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Regnier A, Mélotte E, Aubinet C, Alnagger N, Fischer D, Lagier A, Thibaut A, Laureys S, Kaux JF, Gosseries O. Swallowing dysfunctions in patients with disorders of consciousness: Evidence from neuroimaging data, assessment, and management. NeuroRehabilitation 2024; 54:91-107. [PMID: 38217621 DOI: 10.3233/nre-230135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2024]
Abstract
Following severe brain injuries, a subset of patients may remain in an altered state of consciousness; most of these patients require artificial feeding. Currently, a functional oral phase and the presence of exclusive oral feeding may constitute signs of consciousness. Additionally, the presence of pharyngo-laryngeal secretions, saliva aspiration, cough reflex and tracheostomy are related to the level of consciousness. However, the link between swallowing and consciousness is yet to be fully understood. The primary aim of this review is to establish a comprehensive overview of the relationship between an individual's conscious behaviour and swallowing (reflexive and voluntary). Previous studies of brain activation during volitional and non-volitional swallowing tasks in healthy subjects are also reviewed. We demonstrate that the areas activated by voluntary swallowing tasks (primary sensorimotor, cingulate, insula, premotor, supplementary motor, cerebellum, and operculum) are not specific to deglutitive function but are shared with other motor tasks and brain networks involved in consciousness. This review also outlines suitable assessment and treatment methods for dysphagic patients with disorders of consciousness. Finally, we propose that markers of swallowing could contribute to the development of novel diagnostic guidelines for patients with disorders of consciousness.
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Affiliation(s)
- Amandine Regnier
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
- Department of Physical and Rehabilitation Medicine, University Hospital of Liège, Liège, Belgium
| | - Evelyne Mélotte
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
| | - Charlène Aubinet
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
- Psychology and Neuroscience of Cognition Research Unit, University of Liège, Liège, Belgium
| | - Naji Alnagger
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - David Fischer
- Department of Neurology, Division of Neurocritical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Aude Lagier
- Department of Otorhinolaryngology, University Hospital of Liège, Liège, Belgium
| | - Aurore Thibaut
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
- Joint International Research Unit on Consciousness, CERVO Brain Research Centre, CIUSS, Laval University, Québec, QC, Canada
| | - Jean-François Kaux
- Department of Physical and Rehabilitation Medicine, University Hospital of Liège, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
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Mélotte E, Maudoux A, Panda R, Kaux JF, Lagier A, Herr R, Belorgeot M, Laureys S, Gosseries O. Links Between Swallowing and Consciousness: A Narrative Review. Dysphagia 2023; 38:42-64. [PMID: 35773497 DOI: 10.1007/s00455-022-10452-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 12/06/2021] [Indexed: 01/27/2023]
Abstract
This literature review explores a wide range of themes addressing the links between swallowing and consciousness. Signs of consciousness are historically based on the principle of differentiating reflexive from volitional behaviors. We show that the sequencing of the components of swallowing falls on a continuum of voluntary to reflex behaviors and we describe several types of volitional and non-volitional swallowing tasks. The frequency, speed of initiation of the swallowing reflex, efficacy of the pharyngeal phase of swallowing and coordination between respiration and swallowing are influenced by the level of consciousness during non-pathological modifications of consciousness such as sleep and general anesthesia. In patients with severe brain injury, the level of consciousness is associated with several components related to swallowing, such as the possibility of extubation, risk of pneumonia, type of feeding or components directly related to swallowing such as oral or pharyngeal abnormalities. Based on our theoretical and empirical analysis, the efficacy of the oral phase and the ability to receive exclusive oral feeding seem to be the most robust signs of consciousness related to swallowing in patients with disorders of consciousness. Components of the pharyngeal phase (in terms of abilities of saliva management) and evoked cough may be influenced by consciousness, but further studies are necessary to determine if they constitute signs of consciousness as such or only cortically mediated behaviors. This review also highlights the critical lack of tools and techniques to assess and treat dysphagia in patients with disorders of consciousness.
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Affiliation(s)
- Evelyne Mélotte
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.
- Physical and Rehabilitation Medicine Department, University and University Hospital of Liège, Avenue de l'Hopital 1, 4000, Liège, Belgium.
- Centre du Cerveau², University Hospital of Liège, Liège, Belgium.
| | - Audrey Maudoux
- Sensation and Perception Research Group, GIGA, University and University Hospital of Liège, Liège, Belgium
- Otorhinolaryngology Head and Neck Surgery Department, Robert Debré University Hospital, APHP, Paris, France
| | - Rajanikant Panda
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
| | - Jean-François Kaux
- Physical and Rehabilitation Medicine Department, University and University Hospital of Liège, Avenue de l'Hopital 1, 4000, Liège, Belgium
| | - Aude Lagier
- Otorhinolaryngology Head and Neck Surgery Department, University Hospital of Liège, Liège, Belgium
| | - Roxanne Herr
- Department of Speech and Language Pathology, Faculty of Medicine, University of Strasbourg, Strasbourg, France
| | - Marion Belorgeot
- Physical and Rehabilitation Medicine Department, University Hospital of Nîmes, Nîmes, France
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau², University Hospital of Liège, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau², University Hospital of Liège, Liège, Belgium
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Mélotte E, Belorgeot M, Herr R, Simon J, Kaux JF, Laureys S, Sanz LRD, Lagier A, Morsomme D, Pellas F, Gosseries O. The Development and Validation of the SWADOC: A Study Protocol for a Multicenter Prospective Cohort Study. Front Neurol 2021; 12:662634. [PMID: 33995257 PMCID: PMC8116670 DOI: 10.3389/fneur.2021.662634] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/10/2021] [Indexed: 11/13/2022] Open
Abstract
Background: After a coma, patients with severe brain injury may present disorders of consciousness (DOC). A substantial proportion of these patients also suffer from severe dysphagia. Assessment of and therapy for swallowing disabilities of patients with DOC are essential because dysphagia has major functional consequences and comorbidities. Dysphagia evaluation in patients with DOC is impeded by the lack of adapted tools. The first aim of this study was to create a new tool, the SWallowing Assessment in Disorders Of Consciousness (SWADOC), and propose a validation protocol. The SWADOC was developed to help therapists assess factors related to swallowing in patients with DOC. The second aim was to investigate the relationship between patients' level of consciousness and SWADOC items and scores. Method/Design: In this multicenter prospective cohort, 104 patients with DOC will be tested three times over five consecutive days with the SWADOC. Statistical analyses will focus on the reliability and validity of the SWADOC, especially the intrarater and interrater reliability, internal consistency, measures of dispersion, and concurrent validity with the Facial Oral Tract Therapy Swallowing Assessment of Saliva (FOTT-SAS). The level of consciousness will be assessed with the Simplified Evaluation of CONsciousness Disorders (SECONDs) and the Coma Recovery Scale-Revised (CRS-R). Discussion: The assessment of swallowing abilities among patients with DOC is the first necessary step toward the development of a customized dysphagia care plan. A validated scoring tool will be essential for clinicians to better assess dysphagia in patients with DOC and document the evolution of their disorders. Trial Registration: NCT04706689.
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Affiliation(s)
- Evelyne Mélotte
- Physical and Rehabilitation Medicine Department, University Hospital of Liège, Liège, Belgium.,Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Marion Belorgeot
- Physical and Rehabilitation Medicine Department, University Hospital of Nîmes, Nîmes, France
| | - Roxanne Herr
- Department of Speech and Language Pathology, Faculty of Medicine, University of Strasbourg, Strasbourg, France
| | - Jessica Simon
- Psychology and Neuroscience of Cognition, University of Liège, Liège, Belgium
| | - Jean-François Kaux
- Physical and Rehabilitation Medicine Department, University Hospital of Liège, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Leandro R D Sanz
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Aude Lagier
- Otorhinolaryngology Head and Neck Surgery Department, University Hospital of Liège, Liège, Belgium
| | - Dominique Morsomme
- Otorhinolaryngology Head and Neck Surgery Department, University Hospital of Liège, Liège, Belgium
| | - Frederic Pellas
- Physical and Rehabilitation Medicine Department, University Hospital of Nîmes, Nîmes, France
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau, University Hospital of Liège, Liège, Belgium
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Mélotte E, Maudoux A, Delhalle S, Lagier A, Thibaut A, Aubinet C, Kaux JF, Vanhaudenhuyse A, Ledoux D, Laureys S, Gosseries O. Swallowing in individuals with disorders of consciousness: A cohort study. Ann Phys Rehabil Med 2020; 64:101403. [PMID: 32535170 DOI: 10.1016/j.rehab.2020.04.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/15/2020] [Accepted: 04/18/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND After a period of coma, a proportion of individuals with severe brain injury remain in an altered state of consciousness before regaining partial or complete recovery. Individuals with disorders of consciousness (DOC) classically receive hydration and nutrition through an enteral-feeding tube. However, the real impact of the level of consciousness on an individual's swallowing ability remains poorly investigated. OBJECTIVE We aimed to document the incidence and characteristics of dysphagia in DOC individuals and to evaluate the link between different components of swallowing and the level of consciousness. METHODS We analyzed clinical data on the respiratory status, oral feeding and otolaryngologic examination of swallowing in DOC individuals. We analyzed the association of components of swallowing and participant groups (i.e., unresponsive wakefulness syndrome [UWS] and minimally conscious state [MCS]). RESULTS We included 92 individuals with DOC (26 UWS and 66 MCS). Overall, 99% of the participants showed deficits in the oral and/or pharyngeal phase of swallowing. As compared with the MCS group, the UWS group more frequently had a tracheostomy (69% vs 24%), with diminished cough reflex (27% vs 54%) and no effective oral phase (0% vs 21%). CONCLUSION Almost all DOC participants had severe dysphagia. Some components of swallowing (i.e., tracheostomy, cough reflex and efficacy of the oral phase of swallowing) were related to consciousness. In particular, no UWS participant had an efficient oral phase, which suggests that its presence may be a sign of consciousness. In addition, no UWS participant could be fed entirely orally, whereas no MCS participant orally received ordinary food. Our study also confirms that objective swallowing assessment can be successfully completed in DOC individuals and that specific care is needed to treat severe dysphagia in DOC.
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Affiliation(s)
- Evelyne Mélotte
- Physical and Rehabilitation Medicine Department, University Hospital of Liege, Liege, Belgium; Coma Science Group, GIGA-Consciousness, University of Liege, Liege, Belgium; Centre du Cerveau(2), University Hospital of Liege, Liège, Belgium.
| | - Audrey Maudoux
- Sensation and Perception Research Group GIGA, University of Liege, Liege, Belgium; Otorhinolaryngology Head and Neck Surgery Department, University Hospital of Liege, Liege, Belgium
| | - Sabrina Delhalle
- Otorhinolaryngology Head and Neck Surgery Department, University Hospital of Liege, Liege, Belgium
| | - Aude Lagier
- Otorhinolaryngology Head and Neck Surgery Department, University Hospital of Liege, Liege, Belgium
| | - Aurore Thibaut
- Coma Science Group, GIGA-Consciousness, University of Liege, Liege, Belgium; Centre du Cerveau(2), University Hospital of Liege, Liège, Belgium
| | - Charlène Aubinet
- Coma Science Group, GIGA-Consciousness, University of Liege, Liege, Belgium; Centre du Cerveau(2), University Hospital of Liege, Liège, Belgium
| | - Jean-François Kaux
- Physical and Rehabilitation Medicine Department, University Hospital of Liege, Liege, Belgium
| | - Audrey Vanhaudenhuyse
- Sensation and Perception Research Group GIGA, University of Liege, Liege, Belgium; Algology Department, University Hospital of Liege, Liege, Belgium
| | - Didier Ledoux
- Intensive Care Unit Department, University Hospital of Liege, Liege, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University of Liege, Liege, Belgium; Centre du Cerveau(2), University Hospital of Liege, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness, University of Liege, Liege, Belgium; Centre du Cerveau(2), University Hospital of Liege, Liège, Belgium
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Mélotte E, Maudoux A, Delhalle S, Martial C, Antonopoulos G, Larroque SK, Wannez S, Faymonville ME, Kaux JF, Laureys S, Gosseries O, Vanhaudenhuyse A. Is oral feeding compatible with an unresponsive wakefulness syndrome? J Neurol 2018; 265:954-961. [PMID: 29464377 DOI: 10.1007/s00415-018-8794-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 12/23/2017] [Accepted: 02/10/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aim of the study is to explore the possibility of oral feeding in unresponsive wakefulness syndrome/vegetative state (UWS/VS) patients. METHOD We reviewed the clinical information of 68 UWS/VS patients (mean age 45 ± 11; range 16-79 years) searching for mention of oral feeding. UWS/VS diagnosis was made after repeated behavioural assessments using the Coma Recovery Scale-Revised. Patients also had complementary neuroimaging evaluations (positron emission tomography, functional magnetic resonance imaging and electroencephalography and diffusion tensor imaging). RESULTS Out of the 68 UWS/VS patients, only two could resume oral feeding (3%). The first patient had oral feeding (only liquid and semi liquid) in addition to gastrostomy feeding and the second one could achieve full oral feeding (liquid and mixed solid food). Clinical assessments concluded that they fulfilled the criteria for a diagnosis of UWS/VS. Results from neuroimaging and neurophysiology were typical for the first patient with regard to the diagnosis of UWS/VS but atypical for the second patient. CONCLUSION Oral feeding that implies a full and complex oral phase could probably be considered as a sign of consciousness. However, we actually do not know which components are necessary to consider the swallowing conscious as compared to reflex. We also discussed the importance of swallowing assessment and management in all patients with altered state of consciousness.
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Affiliation(s)
- Evelyne Mélotte
- Physical and Rehabilitation Medicine Department, University Hospital of Liege, Liège, Belgium. .,GIGA Consciousness, Coma Science Group and Neurology Department, University and University Hospital of Liege, Liège, Belgium.
| | - Audrey Maudoux
- GIGA Consciousness, Coma Science Group and Neurology Department, University and University Hospital of Liege, Liège, Belgium.,Otorhinolaryngology Head and Neck Surgery Department, University and University Hospital of Liege, Liège, Belgium
| | - Sabrina Delhalle
- Otorhinolaryngology Head and Neck Surgery Department, University and University Hospital of Liege, Liège, Belgium
| | - Charlotte Martial
- GIGA Consciousness, Coma Science Group and Neurology Department, University and University Hospital of Liege, Liège, Belgium
| | - Georgios Antonopoulos
- GIGA Consciousness, Coma Science Group and Neurology Department, University and University Hospital of Liege, Liège, Belgium
| | - Stephen Karl Larroque
- GIGA Consciousness, Coma Science Group and Neurology Department, University and University Hospital of Liege, Liège, Belgium
| | - Sarah Wannez
- GIGA Consciousness, Coma Science Group and Neurology Department, University and University Hospital of Liege, Liège, Belgium
| | - Marie-Elisabeth Faymonville
- Hypnosis and Pain GIGA Center and Algology and Palliative Care Department, University and University Hospital of Liege, Liège, Belgium
| | - Jean-François Kaux
- Physical and Rehabilitation Medicine Department, University Hospital of Liege, Liège, Belgium
| | - Steven Laureys
- GIGA Consciousness, Coma Science Group and Neurology Department, University and University Hospital of Liege, Liège, Belgium
| | - Olivia Gosseries
- GIGA Consciousness, Coma Science Group and Neurology Department, University and University Hospital of Liege, Liège, Belgium
| | - Audrey Vanhaudenhuyse
- GIGA Consciousness, Coma Science Group and Neurology Department, University and University Hospital of Liege, Liège, Belgium.,Hypnosis and Pain GIGA Center and Algology and Palliative Care Department, University and University Hospital of Liege, Liège, Belgium
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