroke patients have been discussed. The chapter on language disorders in stroke is very simple and easy to understand. The common language dysfunctions in stroke are discussed well. The section on memory dysfunction is short and crisp. One of the intriguing aspects of stroke is right hemisphere syndromes. Although the symptomatologies of right hemisphere stroke have been enumerated, this section could have been organized better to improve readability. Vascular cognitive impairment (VCI) is an important post-stroke disability. Post-stroke dementia and cognitive impairment are covered well including the various criteria used for the diagnosis of VCI. One of the neglected disabilities is anxiety and depression after stroke. The chapter on mood disorders contains the risk factors for anxiety and depression after stroke. In addition, the authors have elaborated on the diagnosis and treatment of these conditions. Stroke disconnection syndromes such as apraxia, agnosia, etc, are described in detail. The common disconnection syndromes are also explained well. Autonomic dysfunctions in stroke are commonly seen. The salient autonomic syndromes that occur following stroke are highlighted along with explanation on the neuroanatomical correlates. Another common speech disorder which occurs in stroke is dysarthria/mutism which can vary according to the site of the lesion and this section also is well covered. The pathophysiology, diagnosis and treatment of post-stroke dysphagia are discussed in a comprehensive manner including the various tools used to evaluate dysphagia. Certain strokes can present with breathing difficulties. The physiology, pathophysiology and clinical syndromes of ventilatory disorders are dealt with methodically. The chapter on lacunar strokes describes the different types of lacunar syndromes and also focus on the pathogenesis and outcome in these patients. The second section of the book begins with a lucid chapter on arterial territories of the brain. Brain maps of various territories in the cerebrum, brainstem and cerebellum are included. The territories depict the neuroimaging sections in clinical practice. This section lays down the foundation for the remaining chapters of the book. All the chapters begin with basic anatomy, aetiology and then elaborate the clinical features. The chapters on thalamic, caudate and putaminal infarcts/haemorrhages are very informative. The pathophysiology of lobar haemorrhage including the mechanisms of raised intracranial tension is explained clearly. The chapter on subarachnoid and intraventricular haemorrhage gives an overview of the two important conditions. The large hemispheric infarction deals with the current concepts in pathophysiology and also about the recent surgical trials. There is some degree of repetition in the chapters on midbrain, pontine and medullary strokes. The presentations, aetiologies and prognosis of cerebellar strokes are appropriate. The strokes in the territories of vertebral, basilar and carotid arterial occlusions are described very well. Finally, the last last two chapters also discuss venous ischaemic and spinal cord syndromes. In the era of modern technology where less importance is given for bedside skills, this book will be a great asset to neurology residents, neurologists and stroke neurologists/physicians.

Treatment of post-stroke dysphagia by vitalstim therapy coupled with conventional swallowing training

To investigate the effects of VitalStim therapy coupled with conventional swallowing training on recovery of post-stroke dysphagia, a total of 120 patients with post-stroke dysphagia were randomly and evenly divided into three groups: conventional swallowing therapy group, VitalStim therapy group, and VitalStim therapy plus conventional swallowing therapy group. Prior to and after the treatment, signals of surface electromyography (sEMG) of swallowing muscles were detected, swallowing function was evaluated by using the Standardized Swallowing Assessment (SSA) and Videofluoroscopic Swallowing Study (VFSS) tests, and swallowing-related quality of life (SWAL-QOL) was evaluated using the SWAL-QOL questionnaire. There were significant differences in sEMG value, SSA, VFSS, and SWAL-QOL scores in each group between prior to and after treatment. After 4-week treatment, sEMG value, SSA, VFSS and SWAL-QOL scores were significantly greater in the VitalStim therapy plus conventional swallowing training group than in the conventional swallowing training group and VitalStim therapy group, but no significant difference existed between conventional swallowing therapy group and VitalStim therapy group. It was concluded that VitalStim therapy coupled with conventional swallowing training was conducive to recovery of post-stroke dysphagia.

Clinical study on puncturing Renying (ST 9) to treat poststroke dysphagia

Objective: To observe the clinical efficacy of puncturing Renying (ST 9) in the treatment of poststroke dysphagia. Methods: Sixty cases of poststroke dysphagia were randomized into two groups, a control group in which 30 cases were given rehabilitation training, and a treatment group in which 30 cases were treated by puncturing Renying (ST 9) and rehabilitation training, with a course of four weeks. Results: The total effective rate for dysphagia was higher in the treatment group than in the control group (P<0.05). Conclusion: Puncturing Renying (ST 9) is quite effective for poststroke dysphagia.

Treatment of post-stroke dysphagia with repetitive transcranial magnetic stimulation

Up to one-third of patients experience swallowing problems in the period immediately after a stroke. To investigate the therapeutic effect of repetitive transcranial magnetic stimulation (rTMS) on post-stroke dysphagia. Twenty-six patients with post-stroke dysphagia due to monohemispheric stroke were randomly allocated to receive real (n = 14) or sham (n = 12) rTMS of the affected motor cortex. Each patient received a total of 300 rTMS pulses at an intensity of 120% hand motor threshold for five consecutive days. Clinical ratings of dysphagia and motor disability were assessed before and immediately after the last session and then again after 1 and 2 months. The amplitude of the motor-evoked potential (MEP) evoked by single-pulse TMS was also assessed before and at 1 month in 16 of the patients. There were no significant differences between patients who received real rTMS and the sham group in age, hand grip strength, Barthel Index or degree of dysphagia at the baseline assessment. Real rTMS led to a significantly greater improvement compared with sham in dysphagia and motor disability that was maintained over 2 months of follow-up. This was accompanied by a significant increase in the amplitude of the oesophageal MEP evoked from either the stroke or non-stroke hemisphere. rTMS may be a useful adjunct to conventional therapy for dysphagia after stroke.