acase@tulane.edu / 0 / Ernest A. Kopecky

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Swallowing difficulties after acute stroke are common. Clinical bedside assessments are used frequently to detect acute dysphagia. Published studies which have assessed the natural history of swallowing using bedside assessments have only observed swallowing for a short period of time. The purpose of this investigation was to monitor the natural progression of dysphagic symptoms in stroke over three month using a clinical assessment. 26 patients consecutively admitted to the regional public hospital were assessed using a clinical assessment consisting of cranial nerve exam, observation of oral intake, water swallow test and inhalation cough challenge. The assessment was implemented within 72 hours post admission and then after one week, three weeks and three months. For this exploratory study, descriptive statistics were used to explore the data set. The results confirm that dysphagia after stroke is common and that there are improvements within three months.

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The purpose of this report is to review critically research focused on oral motor based treatment for pediatric swallowing disorders with the aim of assisting speech-language pathologists in making informed clinical intervention decisions. Oral motor based treatment has become a popular intervention approach among some speech-language pathologists, but the evidence supporting the approach is limited. This report will discuss research studies and review articles with high levels of evidence of treatment efficacy and propose when to use oral motor based treatment approaches in clinical intervention for pediatric swallowing disorders. / text

Swallowing dysfunction (dysphagia) is a common disorder in patients with neurological impairments, head/neck injuries or brain-stem stroke. The main objectives of this thesis were to use acoustical analysis of swallowing and breath sounds for 1) understanding the swallowing mechanism and the main cause of dysphagia, and 2) developing a noninvasive diagnostic technology to detect swallowing aspiration (the entry of bolus into airway); thus, identifying individuals at high risk of severe dysphagia. As the first objective of the study, swallowing mechanism modeling in two groups of healthy individuals and dysphagic patients (due to cerebral palsy or stroke) was approached by using two different assumptions to relate the swallowing sounds either to the pharyngeal response or to the neural activities that initiate the swallow. The results showed that the model with the assumption of neural activities as the cause of dysphagia was a better fit to the available data. As the second main objective of the study, we analyzed breathing and swallowing sounds of 50 dysphagic individuals during the fiberoptic endoscopic evaluation of swallowing (FEES) or the videofluoroscopic swallowing study (VFS). The results showed 91% sensitivity and 85% specificity in identifying patients with severe aspirations. Also, the algorithm was able to detect the silent aspiration among the swallows of each patient. The proposed methods led to development of a non-invasive and reliable diagnostic/screening tool as an aid to the clinical examination of swallowing. The proposed acoustic method can be performed at the patients’ bedside to determine the appropriate further assessment or a dietetic treatment; thus, reducing the health care cost by prioritizing the patients’ referrals to the VFS/FEES tests.

Swallowing difficulties after acute stroke are common. Clinical bedside assessments are used frequently to detect acute dysphagia. Published studies which have assessed the natural history of swallowing using bedside assessments have only observed swallowing for a short period of time. The purpose of this investigation was to monitor the natural progression of dysphagic symptoms in stroke over three month using a clinical assessment. 26 patients consecutively admitted to the regional public hospital were assessed using a clinical assessment consisting of cranial nerve exam, observation of oral intake, water swallow test and inhalation cough challenge. The assessment was implemented within 72 hours post admission and then after one week, three weeks and three months. For this exploratory study, descriptive statistics were used to explore the data set. The results confirm that dysphagia after stroke is common and that there are improvements within three months.

Neural control of swallowing is hierarchical, involving the cerebral cortex and interactions with several other brain regions including the cerebellum. Cortical control of swallowing exhibits functional asymmetry, whereby brain lesions disrupting the stronger ('dominant') hemisphere are implicated in post-stroke dysphagia. A major breakthrough has been the consistent observation that compensatory changes (neuroplasticity) in the undamaged (contralesional) hemisphere are responsible for swallowing recovery. Whilst existing therapies lack evidence-base, neurostimulation interventions capable of facilitating this natural recovery process have the potential to revolutionise swallowing rehabilitation. Whilst data using several neurostimulation modalities have been promising, translating them into much needed clinical therapies has been hampered by clinical study designs lacking homogeneity. In a series of studies, using three different modalities I describe a step-wise approach for developing neurostimulation interventions from bench-to-bedside. Firstly, in a proof of concept experiment, targeted cerebellar repetitive Transcranial Magnetic stimulation (rTMS) was assessed in healthy subjects (n=17), confirming frequency and duration specific (250-pulses of 10-Hz) induction of long-lasting changes in pharyngeal cortical plasticity, effects which were explored with therapeutic potential in a dysphagic patient. Secondly, in a pre-clinical model of post-stroke dysphagia, optimal parameters of cortical transcranial Direct Current Stimulation (tDCS) were tested, confirming reversal of transient neurophysiological and behavioural swallowing deficits induced by a 'virtual-lesion' (10 minutes, 1-Hz rTMS to the 'dominant' hemisphere) in 15 healthy subjects. Finally, in a randomised trial, optimal parameters and dosage (5-Hz, 10 minutes daily for 3-days) of Pharyngeal Electrical Stimulation (PES) were studied in acutely dysphagic stroke patients (n=36) which despite lower than desired recruitment, trended towards reduced dysphagia severity at 2-weeks, earlier hospital discharge and nasogastric tube removal were observed. These studies have shown for the first time that the cerebellum is a viable target for non-invasive brain stimulation swallowing studies and that cortical tDCS can reverse experimental brain lesions, with both techniques having therapeutic potential for post-stroke dysphagia. These clinical trial data add to the increasing evidence base for PES, the modality with the most evidence to date, with longer-term follow-up. The difficulties encountered in the post-stroke clinical trial in both recruitment and outcome measures highlight the importance of mechanistic studies which have often been lacking, in optimising stimulation specific factors; site, duration, intensity, dosing and controls, prior to clinical trials. An independent, larger, multi-centre, international trial of PES, with greater resources is now required to definitively determine its clinical efficacy. In summary, there may be a role for several different neurostimulation modalities in different patient sub-groups and my preliminary observations lead me to hypothesise that future translation of these therapies will depend on targeting population tailored to specific interventions.

Transcutaneous electrical stimulation (TNES) is a controversial treatment method for oropharyngeal dysphagia. Currently, few studies support the effectiveness of TNES for the treatment of dysphagia. This study examines the available research regarding the effectiveness of TNES for the treatment of oropharyngeal dysphagia. / text