Neuromuscular Electrical Stimulation and Electromyographic Biofeedback as Adjunctive Modalities in the Treatment of Oropharyngeal Dysphagia in Stroke

Dysphagia is a symptom related to swallowing disorders that impede or hamper safe, efficient, and comfortable oral ingestion. In addition to compromising the swallowing process, dysphagia may impair overall health, the nutritional status, and lung conditions, impacting quality of life as well. Different proposals for the rehabilitation of oropharyngeal dysphagia have been researched over the years. As a therapeutic strategy aimed at the rehabilitation of oropharyngeal dysphagias, the electromyographic (EMG) biofeedback provides improved strength in swallowing and its coordination, understood as the best muscle recruitment during the function, associated with the attention and performance of cortical functions, simultaneously. Neuromuscular electrical stimulation (NMES) is another therapeutic approach used in the rehabilitation of oropharyngeal dysphagia (NMES). NMES has been recommended as an adjunctive modality to improve the results of exercises based on dysphagia therapy. In view of the possibility of using technological resources in the diagnosis and treatment of oropharyngeal dysphagia, this chapter presents the theoretical and procedural framework aimed at the application of EMG biofeedback and NMES as supporting methods in the treatment of oropharyngeal dysphagia, in cases affected by stroke

Assessment and management of dysphagia in acute stroke: an initial service review of international practice

The international approach to the assessment and management of dysphagia in the acute phase post stroke is little studied. A questionnaire was sent to clinicians in stroke services that explored the current practice in dysphagia screening, assessment, and management within the acute phase post stroke. The findings from four (the UK, the US, Canada, and Australia) of the 22 countries returning data are analysed. Consistent approaches to dysphagia screening and the modification of food and liquid were identified across all four countries. The timing of videofluoroscopy (VFS) assessment was significantly different, with the US utilising this assessment earlier post stroke. Compensatory and Postural techniques were employed significantly more by Canada and the US than the UK and Australia. Only food and fluid modification, tongue exercises, effortful swallow and chin down/tuck were employed by more than fifty percent of all respondents. The techniques used for assessment and management tended to be similar within, but not between, countries. Relationships were found between the use of instrumental assessment and the compensatory management techniques that were employed. The variation in practice that was found, may reflect the lack of an available robust evidence base to develop care pathways and identify the best practice. Further investigation and identification of the impact on dysphagia outcome is needed

Letter by toscano et al regarding article. association of leukoaraiosis with convalescent rehabilitation outcome in patients with ischemic stroke

Given the aforementioned link between leukoaraiosis and swallowing impairment, and the burden of poststroke dysphagia on rehabilitation outcome, it could be of some interest to analyze the relationships between leukoaraiosis, recovery, and dysphagia in your large population

A Pilot Study of the Rehabilitation Services Provided for Patients with Dysphagia in Medical Settings in Jordan

Services provided for dysphaiga conditions are poorly investigated in Jordan. The aim of this study was to explore the rehabilitation services provided to patients with dysphagia in medical settings in Jordan. Data were collected from public and private hospitals, hearing and speech centres, and rehabilitation centres located in Amman province. Thirty-eight participants (16 patients and 22 professionals from various disciplines) were interviewed. There was limited knowledge about dysphagia among healthcare professionals. The provision of rehabilitation services was minimal and secondary to the provision of medical services. Clinical pathways and guidelines need to be devised to organize the work of professionals involved in the management of dysphagia

A service evaluation of parent adherence with dysphagia management therapy guidelines: Reports from family carers supporting children with complex needs in Greece

Purpose: Many children with complex needs exhibit eating, drinking and/or swallowing disorders (dysphagia). These children often have associated learning needs, and require assistance from carers for daily tasks such as eating and drinking. The aim of this study was to identify which strategies to manage dysphagia were challenging for family carers, and reasons for any non-adherence. Method: In this service evaluation researchers observed carers during mealtimes, and investigated carer opinions of strategies used to minimise the risks of dysphagia. Eight children with complex needs aged 3.4 - 7.5 years and their primary family caregiver participated. Results: Adherence with speech and language pathologists’ dysphagia recommendations overall was over 50% in all but one case. For specific strategies, the highest adherence was observed for diet modifications of foods (89%), communication during the mealtime (83%), amount of food to present (81%) and the pacing of fluids and foods (81%). Lower levels of adherence were identified in relation to postural management (58%), environmental changes (58%), utensils (56%) and preparatory strategies (49%). Conclusion: Adherence with use of strategies to support mealtimes was over 50% in all but one case. Findings suggest that support is essential in order to promote safe mealtimes, reduce family carers’ stress and increase knowledge, confidence and adherence in implementing dysphagia guidelines in the family home

An Investigation of Nutrition Risk among Hospitalised Older Adults Admitted to the Assessment, Treatment and Rehabilitation Wards of Waitemata District Health Board Hospitals : A Thesis Presented in Partial Fulfilment of the Requirements for the Degree of Master of Science in Nutrition and Dietetics Massey University, Albany New Zealand

Background: The proportion of older adults in New Zealand is increasing. Studies shows compromised nutrition status is prevalent in older adults, and can exacerbate poor health. It is therefore important to identify those who are malnourished, or those who are at nutrition risk for early nutrition intervention. Nutrition screening tools allow for the identification of nutrition risk status and initiation of nutritional care to result in improved health outcomes. Current data on the prevalence of nutrition risk in hospitalised older adults in New Zealand is limited. Design: Cross-sectional, observational study as part of a multicentre prospective study. Aim: To investigate the prevalence of nutrition risk among older adults (65-84 years) in the Assessment, Treatment and Rehabilitation (AT&R) wards of North Shore and Waitakere Hospitals. Potential nutrition risk factors including dysphagia risk, muscle mass and hand grip strength will also be investigated, as well as other relevant physiological and socio-demographic risk factors. Methods: Participants were recruited within five days of admission to the AT&R wards. Face-to-face interviews and assessments were conducted on the wards. A questionnaire incorporating participant characteristics, health and support data and validated screening and assessment tools were used. Nutrition risk status was assessed by the Mini Nutrition Assessment-Short Form, dysphagia risk status was assessed by the Eating Assessment Tool, cognitive status was assessed by the Montreal Cognitive Assessment and muscle mass was assessed by bioelectrical impedance analysis. Hand grip strength was measured using a hydraulic dynamometer. Results: A total of 89 participants took part in the study. Nutrition risk and malnutrition was evident in 43.8 and 27.0 percent of the study participants respectively. Indicated by the Mini-Nutrition Assessment-Short Form, participants with poor nutritional status were more likely to report reduced food intake, unintentional weight loss, requiring aid with activities of daily living, having previous dietetic input and being at risk of dysphagia compared to participants with ‘normal’ nutritional status. Conclusion: A high percentage of hospitalised older adults recently admitted to the AT&R wards had compromised nutritional status. Routine screening is highly advised to identify nutritional risk and instigate nutritional care

Efficacy of Electrical Stimulation Intervention in Treating Adults with Dysphagia: A Systematic Review

Purpose: Dysphagia is a term used for a swallowing disorder resulting from problems with the oral cavity, pharynx, esophagus, or gastroesophageal junction. Dysphagia can have significant impacts on an individual’s quality of life and statistics suggest that nearly 15 million adults in the United States present with swallowing disorders. Common medical complications associated with dysphagia are malnutrition, dehydration, aspiration pneumonia, and even death. Traditional dysphagia treatment (TDT) for adults currently consists of diet modification, compensatory strategies involving postural adjustments, and swallowing exercises to strengthen musculature. The objective of this systematic review is to determine whether electrical stimulation (ES) improves swallowing function in adults with dysphagia. Methodology: Four indexed databases were searched to obtain studies pertaining to the use of ES in dysphagia treatment and its success. Application of inclusionary and exclusionary criteria narrowed the results and relevant studies were selected for this systematic review. Studies were also hand-selected and appraised for validity to ensure minimal bias. Results: Results of the selected studies revealed varying statistically significant effects of ES as a treatment for adults with dysphagia. However, many studies suggest ES is most effective in producing positive outcomes when coupled with TDT. Conclusion: The results of the systematic review suggest efficacy of ES is highest when it is used in conjunction with TDT. Studies with statistically significant results reported on only a minor improvement with ES. None of the studies reported negative outcomes related to ES. Additional research is needed to determine overall efficacy of ES as an evidence-based intervention for adults with dysphagia resulting from various etiologies.https://scholarworks.uvm.edu/csdms/1005/thumbnail.jp

Optimising medicines administration for patients with dysphagia in hospital:Medical or nursing responsibility?

Dysphagia is common—not only associated with stroke, dementia, Parkinson’s but also in many non-neurological medical problems—and is increasingly prevalent in ageing patients, where malnutrition is common and pneumonia is frequently the main cause of death. To improve the care of people with dysphagia (PWD) and minimise risk of aspiration and choking, the textures of food and drinks are frequently modified. Whilst medicines are usually concurrently prescribed for PWD, their texture is frequently not considered and therefore any minimisation of risk with respect to food and drink may be being negated when such medicines are administered. Furthermore, evidence is starting to emerge that mixing thickeners with medicines can, in certain circumstances, significantly affect drug bioavailability and therefore amending the texture of a medicine may not be straightforward. Research across a number of hospital trusts demonstrated that PWD are three times more likely to experience medication administration errors than those without dysphagia located on the same ward. Errors more commonly seen in PWD were missed doses, wrong formulation and wrong preparation through medicines alteration. Researchers also found that the same patient with dysphagia would be given their medicines in entirely different ways depending on the person administering the medicine. The alteration of medicines prior to administration has potential for patient harm, particularly if the medicine has been designed to release medicines at a pre-defined rate or within a pre-defined location. Alteration of medicines can have significant legal implications and these are frequently overlooked. Dispersing, crushing or mixing medicines can be part of, or misconstrued as, covert administration, thus introducing a further raft of legislation. Guidance within the UK recommends that following identification of dysphagia, the ongoing need for the medicine should be considered, as should the most appropriate route and formulation, with medicines alteration used as a last resort. The patient should be at the centre of any decision making. Evidence suggests that in the UK this guidance is not being followed. This article considers the clinical and legal issues surrounding administration of medicines to PWD from a UK perspective and debates whether medicines optimisation should be the primary responsibility of the prescriber when initiating therapy on the ward or the nurse who administers the medicine

SWALLOWING DISORDERS IN CLINICAL PRACTICE: FUNCTIONAL ANATOMY, ASSESSMENT AND REHABILITATION STRATEGIES

Swallowing is a complex process consisting in transporting food from mouth to the stomach; it involves voluntary and reflex activity of more than 30 nerves and muscles, requiring complex neuromuscular coordination and brainstem and cortical centers for controle. Dysphagia is defined as a alteration in the swallowing process, which cause difficulty in transporting saliva and aliments from the mouth trough the pharynx and esophagus into the stomach . It is a frequent symptom, affecting especially old people, people with neurological diseases, cancers of head and neck or severe reflux . Dysphagia can result from a wide variety of functional or structural deficits of the oral cavity, pharynx, larynx or esophagus, which could e caused by neurological conditions. Dysphagia carries serious health risks: malnutrition, dehydration, increase risk of infections. Effective dysphagia management requires an interdisciplinary approach; the goal of rehabilitation is to identify and treat abnormalities of swallowing while maintaining safe and efficient nutrition. KEY WORDS: swallowing, dysphagia, functional anatomy, rehabilitation, neuroplasticit