1
|
Sasegbon A, Cheng I, Hamdy S. The neurorehabilitation of post-stroke dysphagia: Physiology and pathophysiology. J Physiol 2024. [PMID: 38517302 DOI: 10.1113/jp285564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 02/29/2024] [Indexed: 03/23/2024] Open
Abstract
Swallowing is a complex process involving the precise contractions of numerous muscles of the head and neck, which act to process and shepherd ingested material from the oral cavity to its eventual destination, the stomach. Over the past five decades, information from animal and human studies has laid bare the complex network of neurones in the brainstem, cortex and cerebellum that are responsible for orchestrating each normal swallow. Amidst this complexity, problems can and often do occur that result in dysphagia, defined as impaired or disordered swallowing. Dysphagia is common, arising from multiple varied disease processes that can affect any of the neuromuscular structures involved in swallowing. Post-stroke dysphagia (PSD) remains the most prevalent and most commonly studied form of dysphagia and, as such, provides an important disease model to assess dysphagia physiology and pathophysiology. In this review, we explore the complex neuroanatomical processes that occur during normal swallowing and PSD. This includes how strokes cause dysphagia, the mechanisms through which natural neuroplastic recovery occurs, current treatments for patients with persistent dysphagia and emerging neuromodulatory treatments.
Collapse
Affiliation(s)
- Ayodele Sasegbon
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Centre for Gastrointestinal Sciences, Faculty of Biology, Medicine and Health, Salford Royal Foundation Trust, University of Manchester, Manchester, UK
| | - Ivy Cheng
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Centre for Gastrointestinal Sciences, Faculty of Biology, Medicine and Health, Salford Royal Foundation Trust, University of Manchester, Manchester, UK
- Academic Unit of Human Communication, Learning, and Development, Faculty of Education, The University of Hong Kong, Hong Kong, China
- Institute for Biomagnetism and Biosignalanalysis, University of Münster, Münster, Germany
| | - Shaheen Hamdy
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Centre for Gastrointestinal Sciences, Faculty of Biology, Medicine and Health, Salford Royal Foundation Trust, University of Manchester, Manchester, UK
| |
Collapse
|
2
|
Prum G, Cadeau A, Mallart R, Verin E. Feeding modality evolution in traumatic brain injury patients with severe alteration of consciousness: A observational study. Medicine (Baltimore) 2023; 102:e33831. [PMID: 37653826 PMCID: PMC10470743 DOI: 10.1097/md.0000000000033831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/28/2023] [Accepted: 05/02/2023] [Indexed: 09/02/2023] Open
Abstract
The aim of this study was to compare feeding modalities and the level of consciousness in patients with a severe brain injury during reeducation and rehabilitation. The clinical data of vegetative state or minimal conscious state due to severe traumatic brain injury hospitalized in a coma arousal unit were collected from 2012 to 2019. Feeding modalities were evaluated clinically and with functional endoscopy evaluation of swallowing or video fluoroscopy and functional oral intake scale. Evolution of consciousness was evaluated using Wessex Head Injury Matrix scale (WHIM). Comparison between WHIM score and feeding modalities were performed at admission and at discharge of the arousal unit. Of the 93 patients considered, 33 were included corresponding to inclusion criteria (traumatic brain injury, disorder of consciousness and age > 18 years). The mean age was 44.8 ± 16.8 years, and there were 6 females for 27 males. At admission, all patients were fed by gastrostomy (n = 25) or by nasogastric tube (n = 8) and 27 had a tracheostomy. At discharge, 10 patients keep an exclusive alimentation by gastrostomy (Group 1, G1) as 23 had exclusive oral feeding (Group 2, G2). The score of the WHIM at admission was identical in both groups (21.7 ± 10.9 (G1) vs. 21.0 ± 15.33 (G2) (ns)). At discharge, WHIM increased to 38.3 ± 15.4 in G1 and to 49.8 ± 9.7 in G2 (P < .05). WHIM score was significantly higher in G2 than in G1 (P < .05). There was a positive correlation between functional oral intake scale and WHIM at discharge. Our results demonstrated that recovery of oral feeding in patients with a severe traumatic brain injury appeared in those who had the better improvement of consciousness level.
Collapse
Affiliation(s)
- Grégoire Prum
- Physical and Rehabilitation Medicine, Rouen University Hospital, Rouen, France
- Rouen Laboratory of Anatomy, Faculty of Medicine, Rouen Normandy University, Rouen, France
| | - Anna Cadeau
- Physical and Rehabilitation Medicine, Rouen University Hospital, Rouen, France
| | - Remi Mallart
- Physical and Rehabilitation Medicine, Rouen University Hospital, Rouen, France
| | - Eric Verin
- Physical and Rehabilitation Medicine, Rouen University Hospital, Rouen, France
- Rouen University Hospital, Rouen, France
- EA 3830, Research Group on Ventilatory Handicap, GRHV, Normandy University, Rouen, France
| |
Collapse
|
3
|
Cheng I, Takahashi K, Miller A, Hamdy S. Cerebral control of swallowing: An update on neurobehavioral evidence. J Neurol Sci 2022; 442:120434. [PMID: 36170765 DOI: 10.1016/j.jns.2022.120434] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 09/07/2022] [Accepted: 09/18/2022] [Indexed: 01/07/2023]
Abstract
This review aims to update the current knowledge on the cerebral control of swallowing. We review data from both animal and human studies spanning across the fields of neuroanatomy, neurophysiology and neuroimaging to evaluate advancements in our understanding in the brain's role in swallowing. Studies have collectively shown that swallowing is mediated by multiple distinct cortical and subcortical regions and that lesions to these regions can result in dysphagia. These regions are functionally connected in separate groups within and between the two hemispheres. While hemispheric dominance for swallowing has been reported in most human studies, the laterality is inconsistent across individuals. Moreover, there is a shift in activation location and laterality between swallowing preparation and execution, although such activation changes are less well-defined than that for limb motor control. Finally, we discussed recent neurostimulation treatments that may be beneficial for dysphagia after brain injury through promoting the reorganization of the swallowing neural network.
Collapse
Affiliation(s)
- Ivy Cheng
- Centre for Gastrointestinal Sciences, Division of Diabetes, Gastroenterology and Endocrinology, School of Medical Sciences, University of Manchester, UK.
| | - Kazutaka Takahashi
- Department of Organismal Biology and Anatomy, University of Chicago, USA
| | - Arthur Miller
- Division of Orthodontics, Department of Orofacial, Sciences, School of Dentistry, University of California at San Francisco, USA
| | - Shaheen Hamdy
- Centre for Gastrointestinal Sciences, Division of Diabetes, Gastroenterology and Endocrinology, School of Medical Sciences, University of Manchester, UK
| |
Collapse
|
4
|
Michou E, Hamdy S. Reversal of the effects of focal suppression on pharyngeal corticobulbar tracts by chemesthesis coupled with repeated swallowing. Neurogastroenterol Motil 2022; 34:e14286. [PMID: 34729879 DOI: 10.1111/nmo.14286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/27/2021] [Accepted: 10/12/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Previous reports suggested the potential benefit of chemesthesis in the form of carbonated water (CW) integrated within dysphagia rehabilitation protocols. Here, we examined the effects of CW within a repeated swallowing protocol following focal suppression to pharyngeal cortical representation as a prelude to its application in dysphagic patients. METHODS Fourteen healthy volunteers participated in a 3-arm study. Each participant underwent baseline corticobulbar pharyngeal and thenar motor-evoked potential (MEP) measurements with Transcranial Magnetic Stimulation (TMS). Subjects were then conditioned with 1Hz repetitive (r)TMS to induce focal unilateral suppression of the corticopharyngeal hotspot before randomization to each of three arms with 40 swallows of CW, non-CW and saliva swallowing on separate days. Corticobulbar and thenar MEPs were collected for up to 1 h and analyzed using repeated measures (rm)ANOVA. RESULTS A 2-way rmANOVA for Intervention x Time showed a significant effect of Intervention (F(1,13) = 7.519, p = 0.017) in both ipsi- and contra-lesional corticopharyngeal projections. Carbonation showed superiority in facilitating change by increasing pharyngeal cortical MEPs compared to non-CW (z = -3.05, p = 0.002) and saliva swallowing (z = -2.6, p = 0.008). No change in thenar representation (control) was observed nor in MEP latencies from both pharyngeal and thenar musculature. CONCLUSIONS We conclude that interventional paradigms with CW have the capacity to reverse the effects of a focal suppression with 1Hz rTMS more strongly than non-CW or saliva swallowing alone, producing site specific bi-hemispheric changes in corticopharyngeal excitability. Our data suggest that carbonation produces the effects through a mainly cortical mechanism.
Collapse
Affiliation(s)
- Emilia Michou
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, Clinical Sciences Building, Salford Royal Hospital, University of Manchester, Salford, UK.,Department of Speech and Language Therapy, School of Health Rehabilitation Sciences, University of Patras, Patras, Greece
| | - Shaheen Hamdy
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, Clinical Sciences Building, Salford Royal Hospital, University of Manchester, Salford, UK
| |
Collapse
|
5
|
Sasegbon A, Hammerbeck U, Michou E, Cheng I, Zhang M, James C, Hamdy S. A feasibility pilot study of the effects of neurostimulation on swallowing function in Parkinson’s Disease. AMRC OPEN RESEARCH 2022; 3:19. [PMID: 35726231 PMCID: PMC7612876 DOI: 10.12688/amrcopenres.13007.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Introduction Dysphagia often occurs during Parkinson’s disease (PD) and can have severe consequences. Recently, neuromodulatory techniques have been used to treat neurogenic dysphagia. Here we aimed to compare the neurophysiological and swallowing effects of three different types of neurostimulation, 5 Hertz (Hz) repetitive transcranial magnetic stimulation (rTMS), 1 Hz rTMS and pharyngeal electrical stimulation (PES) in patients with PD. Method 12 PD patients with dysphagia were randomised to receive either 5 Hz rTMS, 1 Hz rTMS, or PES. In a cross-over design, patients were assigned to one intervention and received both real and sham stimulation. Patients received a baseline videofluoroscopic (VFS) assessment of their swallowing, enabling penetration aspiration scores (PAS) to be calculated for: thin fluids, paste, solids and cup drinking. Swallowing timing measurements were also performed on thin fluid swallows only. They then had baseline recordings of motor evoked potentials (MEPs) from both pharyngeal and (as a control) abductor pollicis brevis (APB) cortical areas using single-pulse TMS. Subsequently, the intervention was administered and post interventional TMS recordings were taken at 0 and 30 minutes followed by a repeat VFS within 60 minutes of intervention. Results All interventions were well tolerated. Due to lower than expected recruitment, statistical analysis of the data was not undertaken. However, with respect to PAS swallowing timings and MEP amplitudes, there was small but visible difference in the outcomes between active and sham. Conclusion PES, 5 Hz rTMS and 1 Hz rTMS are tolerable interventions in PD related dysphagia. Due to small patient numbers no definitive conclusions could be drawn from the data with respect to individual interventions improving swallowing function and comparative effectiveness between interventions. Larger future studies are needed to further explore the efficacy of these neuromodulatory treatments in Parkinson’s Disease associated dysphagia.
Collapse
Affiliation(s)
- Ayodele Sasegbon
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, Greater Manchester, Stott Lane, Salford M6 8HD, UK
| | - Ulrike Hammerbeck
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, Greater Manchester, Stott Lane, Salford M6 8HD, UK
| | - Emilia Michou
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, Greater Manchester, Stott Lane, Salford M6 8HD, UK
- Department of Speech and Language Therapy, University of Patras, Patras, Greece
| | - Ivy Cheng
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, Greater Manchester, Stott Lane, Salford M6 8HD, UK
| | - Mengqing Zhang
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, Greater Manchester, Stott Lane, Salford M6 8HD, UK
| | - Charlotte James
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, Greater Manchester, Stott Lane, Salford M6 8HD, UK
| | - Shaheen Hamdy
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, Greater Manchester, Stott Lane, Salford M6 8HD, UK
| |
Collapse
|
6
|
The Effects of Midline Cerebellar rTMS on Human Pharyngeal Cortical Activity in the Intact Swallowing Motor System. THE CEREBELLUM 2020; 20:101-115. [PMID: 32979188 PMCID: PMC7862520 DOI: 10.1007/s12311-020-01191-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/09/2020] [Indexed: 12/25/2022]
Abstract
We sought to compare the effects of 10 Hz cerebellar vermis (vs. unilateral hemispheric and sham) repetitive transcranial magnetic stimulation (rTMS) on cortical neuroelectrical activity and thereafter 10 Hz cerebellar vermis (vs. sham) rTMS on swallowing behaviour. Healthy participants (n = 25) were randomly allocated to receive vermis, unilateral hemisphere or sham 10 Hz cerebellar rTMS. Recordings were made using pharyngeal electromyography and manometry catheters, obtaining motor-evoked potentials (MEPs) and pressure recordings. The amplitudes of MEPs elicited using single-pulse TMS delivered to the pharyngeal areas of the motor cortex bilaterally were measured pre- and post-cerebellar stimulation. As in previous studies, abductor policis brevis (APB) MEPs were measured to assess post-rTMS modulation specificity. Swallowing was assessed using a swallowing accuracy task. Measurements were made at baseline and 15-min intervals for an hour post-intervention. Measurements involved TMS being used to elicit 10 MEPs bilaterally over the pharyngeal areas of the motor cortex, over the APB cortical representation adjacent to the pharyngeal area with the lowest resting motor threshold and 5 MEPs bilaterally over pharyngeal areas of the cerebellar hemispheres. Swallowing accuracy was assessed by giving participants 10 attempts to swallow and hit a digital target. Cerebellar vermis rTMS caused significant suppression of cortical pharyngeal MEP amplitudes compared with unilateral rTMS and sham (P = 0.0005, 0.002). APB and cerebellar MEP amplitudes were unaffected as were pharyngeal and APB MEP latencies. Following cerebellar vermis rTMS there was a significant reduction in swallowing accuracy compared with sham (P = 0.001). Our findings demonstrate cerebellar vermis rTMS exerts a suppressive effect on pharyngeal motor cortical activity and swallowing behaviour.
Collapse
|
7
|
Sasegbon A, Cheng I, Zhang M, Hamdy S. Advances in the Use of Neuromodulation for Neurogenic Dysphagia: Mechanisms and Therapeutic Application of Pharyngeal Electrical Stimulation, Transcranial Magnetic Stimulation, and Transcranial Direct Current Stimulation. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2020; 29:1044-1064. [PMID: 32650660 DOI: 10.1044/2020_ajslp-19-00073] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Purpose The swallowing motor system and, specifically, its cortical substrates appear to have certain unique properties that make it highly susceptible to brain plasticity, both driven and following injury. Furthermore, neurogenic dysphagia is a common complication of brain disease, associated with poor outcomes, and yet treatment options remain limited. Therefore, translating the physiology of neurostimulation into clinical populations becomes imperative. In this review, we describe therapeutic application of neuroplasticity in the human swallowing motor system by initially examining the role of pharyngeal electrical stimulation from a mechanistic perspective and then reporting on clinical studies using this approach. Thereafter, we explore the application of noninvasive brain stimulation, which has previously been used to treat nervous system disorders such as depression, pain modulation, and cognitive impairment. Transcranial brain stimulations, in particular, transcranial magnetic stimulation and transcranial direct current stimulation, have been utilized by a number of investigators for rehabilitation in early-stage clinical trials, including dysphagia after neurological disease. In this review, we assess its usefulness in neurogenic dysphagia. Conclusion Early studies indicate these emerging neurostimulatory techniques hold future therapeutic promise. However, both a greater number of and larger clinical trials are required to provide evidence delineating their efficacy and scope of application.
Collapse
Affiliation(s)
- Ayodele Sasegbon
- Faculty of Biology, Medicine, and Health, University of Manchester, Salford, United Kingdom
| | - Ivy Cheng
- Faculty of Biology, Medicine, and Health, University of Manchester, Salford, United Kingdom
| | - Mengqing Zhang
- Faculty of Biology, Medicine, and Health, University of Manchester, Salford, United Kingdom
| | - Shaheen Hamdy
- Faculty of Biology, Medicine, and Health, University of Manchester, Salford, United Kingdom
| |
Collapse
|
8
|
Zhang G, Gao C, Ruan X, Liu Y, Li Y, Li E, Jiang L, Liu L, Chen X, Jiang X, Xu G, Lan Y, Wei X. Intermittent Theta-Burst Stimulation Over the Suprahyoid Muscles Motor Cortex Facilitates Increased Degree Centrality in Healthy Subjects. Front Hum Neurosci 2020; 14:200. [PMID: 32612517 PMCID: PMC7309184 DOI: 10.3389/fnhum.2020.00200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 05/05/2020] [Indexed: 11/21/2022] Open
Abstract
Theta-burst stimulation (TBS), a variant of repetitive transcranial magnetic stimulation (rTMS), can potentially benefit the treatment of swallowing disorders. However, the after-effects of TBS on the swallowing motor cortex remain uncertain. The newly developed graph-based analysis of the centrality approach has been increasingly used to explore brain networks. The purpose of this study was to identify degree centrality (DC) alterations in the brain network after different TBS protocols were performed over the suprahyoid muscles motor cortex in healthy subjects. A total of 40 right-handed healthy subjects (mean age: 23.73 ± 2.57 years, range: 21–30, 20 females) were included in this study and randomly assigned to two groups, including the continuous TBS (cTBS) group and the intermittent TBS (iTBS) group. All of the subjects underwent resting-state functional magnetic resonance imaging (rs-fMRI) scanning before and after TBS implementation. Compared to the baseline, cTBS resulted in increased DC values in the left inferior frontal gyrus (P < 0.01). In the iTBS group, decreased DC was observed in the left cerebellum and left medial frontal gyrus; However, increased DC was observed in several brain areas including the right superior temporal gyrus, right superior frontal gyrus, right postcentral gyri and left paracentral lobule (P < 0.01). These results indicated that cTBS mainly results in increasing DC in the ipsilateral. However, iTBS is capable of facilitating the excitability of the swallowing motor cortex and increasing the connectivity of multiple brain regions, including the bilateral sensorimotor network, and might have therapeutic potential in the treatment of swallowing disorders.
Collapse
Affiliation(s)
- Guoqin Zhang
- Department of Radiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Cuihua Gao
- Department of Radiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Xiuhang Ruan
- Department of Radiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Yanli Liu
- Department of Radiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Yuting Li
- The Second Affiliated Hospital, South China University of Technology, Guangzhou, China
| | - E Li
- Department of Radiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Lisheng Jiang
- Department of Rehabilitation Medicine, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Lingling Liu
- Department of Radiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Xin Chen
- Department of Radiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China.,The Second Affiliated Hospital, South China University of Technology, Guangzhou, China
| | - Xinqing Jiang
- Department of Radiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China.,The Second Affiliated Hospital, South China University of Technology, Guangzhou, China
| | - Guangqing Xu
- Department of Rehabilitation Medicine, Beijing Tiantan Hospital, The Capital Medical University, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yue Lan
- The Second Affiliated Hospital, South China University of Technology, Guangzhou, China.,Department of Rehabilitation Medicine, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Xinhua Wei
- Department of Radiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China.,The Second Affiliated Hospital, South China University of Technology, Guangzhou, China
| |
Collapse
|
9
|
Sasegbon A, Smith CJ, Bath P, Rothwell J, Hamdy S. The effects of unilateral and bilateral cerebellar rTMS on human pharyngeal motor cortical activity and swallowing behavior. Exp Brain Res 2020; 238:1719-1733. [PMID: 32232540 PMCID: PMC7413876 DOI: 10.1007/s00221-020-05787-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 03/16/2020] [Indexed: 11/16/2022]
Abstract
The cerebellum is recognised to bilaterally modulate sensorimotor function and has recently been shown to play a role in swallowing. Unilateral cerebellar repetitive trans-cranial magnetic stimulation (rTMS) excites corticobulbar motor pathways to the pharynx but the effects of bilateral versus unilateral cerebellar rTMS on these pathways are unknown. In this three-part cross-over study, healthy participants (n = 13) were randomly allocated to receive unilateral or bilateral 10 Hz cerebellar rTMS. Participants were intubated with pharyngeal electromyography and/or manometry catheters for motor evoked potentials (MEPs) and pressure recordings. In part 1 of the study, single pulse TMS was used to measure baseline motor cortical pharyngeal MEP (PMEP) and hemispheric cerebellar MEP (CMEP) amplitudes, before cerebellar rTMS was administered. Repeat measures of PMEP amplitude were performed at 15-min intervals for an hour post unilateral and bilateral rTMS. Thereafter, in two further studies, a cortical ‘virtual lesion’ (V/L) was applied prior to cerebellar rTMS with pre and post PMEPs (part 2) and measurements of swallowing accuracy (part 3) using a behavioural task. Compared to baseline, unilateral and bilateral cerebellar rTMS provoked increases in pharyngeal cortical excitation (P = 0.028, 0.0005, respectively). Bilateral rTMS was significantly more effective than unilateral in causing cortical excitation (P = 0.0005) and in reversing the suppressive neurological (P = 0.0005) and behavioural (P = 0.0005) effects of a cortical V/L. Our findings suggest bilateral cerebellar rTMS has greater facilitatory effects on corticobulbar motor pathways to the pharynx than unilateral stimulation with the potential to be a more effective clinical therapy if its effects are reproduced in populations with neurogenic dysphagia.
Collapse
Affiliation(s)
- Ayodele Sasegbon
- Gastrointestinal (GI) Sciences, Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Salford Royal Hospital (part of the Manchester Academic Health Sciences Center (MAHSC)), Clinical Sciences Building, Eccles Old Road, Salford, M6 8HD, UK
| | - Craig J Smith
- Division of Cardiovascular Sciences, Manchester Centre for Clinical Neurosciences, Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Salford Royal Hospital, Manchester Academic Health Sciences Centre (MAHSC), Salford, UK
| | - Philip Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - John Rothwell
- Sobell Department of Motor Neuroscience and Movement Disorders, University College London, London, UK
| | - Shaheen Hamdy
- Gastrointestinal (GI) Sciences, Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Salford Royal Hospital (part of the Manchester Academic Health Sciences Center (MAHSC)), Clinical Sciences Building, Eccles Old Road, Salford, M6 8HD, UK.
| |
Collapse
|
10
|
Li WQ, Lin T, Li X, Jing YH, Wu C, Li MN, Ding Q, Lan Y, Xu GQ. TMS brain mapping of the pharyngeal cortical representation in healthy subjects. Brain Stimul 2020; 13:891-899. [PMID: 32289722 DOI: 10.1016/j.brs.2020.02.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 02/25/2020] [Accepted: 02/28/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Brain mapping is fundamental to understanding brain organization and function. However, a major drawback to the traditional Brodmann parcellation technique is the reliance on the use of postmortem specimens. It has therefore historically been difficult to make any comparison regarding functional data from different regions or hemispheres within the same individual. Moreover, this method has been significant limited by subjective boundaries and classification criteria and therefore suffer from reproducibility issues. The development of transcranial magnetic stimulation (TMS) offers an alternative approach to brain mapping, specifically the motor cortical regions by eliciting quantifiable functional reactions. OBJECTIVE To precisely describe the motor cortical topographic representation of pharyngeal constrictor musculature using TMS and to further map the brain for use as a tool to study brain plasticity. METHODS 51 healthy subjects (20 male/31 female, 19-26 years old) were tested using single-pulse TMS combined with intraluminal catheter-guided high-resolution manometry and a standardized grid cap. We investigated various parameters of the motor-evoked potential (MEP) that include the motor map area, amplitude, latency, center of gravity (CoG) and asymmetry index. RESULTS Cortically evoked response latencies were similar for the left and right hemispheres at 6.79 ± 0.22 and 7.24 ± 0.27 ms, respectively. The average scalp positions (relative to the vertex) of the pharyngeal motor cortical representation were 10.40 ± 0.19 (SE) cm medio-lateral and 3.20 ± 0.20 (SE) cm antero-posterior in the left hemisphere and 9.65 ± 0.24 (SE) cm medio-lateral and 3.18 ± 0.23 (SE) cm antero-posterior in the right hemisphere. The mean motor map area of the pharynx in the left and right hemispheres were 9.22 ± 0.85(SE) cm2and 10.12 ± 1.24(SE) cm2, respectively. The amplitudes of the MEPs were 35.94 ± 1.81(SE)uV in the left hemisphere and 34.49 ± 1.95(SE)uV in the right hemisphere. By comparison, subtle but consistent differences in the degree of the bilateral hemispheric representation were also apparent both between and within individuals. CONCLUSION The swallowing musculature has a bilateral motor cortical representation across individuals, but is largely asymmetric within single subjects. These results suggest that TMS mapping using a guided intra-pharyngeal EMG catheter combined with a standardized gridded cap might be a useful tool to localize brain function/dysfunction by linking brain activation to the corresponding physical reaction.
Collapse
Affiliation(s)
- Wan-Qi Li
- Department of Rehabilitation Medicine, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Tuo Lin
- Department of Rehabilitation Medicine, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China.
| | - Xue Li
- Department of Rehabilitation Medicine, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China.
| | - Ying-Hua Jing
- Department of Rehabilitation Medicine, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Cheng Wu
- Department of Rehabilitation Medicine, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Meng-Ni Li
- Department of Rehabilitation Medicine, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Qian Ding
- Department of Rehabilitation Medicine, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Yue Lan
- Department of Rehabilitation Medicine, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China; Department of Rehabilitation Medicine, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China.
| | - Guang-Qing Xu
- Department of Rehabilitation Medicine, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China.
| |
Collapse
|
11
|
Papadopoulou SL, Ploumis A, Exarchakos G, Theodorou SJ, Beris A, Fotopoulos AD. Versatility of Repetitive Transcranial Magnetic Stimulation in the Treatment of Poststroke Dysphagia. J Neurosci Rural Pract 2019; 9:391-396. [PMID: 30069097 PMCID: PMC6050778 DOI: 10.4103/jnrp.jnrp_68_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Soultana L Papadopoulou
- Department of Orthopedic Surgery, University of Ioannina Medical School, University Hospital of Ioannina, Greece
| | - Avraam Ploumis
- Department of Physical Medicine and Rehabilitation, University of Ioannina Medical School, University Hospital of Ioannina, Greece
| | - G Exarchakos
- Department of Otorhinolaryngology, University of Ioannina Medical School, University Hospital of Ioannina, Greece
| | - S J Theodorou
- Department of Radiology, University of Ioannina Medical School, University Hospital of Ioannina, Greece
| | - A Beris
- Department of Orthopedic Surgery, University of Ioannina Medical School, University Hospital of Ioannina, Greece
| | - A D Fotopoulos
- Department of Nuclear Medicine, University of Ioannina Medical School, University Hospital of Ioannina, Greece
| |
Collapse
|
12
|
Raginis-Zborowska A, Cheng I, Pendleton N, Payton A, Ollier W, Michou E, Hamdy S. Genetic influences on the variability of response to repetitive transcranial magnetic stimulation in human pharyngeal motor cortex. Neurogastroenterol Motil 2019; 31:e13612. [PMID: 31033149 DOI: 10.1111/nmo.13612] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/04/2019] [Accepted: 04/15/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recent studies have reported substantial variability in response to repetitive transcranial magnetic stimulation (rTMS). We hypothesized that an individual's genetic predisposition may contribute to such variability in the pharyngeal motor cortex. This study aimed to investigate the response to 1 and 5 Hz rTMS paradigms on pharyngeal motor cortex in healthy participants and its relationship with genetic predisposition. METHODS Forty-one healthy participants (25.4 ± 4.6 years old) received either or both 1 Hz (n = 39) and 5 Hz rTMS (n = 40) over pharyngeal motor cortex. Pharyngeal and thenar motor-evoked potentials were recorded at baseline and for 1 hour post-rTMS. The participants were then classified according to their response. The associations between rTMS response and gender, time of day of the stimulation, and eight prespecified single nucleotide polymorphisms (SNPs) were analyzed. KEY RESULTS There was no direction-specific response to either paradigm (1 Hz: F[3.69, 129.21] = 0.78, P = 0.56; 5 Hz: F[4.08, 146.85] = 1.38, P = 0.25). Only 13% of participants showed the expected bidirectional response (inhibition for 1 Hz and excitation for 5 Hz). Significant associations were found between response and COMT (1 Hz: P = 0.03) and DRD2 (1 Hz: P = 0.02; 5 Hz: P = 0.04) polymorphisms. Carriers of minor allele G from SNP rs6269 (COMT) were more likely to show inhibitory or excitatory outcomes after 1 Hz rTMS. By contrast, carriers of minor allele A from SNP rs1800497 (DRD2) were more likely to show no response to 1 Hz rTMS and inhibition after 5 Hz rTMS. CONCLUSIONS & INFERENCES Two SNPs from COMT and DRD2 genes may partially explain the response variability to rTMS in the pharyngeal motor system. Further research should focus on stratified approaches for neurostimulatory dysphagia treatment using rTMS.
Collapse
Affiliation(s)
- Alicja Raginis-Zborowska
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, Centre for Gastrointestinal Sciences, School of Medical Sciences, The University of Manchester, Manchester, UK
| | - Ivy Cheng
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, Centre for Gastrointestinal Sciences, School of Medical Sciences, The University of Manchester, Manchester, UK
| | - Neil Pendleton
- Division of Neuroscience and Experimental Psychology, Faculty of Biology, Medicine and Health, School of Medical Sciences, The University of Manchester, Manchester, UK
| | - Antony Payton
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, The University of Manchester, Manchester, UK
| | - William Ollier
- School of Health Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK
| | - Emilia Michou
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, Centre for Gastrointestinal Sciences, School of Medical Sciences, The University of Manchester, Manchester, UK.,Department of Speech and Language Therapy, Western Greece University of Applied Sciences, Patras, Greece
| | - Shaheen Hamdy
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, Centre for Gastrointestinal Sciences, School of Medical Sciences, The University of Manchester, Manchester, UK
| |
Collapse
|
13
|
Factors Influencing Oral Intake Improvement and Feeding Tube Dependency in Patients with Poststroke Dysphagia. J Stroke Cerebrovasc Dis 2019; 28:1421-1430. [PMID: 30962081 DOI: 10.1016/j.jstrokecerebrovasdis.2019.03.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/05/2019] [Accepted: 03/07/2019] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE To assess ischemic stroke patients regarding the relationship between lesion locations, swallowing impairment, medical and demographic factors and (1) oral intake improvement and (2) feeding tube dependency at discharge from their acute hospital stay. METHODS We conducted an exploratory, retrospective observational longitudinal cohort study of acute, first-ever, ischemic stroke patients. Patients who had an initial nonoral feeding recommendation from a speech and language pathologist and who underwent a modified barium swallow study within their hospital stay were included. Oral intake status was measured with the Functional Oral Intake Scale (FOIS) as the change in FOIS during the hospital stay and as feeding tube dependency at hospital discharge. Associations were assessed with multiple linear regression modeling controlling for age, comorbidities, and hospital length of stay. RESULTS We included 44 stroke patients. At hospital discharge, 93% of patients had oral intake restrictions and 30% were feeding tube dependent. Following multiple linear regression modeling, age, damage to the left superior frontal gyrus, dorsal anterior cingulate gyrus, hypothalamus, and nucleus accumbens were significant predictors for FOIS change. Feeding tube dependency showed no significant associations with any prognostic variables when controlling for confounders. CONCLUSIONS The vast majority of patients with an initial nonoral feeding recommendation are discharged with oral intake restrictions indicating a continued need for swallowing assessments and treatment after discharge. Lesion locations associated with motivation, reward, and drive to consume food as well as swallowing impairment, higher age, and more comorbidities were related to less oral intake improvement.
Collapse
|
14
|
Sasegbon A, Watanabe M, Simons A, Michou E, Vasant DH, Magara J, Bath PM, Rothwell J, Inoue M, Hamdy S. Cerebellar repetitive transcranial magnetic stimulation restores pharyngeal brain activity and swallowing behaviour after disruption by a cortical virtual lesion. J Physiol 2019; 597:2533-2546. [PMID: 30907429 PMCID: PMC6487931 DOI: 10.1113/jp277545] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 03/21/2019] [Indexed: 01/14/2023] Open
Abstract
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.
Abstract 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. 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.
Collapse
Affiliation(s)
- Ayodele Sasegbon
- Gastrointestinal (GI) Sciences, Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, University of Manchester, Salford Royal Hospital (part of the Manchester Academic Health Sciences Center (MAHSC)), Salford, UK
| | - Masahiro Watanabe
- Gastrointestinal (GI) Sciences, Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, University of Manchester, Salford Royal Hospital (part of the Manchester Academic Health Sciences Center (MAHSC)), Salford, UK.,Division of Dysphagia Rehabilitation, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Andre Simons
- Gastrointestinal (GI) Sciences, Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, University of Manchester, Salford Royal Hospital (part of the Manchester Academic Health Sciences Center (MAHSC)), Salford, UK
| | - Emilia Michou
- Gastrointestinal (GI) Sciences, Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, University of Manchester, Salford Royal Hospital (part of the Manchester Academic Health Sciences Center (MAHSC)), Salford, UK.,Department of Speech and Language Therapy, Technological Educational Institute of Western Greece, Patras, Greece
| | - Dipesh H Vasant
- Gastrointestinal (GI) Sciences, Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, University of Manchester, Salford Royal Hospital (part of the Manchester Academic Health Sciences Center (MAHSC)), Salford, UK.,Manchester University Foundation Trust, Neurogastroenterology, Wythenshawe Hospital, Manchester, UK
| | - Jin Magara
- Division of Dysphagia Rehabilitation, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Philip M Bath
- Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - John Rothwell
- Sobell Department of Motor Neuroscience and Movement Disorders, University College London, London, UK
| | - Makoto Inoue
- Division of Dysphagia Rehabilitation, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Shaheen Hamdy
- Gastrointestinal (GI) Sciences, Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, University of Manchester, Salford Royal Hospital (part of the Manchester Academic Health Sciences Center (MAHSC)), Salford, UK
| |
Collapse
|
15
|
Direct and Indirect Therapy: Neurostimulation for the Treatment of Dysphagia After Stroke. Dysphagia 2018. [DOI: 10.1007/174_2017_147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
16
|
Sasegbon A, Hamdy S. The anatomy and physiology of normal and abnormal swallowing in oropharyngeal dysphagia. Neurogastroenterol Motil 2017; 29. [PMID: 28547793 DOI: 10.1111/nmo.13100] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 04/05/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Eating and drinking are enjoyable activities that positively impact on an individual's quality of life. The ability to swallow food and fluid is integral to the process of eating. Swallowing occupies a dual role being both part of the enjoyment of eating and being a critically important utilitarian activity to enable adequate nutrition and hydration. Any impairment to the process of swallowing can negatively affect a person's perception of their quality of life. The process of swallowing is highly complex and involves muscles in the mouth, pharynx, larynx, and esophagus. The oropharynx is the anatomical region encompassing the oral cavity and the pharynx. Food must be masticated, formed into a bolus and transported to the pharynx by the tongue whereas fluids are usually held within the mouth before being transported ab-orally. The bolus must then be transported through the pharynx to the esophagus without any matter entering the larynx. The muscles needed for all these steps are coordinated by swallowing centers within the brainstem which are supplied with sensory information by afferent nerve fibers from several cranial nerves. The swallowing centers also receive modulatory input from higher centers within the brain. Hence, a swallow has both voluntary and involuntary physiologic components and the term dysphagia is given to difficult swallowing while oropharyngeal dysphagia is difficult swallowing due to pathology within the oropharynx. PURPOSE Problems affecting any point along the complex swallowing pathway can result in dysphagia. This review focuses on the anatomy and physiology behind normal and abnormal oropharyngeal swallowing. It also details the common diseases and pathology causing oropharyngeal dysphagia.
Collapse
Affiliation(s)
- A Sasegbon
- Gastrointestinal (GI) Sciences, Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, University of Manchester, Salford Royal Hospital (part of the Manchester Academic Health Sciences Centre (MAHSC)), Salford, UK
| | - S Hamdy
- Gastrointestinal (GI) Sciences, Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, University of Manchester, Salford Royal Hospital (part of the Manchester Academic Health Sciences Centre (MAHSC)), Salford, UK
| |
Collapse
|
17
|
May NH, Pisegna JM, Marchina S, Langmore SE, Kumar S, Pearson WG. Pharyngeal Swallowing Mechanics Secondary to Hemispheric Stroke. J Stroke Cerebrovasc Dis 2017; 26:952-961. [PMID: 27913200 PMCID: PMC5409864 DOI: 10.1016/j.jstrokecerebrovasdis.2016.11.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 10/21/2016] [Accepted: 11/02/2016] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Computational analysis of swallowing mechanics (CASM) is a method that utilizes multivariate shape change analysis to uncover covariant elements of pharyngeal swallowing mechanics associated with impairment using videofluoroscopic swallowing studies. The goals of this preliminary study were to (1) characterize swallowing mechanics underlying stroke-related dysphagia, (2) decipher the impact of left and right hemispheric strokes on pharyngeal swallowing mechanics, and (3) determine pharyngeal swallowing mechanics associated with penetration-aspiration status. METHODS Videofluoroscopic swallowing studies of 18 dysphagic patients with hemispheric infarcts and age- and gender-matched controls were selected from well-controlled data sets. Patient data including laterality and penetration-aspiration status were collected. Coordinates mapping muscle group action during swallowing were collected from videos. Multivariate morphometric analyses of coordinates associated with stroke, affected hemisphere, and penetration-aspiration status were performed. RESULTS Pharyngeal swallowing mechanics differed significantly in the following comparisons: stroke versus controls (D = 2.19, P < .0001), right hemispheric stroke versus controls (D = 3.64, P < .0001), left hemispheric stroke versus controls (D = 2.06, P < .0001), right hemispheric stroke versus left hemispheric stroke (D = 2.89, P < .0001), and penetration-aspiration versus within normal limits (D = 2.25, P < .0001). Differences in pharyngeal swallowing mechanics associated with each comparison were visualized using eigenvectors. CONCLUSIONS Whereas current literature focuses on timing changes in stroke-related dysphagia, these data suggest that mechanical changes are also functionally important. Pharyngeal swallowing mechanics differed by the affected hemisphere and the penetration-aspiration status. CASM can be used to identify patient-specific swallowing impairment associated with stroke injury that could help guide rehabilitation strategies to improve swallowing outcomes.
Collapse
Affiliation(s)
- Nelson H May
- Department of Cellular Biology and Anatomy, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Jessica M Pisegna
- Department of Speech, Language and Hearing Sciences, Boston University, Boston, Massachusetts
| | - Sarah Marchina
- Department of Neurology, Stroke Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Susan E Langmore
- Department of Speech, Language and Hearing Sciences, Boston University, Boston, Massachusetts
| | - Sandeep Kumar
- Department of Neurology, Stroke Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - William G Pearson
- Department of Cellular Biology and Anatomy, Medical College of Georgia, Augusta University, Augusta, Georgia.
| |
Collapse
|
18
|
Al-Toubi A, Daniels SK, Huckabee ML, Corey DM, Doeltgen SH. Behavioural and neurophysiological disruption of corticobulbar motor systems and their effects on sequential pharyngeal swallowing. Physiol Behav 2016; 165:69-76. [PMID: 27378508 DOI: 10.1016/j.physbeh.2016.06.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 05/04/2016] [Accepted: 06/30/2016] [Indexed: 11/24/2022]
Abstract
Primary motor networks are known to be involved in the control of voluntary oral movements as well as the modulation of pharyngeal movements during experimentally controlled single swallows performed on command. The role of these networks in the more typical task of sequential swallowing remains unexplored. This study evaluated the hypothesis that experimental disruption of motor cortical activation would reduce the rate and regularity of repeatedly performed volitional or volitionally initiated motor tasks controlled by corticospinal (finger tapping) and corticobulbar (eyebrow movement, jaw opening, volitional sequential swallowing) motor systems, but would not influence a more reflexive corticobulbar task (reflexive sequential swallowing to pharyngeal water infusion). This premise was investigated in 24 healthy participants using two techniques: a dual task paradigm and a transcranial magnetic stimulation paradigm. Disruption effects were quantified by changes in rate and regularity of performance for each tested motor task. In summary, volitional motor tasks controlled by corticospinal motor networks (finger tapping) are more susceptible to behavioural and neurophysiological disruption than tasks controlled by cortiobulbar motor networks containing a reflexive component (both volitional and experimentally initiated consecutive swallowing). Purely volitional motor tasks controlled by the corticobulbar motor system (eyebrow raising or jaw opening) were affected in similar ways as the volitional corticospinal motor tasks. In summary, tasks involving sequential pharyngeal swallowing - whether volitionally or experimentally initiated - are largely robust against disruption of primary cortical motor networks, supporting a key role of medullary CPGs in the motor control of sequential pharyngeal swallowing.
Collapse
Affiliation(s)
- Aamir Al-Toubi
- New Zealand Brain Research Institute, 66 Stewart Street, Christchurch 8011, New Zealand; Speech and Language Pathology Clinic, Department of Rehabilitation, The Royal Hospital, Muscat, Oman
| | - Stephanie K Daniels
- Department of Communication Sciences and Disorders, University of Houston, 4455 Cullen Blvd Rm 100, Houston, TX, 77204-6018, United States; Research Service, Michael E. DeBakey VA Medical Center, Houston, TX, 2002 Holcombe Blvd, Houston, TX 7703, United States
| | - Maggie-Lee Huckabee
- New Zealand Brain Research Institute, 66 Stewart Street, Christchurch 8011, New Zealand; Department of Communication Disorders, The University of Canterbury, Christchurch NZ, Private Bag 4800, Christchurch 8140, New Zealand; Rose Centre for Stroke Recovery and Research, Christchurch NZ, Private Bag 4800, Christchurch 8140, New Zealand
| | - David M Corey
- Department of Psychology, Tulane University, New Orleans, LA, Department of Psychology, Tulane University 2007 Percival Stern Hall, New Orleans, LA 70118, United States
| | - Sebastian H Doeltgen
- Discipline of Speech Pathology, School of Health Sciences, Flinders University, Adelaide, Australia.
| |
Collapse
|
19
|
Cugy E, Leroi AM, Kerouac-Laplante J, Dehail P, Joseph PA, Gerardin E, Marie JP, Verin É. Effect of submental sensitive transcutaneous electrical stimulation on virtual lesions of the oropharyngeal cortex. Ann Phys Rehabil Med 2016; 59:94-9. [PMID: 26717886 DOI: 10.1016/j.rehab.2015.10.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 10/18/2015] [Accepted: 10/29/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aim of this study was to assess the effect of submental sensitive transcutaneous electrical stimulation (SSTES) on pharyngeal cortical representation after the creation of an oropharyngeal cortical virtual lesion in healthy subjects. METHODS Motor-evoked potential amplitude of the mylohyoid muscles was measured with transcranial magnetic stimulation (TMS), the oropharyngeal cortex was mapped by cartography, and videofluoroscopic parameters of swallowing function were measured before and after SSTES (at the end of SSTES [0 min] and at 30 and 60 min), after the creation of a cortical virtual lesion (repetitive TMS, 1 Hz, 20 min on the dominant swallowing hemisphere). RESULTS Nine subjects completed the study. After 20 min of SSTES, motor-evoked potential amplitude increased (P<0.05), as did swallow reaction time after repetitive TMS, as seen on videofluoroscopy, which was reversed after electrical stimulation. On cortical mapping, the number of points with a cortical response increased in the dominant lesioned hemisphere (P<0.05), remaining constant at 60 min (P<0.05). CONCLUSION SSTES may be effective for producing cortical plasticity for mylohyoid muscles and reverses oropharyngeal cortical inhibition in healthy subjects. It could be a simple non-invasive way to treat post-stroke dysphagia.
Collapse
Affiliation(s)
- Emmanuelle Cugy
- Service de MPR, centre hospitalier Arcachon, 33260 La Teste de Buch, France; Service de MPR, CHU de Bordeaux, 33076 Bordeaux, France; EA 4136, université de Bordeaux, 33000 Bordeaux, France
| | - Anne-Marie Leroi
- Service de physiologie, CHU de Rouen, 1, rue de Germont, 76031 Rouen cedex, France
| | | | - Patrick Dehail
- Service de MPR, CHU de Bordeaux, 33076 Bordeaux, France; EA 4136, université de Bordeaux, 33000 Bordeaux, France
| | - Pierre-Alain Joseph
- Service de MPR, CHU de Bordeaux, 33076 Bordeaux, France; EA 4136, université de Bordeaux, 33000 Bordeaux, France
| | | | - Jean-Paul Marie
- EA 3830, université de Rouen, 76000 Rouen, France; Service de chirurgie cervicofaciale, CHU de Rouen, 76031 Rouen, France
| | - Éric Verin
- Service de physiologie, CHU de Rouen, 1, rue de Germont, 76031 Rouen cedex, France; EA 3830, université de Rouen, 76000 Rouen, France; Pôle 3R, CHU de Rouen, 76031 Rouen, France.
| |
Collapse
|
20
|
Chen YW, Chang KH, Chen HC, Liang WM, Wang YH, Lin YN. The effects of surface neuromuscular electrical stimulation on post-stroke dysphagia: a systemic review and meta-analysis. Clin Rehabil 2016; 30:24-35. [PMID: 25697453 DOI: 10.1177/0269215515571681] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 01/14/2015] [Indexed: 11/02/2023]
Abstract
OBJECTIVE In this study, we intended to evaluate whether swallow treatment with neuromuscular electrical stimulation is superior to that without neuromuscular electrical stimulation, and whether neuromuscular electrical stimulation alone is superior to swallow therapy. METHODS We searched the PubMed and Scopus databases from their earliest record to 31 December 2014 for randomized and quasi-randomized controlled trials that used neuromuscular electrical stimulation to treat post-stroke dysphagia. The Jadad scale was used to assess the quality of the included studies. We extracted the mean differences and standard deviation (SD) between baseline and posttreatment or posttreatment mean and SD for selected outcomes measured in the experimental and control groups for subsequent meta-analyses. RESULTS Eight studies were identified. For the comparison "swallow treatment with neuromuscular electrical stimulation vs. swallow treatment without neuromuscular electrical stimulation," we found a significant standardized mean difference (SMD) of 1.27 (95% confidence interval (CI) = 0.51-2.02, P = 0.001) with significant heterogeneity (I(2) = 85%). The meta-analysis for the comparison of neuromuscular electrical stimulation alone and swallow therapy demonstrated a non-significant SMD of 0.25 (95% CI = -0.16-0.65, P = 0.23) without significant heterogeneity (I(2) = 16%). CONCLUSION Swallow treatment with neuromuscular electrical stimulation seems to be more effective than that without neuromuscular electrical stimulation for post-stroke dysphagia in the short term considering the limited number of studies available. Evidence was insufficient to indicate that neuromuscular electrical stimulation alone was superior to swallow therapy.
Collapse
Affiliation(s)
- Yi-Wen Chen
- Department of Physical Medicine and Rehabilitation, Wan Fang Hospital, Taipei Medical University, Taipai, Taiwan
| | - Kwang-Hwa Chang
- Department of Physical Medicine and Rehabilitation, Wan Fang Hospital, Taipei Medical University, Taipai, Taiwan Institute of Injury Prevention and Control, Taipei Medical University, Taipai, Taiwan
| | - Hung-Chou Chen
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Wen-Miin Liang
- Biostatistics Center, China Medical University, Taichung, Taiwan
| | - Ya-Hui Wang
- Department of Physical Medicine and Rehabilitation, Wan Fang Hospital, Taipei Medical University, Taipai, Taiwan
| | - Yen-Nung Lin
- Department of Physical Medicine and Rehabilitation, Wan Fang Hospital, Taipei Medical University, Taipai, Taiwan Institute of Injury Prevention and Control, Taipei Medical University, Taipai, Taiwan
| |
Collapse
|
21
|
Momosaki R, Abo M, Watanabe S, Kakuda W, Yamada N, Kinoshita S. Repetitive Peripheral Magnetic Stimulation With Intensive Swallowing Rehabilitation for Poststroke Dysphagia: An Open-Label Case Series. Neuromodulation 2015; 18:630-4; discussion 634-5. [PMID: 25950817 DOI: 10.1111/ner.12308] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 03/04/2015] [Accepted: 04/01/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The purpose of this pilot study was to determine the safety and feasibility of a six-day protocol of in-hospital repetitive peripheral magnetic stimulation combined with intensive swallowing rehabilitation (rPMS-ISR) for poststroke dysphagia. METHODS The subjects were eight patients with dysphagia caused by bilateral cerebral infarction (age: 62-70; time from onset of stroke: 27-39 months). rPMS was applied to the suprahyoid muscles, at strength set at 90% of the minimal intensity that elicited pain with a parabolic coil. One train of stimuli comprised 20 Hz for 3 sec followed by 27-sec rest. A single session included delivery of repetitive 20 trains of stimuli over 10 min, followed by 20 min of swallowing rehabilitation. Each patient received this combination treatment twice daily, morning and afternoon, over six consecutive days. Swallowing function was evaluated before and after intervention. RESULTS rPMS-ISR induced significant improvement in swallowing ability, laryngeal elevation delay time, penetration aspiration scale, and swallowing quality of life (p < 0.01), but had no significant effect on the functional oral intake scale. CONCLUSION The six-day in-hospital RPMS-ISR protocol seems safe and feasible for poststroke patients with dysphagia. The combination protocol improved swallowing function. Further larger studies are needed to confirm its efficacy.
Collapse
Affiliation(s)
- Ryo Momosaki
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Minato-Ku, Tokyo, Japan
| | - Masahiro Abo
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Minato-Ku, Tokyo, Japan
| | - Shu Watanabe
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Minato-Ku, Tokyo, Japan
| | - Wataru Kakuda
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Minato-Ku, Tokyo, Japan
| | - Naoki Yamada
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Minato-Ku, Tokyo, Japan
| | - Shoji Kinoshita
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Minato-Ku, Tokyo, Japan
| |
Collapse
|
22
|
Doeltgen SH, Bradnam LV, Young JA, Fong E. Transcranial non-invasive brain stimulation in swallowing rehabilitation following stroke — A review of the literature. Physiol Behav 2015; 143:1-9. [DOI: 10.1016/j.physbeh.2015.02.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 02/11/2015] [Accepted: 02/16/2015] [Indexed: 01/20/2023]
|
23
|
Macrae PR, Jones RD, Huckabee ML. The effect of swallowing treatments on corticobulbar excitability: a review of transcranial magnetic stimulation induced motor evoked potentials. J Neurosci Methods 2014; 233:89-98. [PMID: 24932964 DOI: 10.1016/j.jneumeth.2014.06.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 06/07/2014] [Accepted: 06/09/2014] [Indexed: 10/25/2022]
Abstract
Transcranial magnetic stimulation (TMS) has been used extensively as a method of investigating the corticomotor physiology of many motor tasks, including healthy and disordered swallowing. Changes in excitability of cortical projections to various swallowing muscles have been documented in response to treatments with TMS induced motor evoked potentials (MEPs). These studies have provided valuable insight into CNS response to swallowing impairment, and more importantly, the adaptations associated with functional recovery. However, unique obstacles are presented when investigating corticobulbar neurophysiology associated with the complex task of swallowing. Stringent methodological control and supplementary outcome measures are required to ensure robust and clinically applicable findings. This article offers a tutorial for the researcher who may be considering the use of TMS for investigating changes in cortical excitability associated with various swallowing paradigms. Included is a review of the mechanisms of TMS and what can be measured with this technique, a summary of existing research using MEPs to investigate swallowing, a review of methodological factors that may influence outcomes, and proposed directions for new areas of research.
Collapse
Affiliation(s)
- Phoebe R Macrae
- New Zealand Brain Research Institute, 66 Stewart Street, Christchurch, New Zealand; Department of Communication Disorders, University of Canterbury, Private Bag 4800, Christchurch, New Zealand.
| | - Richard D Jones
- New Zealand Brain Research Institute, 66 Stewart Street, Christchurch, New Zealand; Department of Communication Disorders, University of Canterbury, Private Bag 4800, Christchurch, New Zealand; Department of Medicine, University of Otago, Private Bag 4710, Christchurch, New Zealand; Department of Medical Physics and Bioengineering, Canterbury District Health Board, Private Bag 4710, Christchurch, New Zealand.
| | - Maggie-Lee Huckabee
- New Zealand Brain Research Institute, 66 Stewart Street, Christchurch, New Zealand; Department of Communication Disorders, University of Canterbury, Private Bag 4800, Christchurch, New Zealand.
| |
Collapse
|
24
|
Vasant DH, Mistry S, Michou E, Jefferson S, Rothwell JC, Hamdy S. Transcranial direct current stimulation reverses neurophysiological and behavioural effects of focal inhibition of human pharyngeal motor cortex on swallowing. J Physiol 2013; 592:695-709. [PMID: 24247983 PMCID: PMC3934709 DOI: 10.1113/jphysiol.2013.263475] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
The human cortical swallowing system exhibits bilateral but functionally asymmetric representation in health and disease as evidenced by both focal cortical inhibition (pre-conditioning with 1 Hz repetitive transcranial magnetic stimulation; rTMS) and unilateral stroke, where disruption of the stronger (dominant) pharyngeal projection alters swallowing neurophysiology and behaviour. Moreover, excitatory neurostimulation protocols capable of reversing the disruptive effects of focal cortical inhibition have demonstrated therapeutic promise in post-stroke dysphagia when applied contralaterally. In healthy participants (n = 15, 8 males, mean age (±SEM) 35 ± 9 years), optimal parameters of transcranial direct current stimulation (tDCS) (anodal, 1.5 mA, 10 min) were applied contralaterally after 1 Hz rTMS pre-conditioning to the strongest pharyngeal projection. Swallowing neurophysiology was assessed in both hemispheres by intraluminal recordings of pharyngeal motor-evoked responses (PMEPs) to single-pulse TMS as a measure of cortical excitability. Swallowing behaviour was examined using a pressure-based reaction time protocol. Measurements were made before and for up to 60 min post intervention. Subjects were randomised to active or sham tDCS after 1 Hz rTMS on separate days and data were compared using repeated measures ANOVA. Active tDCS increased PMEPs bilaterally (F1,14 = 7.4, P = 0.017) reversing the inhibitory effects of 1 Hz rTMS in the pre-conditioned hemisphere (F1,14 = 10.1, P = 0.007). Active tDCS also enhanced swallowing behaviour, increasing the number of correctly timed challenge swallows compared to sham (F1,14 = 6.3, P = 0.025). Thus, tDCS to the contralateral pharyngeal motor cortex reverses the neurophysiological and behavioural effects of focal cortical inhibition on swallowing in healthy individuals and has therapeutic potential for dysphagia rehabilitation.
Collapse
Affiliation(s)
- Dipesh H Vasant
- Gastrointestinal Centre, Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Salford Royal NHS Foundation Trust, Salford M6 8HD, UK.
| | | | | | | | | | | |
Collapse
|