Comparison of dysphagia outcomes between rostral and caudal lateral medullary infarct patients

Theta-burst transcranial magnetic stimulation for dysphagia patients during recovery stage of stroke: a randomized controlled trial

BACKGROUND

The Theta-burst Transcranial Magnetic Stimulation (TBS) is an emerging modality of Repetitive Transcranial Magnetic Stimulation (rTMS). However, the efficacy of TBS on post-stroke recovery-stage patients with dysphagia remains unclear.

AIM

To investigate the effect of intermittent theta burst stimulation (iTBS) and continuous theta burst stimulation (cTBS) in post-stroke dysphagia patients within the recovery stage.

DESIGN

Randomized controlled double blinded trial.

SETTING

Inpatient.

POPULATION

Ninety patients with dysphagia after stroke within 1 to 6 months.

METHODS

Patients were divided into the supratentorial group and the brainstem group, and both of groups were further divided into three subgroups, including the sham subgroups, the iTBS subgroups, and the cTBS subgroups. Each of subgroups received 30 min of traditional swallowing rehabilitation treatment every day for 4 weeks. In addition, the iTBS subgroups received iTBS over the cortex of the suprahyoid muscles on the affected hemisphere, the cTBS subgroups received cTBS on the unaffected hemisphere, and the sham subgroups received sham stimulation on unilateral hemisphere. Standardized swallowing assessment (SSA), Oral Motor Function Scale (OMFS) and fiberoptic endoscopic examination of swallowing (FEES) were assessed before and after treatments.

RESULTS

In the supratentorial group, compared with the sham and cTBS subgroups, the iTBS subgroups showed significant improvement in SSA, OMFS, vocal folds movement, laryngeal sensation, and Rosenbek Penetration-Aspiration Scale (PAS) (P<0.05). In the brainstem group, compared with the sham subgroup, the iTBS subgroup significantly improved SSA, OMFS, Yale Pharyngeal Residue Severity Rating Scale (YPR-SRS) and PAS (P<0.05), and the cTBS subgroup significantly improved SSA, YPR-SRS and PAS (P<0.05).

CONCLUSIONS

This study demonstrated that iTBS might be an effective stimulation pattern to improve the overall swallowing function whether in supratentorial stroke patients or brainstem stroke patients.

CLINICAL REHABILITATION IMPACT

iTBS seems to be a promising approach for rehabilitation of overall swallowing function in post-stroke patients.

Reliability and Validity of Non-Instrumental Clinical Assessments for Adults with Oropharyngeal Dysphagia: A Systematic Review

This systematic review on non-instrumental clinical assessment in adult oropharyngeal dysphagia (OD) provides an overview of published measures with reported reliability and validity. In alignment with PRISMA, four databases (CINAHL, Embase, PsycINFO, and PubMed) were searched, resulting in a total of 16 measures and 32 psychometric studies included. The included measures assessed any aspect of swallowing, consisted of at least one specific subscale relating to swallowing, were developed by clinical observation, targeted adults, and were developed in English. The included psychometric studies focused on adults, reported on measures for OD-related conditions, described non-instrumental clinical assessments, reported on validity or reliability, and were published in English. Methodological quality was assessed using the standard quality assessment QualSyst. Most measures targeted only restricted subdomains within the conceptual framework of non-instrumental clinical assessments. Across the 16 measures, hypothesis testing and reliability were the most reported psychometrics, whilst structural validity and content validity were the least reported. Overall, data on the reliability and validity of the included measures proved incomplete and frequently did not meet current psychometric standards. Future research should focus on the development of comprehensive non-instrumental clinical assessments for adults with OD using contemporary psychometric research methods.

Increased cortical-medulla functional connectivity is correlated with swallowing in dysphagia patients with subacute infratentorial stroke

Patients with infratentorial stroke (IS) exhibit more severe dysphagia and a higher risk of aspiration than patients with supratentorial stroke. Nevertheless, a large proportion of patients with IS regain swallowing function within 6 months; however, the neural mechanism for this recovery remains unclear. We aimed to investigate possible neuroplastic changes involved using functional magnetic resonance imaging (fMRI) and their relation to swallowing function. We assessed 21 patients with IS (mean age: 59.9 ± 11.1 years) exhibiting dysphagia in the subacute phase and 21 healthy controls (mean age: 57.1 ± 7.8 years). Patient evaluations were based on the functional oral intake scale (FOIS), videofluoroscopic swallow study (VFSS), and fMRI. Temporal swallowing measures and the penetration-aspiration scale (PAS) were obtained using VFSS. Whole-brain-medulla resting-state functional connectivity (rsFC) was calculated and compared between patients and healthy controls. The rsFCs were also correlated with functional measures within the patient group. In patients with IS, whole-brain-medulla rsFCs were significantly higher in the precuneus, the left and right precentral gyrus, and the right supplementary motor area compared to those in healthy controls (P < 0.001, family-wise error-corrected cluster-level P < 0.05). The rsFCs to the medulla for the left (r = -0.507, P = 0.027) and right side (r = -0.503, P = 0.028) precentral gyrus were negatively correlated with the PAS. The rsFC between the left (r = 0.470, P = 0.042) and right (r = 0.459, P = 0.048) precentral gyrus to the medulla was positively correlated with upper esophageal sphincter opening durations (UOD). In addition, PAS was also correlated with UOD (r = -0.638, P = 0.003) whereas the laryngeal closure duration was correlated with the hyoid bone movement duration (r = 0.550, P = 0.015). Patients with IS exhibited overall modulation of cortical-medulla connectivity during the subacute phase. Patients with higher connectivities showed better swallowing performance. These findings support that there is cortical involvement in swallowing regulation after IS and can aid in determining potential treatment targets for dysphagia.

Analysis of Factors That Influence the Prognosis of Swallowing Function Rehabilitation Therapy in Patients with Dysphagia After Medullary Infarction

PURPOSE

This study investigated the factors that influence the prognosis of swallowing function rehabilitation therapy in patients with dysphagia after medullary infarction.

PATIENTS AND METHODS

This retrospective study was conducted using the clinical data of 51 patients who were diagnosed with dysphagia after medullary infarction and hospitalized at our institution between January 2019 and January 2021. As per the water swallow test (WST) grade at 1 month after rehabilitation treatment, patients were classified into the good prognosis group and the poor prognosis group. Univariate analysis as well as univariate and multivariate logistic regression analysis were used to analyze factors that influence the prognosis of swallowing function rehabilitation therapy in patients with dysphagia after medullary infarction. Receiver operating characteristic (ROC) curves were then used to test the predictive ability of the significant parameters to predict the prognosis of the rehabilitation therapy in these patients.

RESULTS

Univariate analysis and univariate logistic regression analysis showed that previous stroke (odds ratio [OR] = 1.361), dysarthria (OR = 3.771), disease course (OR = 1.112), National Institutes of Health Stroke Scale (NIHSS) score at admission (OR = 2.596), and infarct site (OR = 11.071) were all significantly correlated with the prognosis of swallowing function rehabilitation therapy in patients with dysphagia after medullary infarction (P < 0.05). Multivariate logistic regression analysis showed that dysarthria (OR = 5.519, 95% confidence interval (CI) 1.413-21.566), infarct site (OR = 18.634, 95% CI 1.696-204.73), and the NIHSS score (OR = 1.001, 95% CI 1.536-4.820) were independent influencing factors of the prognosis of swallowing function rehabilitation therapy in these patients. The ROC curve showed that the area under the curve for the combined prediction of the three indicators was 0.943.

CONCLUSION

The NIHSS score, dysarthria, and infarct site are independent influencing factors for the prognosis of swallowing function rehabilitation therapy in patients with dysphagia after medullary infarction.

Videofluoroscopic Swallowing Study Findings Associated With Subsequent Pneumonia in Patients With Dysphagia Due to Frailty

Dysphagia in frailty or deconditioning without specific diagnosis that may cause dysphagia such as stroke, traumatic brain injury, or laryngeal pathology, has been reported in previous studies; however, little is known about which findings of the videofluoroscopic swallowing study (VFSS) are associated with subsequent pneumonia and how many patients actually develop subsequent pneumonia in this population. In this study, we followed 190 patients with dysphagia due to frailty or deconditioning without specific diagnosis that may cause dysphagia for 3 months after VFSS and analyzed VFSS findings for the risk of developing pneumonia. During the study period, the incidence of subsequent pneumonia was 24.74%; regarding the VFSS findings, (1) airway penetration (PAS 3) and aspiration (PAS 7 and 8) were associated with increased risk of developing pneumonia, and (2) the functional dysphagia scale (FDS) scores of the patients who developed subsequent pneumonia were higher than those of the patients who did not develop subsequent pneumonia. Our study findings might assist clinicians in making clinical decisions based on the VFSS findings in this population.

Dysphagia prognosis prediction via corticobulbar tract assessment in lateral medullary infarction: a diffusion tensor tractography study

We investigated the capacity for dysphagia prognosis prediction using diffusion tensor tractography (DTT) to assess the state of the corticobulbar tract (CBT) during the initial period following lateral medullary infarction (LMI). Twenty patients with LMI and 20 control subjects were recruited for this study. The patients were classified into two subgroups: subgroup A (16 patients with nasogastric tube required for six months or less after LMI onset) and subgroup B (4 patients with nasogastric tube required for more than six months after onset). DTT was used to reconstruct the CBTs of each patient and control subject, and the fractional anisotropy (FA) and tract volume (TV) measurements were obtained. In the affected hemisphere, the FA value of the CBT was significantly lower in subgroup B than in subgroup A and the control group (p < 0.05), with no significant difference between subgroup A and the control group. In the affected and unaffected hemispheres, the TV values of CBT in subgroups A and B were lower than those of the control group (p < 0.05), with no significant difference between subgroups A and B. In addition, among the four patients of subgroup B, reconstruction of the CBT was not possible in three patients, and the remaining patients exhibited on old lesion in the corona radiate involving descending pathway of the CBT in the affected hemisphere. We found that the injury severity of the CBT in the affected hemisphere appeared to be related to a poor dysphagia prognosis following LMI. Our results suggest that evaluation of the CBT state during the early post-LMI could be useful for dysphagia prognosis prediction.

Dysphagia in Lateral Medullary Syndrome: A Narrative Review

Dysphagia is a common clinical feature of lateral medullary syndrome (LMS) and is clinically relevant because it is related to aspiration pneumonia, malnutrition, increased mortality, and prolonged hospital stay. Herein, the pathophysiology, prognosis, and treatment of dysphagia in LMS are reviewed. The pathophysiology, prognosis, and treatment of dysphagia in LMS are closely interconnected. Although the pathophysiology of dysphagia in LMS has not been fully elucidated, previous studies have suggested that the medullary central pattern generators coordinate the pharyngeal phases of swallowing. Investigation of the extensive neural connections of the medulla oblongata is important in understanding the pathophysiologic mechanism of dysphagia in LMS. Previous studies have reported that most patients with dysphagia in LMS have a relatively good prognosis. However, some patients require tube feeding for several months, even years, due to severe dysphagia, and little has been reported about conditions associated with a poor prognosis of dysphagia in LMS. Concerning specific therapeutic modalities for dysphagia in LMS, in addition to general modalities used for dysphagia treatment in stroke patients, non-invasive modalities, including repetitive transcranial magnetic stimulation and transcranial direct current stimulation, as well as invasive modalities, such as botulinum toxin injection, balloon catheter dilatation, and myotomy for relaxation of the cricopharyngeal muscle, have been applied. For the appropriate application of therapeutic modalities, clinicians should be aware of the recovery mechanisms and prognosis of dysphagia in LMS. Further studies on this topic, as well as studies involving large numbers of subjects on specific therapeutic modalities, should be encouraged.

Factors Influencing Oral Intake Improvement and Feeding Tube Dependency in Patients with Poststroke Dysphagia

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.