An overview of dysphagia rehabilitation for stroke patients

Matos, Klayne Cunha; Oliveira, Vanessa Fernandes de; Oliveira, Paula Luanna Carvalho de; Braga Neto, Pedro

doi:10.1590/0004-282X-ANP-2021-0073

Brasil

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View and Review • Arq. Neuro-Psiquiatr. 80 (1) • Jan 2022 • https://doi.org/10.1590/0004-282X-ANP-2021-0073 linkcopy

An overview of dysphagia rehabilitation for stroke patients

Uma revisão das terapias de reabilitação para disfagia em pacientes com acidente vascular cerebral

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Background: Dysphagia is characterized by difficulty in the swallowing pattern at any stage of this neuromuscular process. It is a frequent symptom after stroke.

Objective: This study aimed to investigate the most commonly used phonoaudiological interventions as therapy for the treatment of swallowing disorders in patients with dysphagia after stroke.

Methods: We performed a review of studies indexed in MEDLINE-PubMed, LILACS, Cochrane, and Clinical trials.gov focusing on speech-language interventions for adult dysphagic patients after stroke between January 2008 and January 2021.

Results: Thirty-six articles of clinical trials were selected. Eleven different types of therapies have been studied. Studies on the efficacy of therapeutic interventions for the rehabilitation of adult patients with dysphagia after stroke are still scarce. Most techniques are combined with conventional therapy, so the effectiveness of the other techniques alone cannot be assessed.

Conclusions: Therapeutic interventions should be selected in accordance with the possibilities and limitations of the patients, and especially with the findings of the clinical evaluation and with its objective.

Keywords: Deglutition Disorders; Stroke; Speech Therapy; Rehabilitation

References	Country	Patients	Diagnosis	Study design	Outcomes	Intervention	Intervention time	Results	Follow-up
Terré,R.; Mearin, F., 20149	Spain	20	STROKE and TBI	Randomized; controlled; prospective	VFSS; FOIS	GI- EE and TC GC - EE placebo eTC	20 sessions/60 min-5 times a week	FOIS increased 4.9 points (GI); 3.1 points (GC).	1, 3 months
Sun, S.F et al., 20137	Taiwan	29	STROKE	Clinic; prospective	FOIS; Dysphagia scale	EE e TC separately	NMES and TC 12 sessions/60 min - 3 times a week	FOIS and dysphagia scale improved after NMES, for 6 months and 2 years (p \ 0.001, each)	6 months, 2 years
Rofes, L. et al., 201310	Spain	20	STROKE	Randomized; double-blind	VFSS (PAS)	Motor EE group Sensory EE group	10 sessions/ 30 min - 5 times a week	Sensory and motor EE reduced the insecure deglutition number in (p < 0.001), and (p = 0.002)	No follow-up
Park, J. S. et al., 201613	Korea	50	STROKE	Randomized; Controlled; Single-blind	VFSS (PAS e VDS)	GI - EE and forced swallowing exercise GC - EE placebo and forced swallowing exercise	30 sessions/30 min - 5 times a week	GI increased oral and pharyngeal phase in VDS (P < 0.00, P = 002 and P < 0.00), and PAS (P < 0.00).	No follow-up
Park, J. W. et al., 201215	Korea	20	STROKE	Randomized; Controlled; Double-blind	VFSS (PAS; UES)	GI - Motor EE and forced swallowing GC- Sensory EE and forced deglutition	12 sessions/20 min - 3 times a week	GI increased vertical larynx movement (p\0.05).	No follow-up
Konecny, P.; Elfmark, M., 201811	Czech Republic	108	STROKE	Randomized; Controlled; Prospective	VFSS	GI - Motor EE and TC GC - TC	20 sessions/20 min - 5 times a week	The difference in the oral and pharynx transit time after therapy between the GI and the GC (P = 0.01 e P= 0.009)	No follow-up
Lim, K. B. et al., 200914	Korea	28	STROKE	Randomized; Controlled	VFSS	GI - EE muscular and tactile-thermic stimulation GC - Tactile-thermic stimulation	20 sessions/60 min - 5 times a week	GI with higher scores in PAS; 2 in semi-solid (p < 0.05) and 2.5 in liquids (p < 0.05)	No follow-up
Meng, P. et al., 201712	China	30	STROKE	Randomized	VFSS; DOSS	GA - EE with electrodes along the suprahyoid and along with the superior and inferior thyroid parts and TC GB - EE with 1 pair of electrodes in the geniohyoid region and 1 pair in the mylohyoid region and TC GC - TC	10 sessions/30 min - 5 times a week	Improvement in DOSS in groups A and B (P<0.005) in relation to GC.	No follow-up
Xia, W. et al.,201118	China	120	STROKE	Randomized; prospective	SSA; VFSS	G1 - Conventional therapy G2 - EE G3 - Conventional therapy and EE	40 sessions/30 min - 2 times a day, 5 times a week for 4 weeks	SSA, VFSS increased more in G3 than in G1 and G2 (P < 0.01).	No follow-up
LI, L et al., 201517	China	135	STROKE	Randomized; controlled	SSA	G1 - EE G2 - TC G3 - EE and TC	20 sessions/60 min - 5 times per week for 4 weeks	SSA improved in G3 (P <0.01)	4 weeks
Ploumis, A. et al., 201844	Greece	70	STROKE	Randomized, controlled, prospective.	VFSS; PAS	GI - Cervical exercises and conventional therapy GC - Conventional therapy	30 min daily sessions/12 weeks	Improved swallowing (P < 0.05) and PAS (P < 0.001)	No follow-up
Umay, E. et al., 20178	India	98	STROKE	Randomized; controlled	MASA; SSA	GI - Sensory EE and TC GC - Sensory EE placebo and TC	20 sessions/60 min - 5 times a week for 4 weeks	All parameters improved in G1 (P <0.025).	No follow-up
Park, S.J. et al., 201934	Korea	10	STROKE	Clinical; prospective	VFS; PAS	NMES and EMG-BF	20 sessions/30 min - 5 times a week	Significant differences between oral (P = 0.015) and pharyngeal (P = 0.016) VFS. Improved PAS (P = 0.031).	No follow-up
Carnaby, G.D et al., 202020	USA	53	STROKE	Randomized; controlled; double-blind	FOIS, MASA	G1 - TC and EENM G2 - TC and EENM placebo G3 - TC	15 sessions/60 min - 3 weeks	MASA was different among groups different (p ≤ 0.0001) G2 had the best FOIS result (p≤0.0001).	3 months

Reference	Country	Patients	Diagnosis	Study design	Outcomes	Intervention	Intervention time	Results	Follow-up
Hyun, Y. et al., 201729	Korea	26	Stroke	Randomized; multicenter controlled; prospective; double-blind.	DOSS	GI - ETCC and TC. GC - Placebo ETCC and TC	10 sessions/20 min - 5 times a week	DOSS - Significant improvement (0.62 points on GI)	No follow-up
Cheng, I. K. Y. et al., 201721	China	15	Stroke	Randomized; controlled; double-blind.	VFSS; IOPI	GI - Active EMTr GC - Simulated EMTr	10 applications - 5 times a week	No significant results	2, 6 and 12 months
Cheng, I. K. Y. et al., 201422	China	4	Stroke	Randomized; controlled.	VFSS; IOPI	GI - Active EMTr/ Tongue motor cortex stimulation GC - Simulated EMTr	10 sessions/30 min - 5 times a week	No significant deglutition improvement on GI	1 week, 1 month
Du, J. et al., 201623	China	40	Ischemic stroke	Randomized; controlled; double-blind.	SSA	G1 - High-frequency EMTr (3Hz) G2 - Low-frequency EMTr (1Hz) G3 - Simulated EMTr	5 sessions	Better G1 and G2 dysphagia improvement after 5 days compared to the other group, remaining for 5 months.	1, 2 and 3 months
Park, J.W. et al., 201315	Korea	18	Stroke	Randomized; controlled; double-blind.	VFSS (PAS and VDS)	GI - Contralesional pharyngeal motor cortex EMTr 5Hz GC - Placebo (same conditions)	20 sessions/10 min	VDC and PAS improved significantly on the GI (P<0.005)	2 weeks
Shigematsu, T. et al., 201330	Japan	20	Stroke	Prospective; double-blind.	DOSS	GI - TC and 1-mA ETCC (contralesional pharyngeal motor cortex) GC - Simulated ETCC and TC	10 sessions/20min - Once a day	1.4 points (P=0.006) improvement and after 1 month 2.8 points (P=0.004) improvement on the GI.	1 month
Krueger, S. S. et al., 201831	Germany	59	Ischemic stroke	Randomized; double-blind.	FEDSS; SSA	Contralesional pharyngeal motor cortex ETCC group Placebo ETCC group	4 sessions/20min	Significant dysphagia improvement on the ETCC group when compared to the placebo group (P<0.0005)	No follow-up

References	Country	Patients (n)	Diagnosis	Study Design	Outcomes	Intervention	Intervention time	Results	Follow-up
Bath, P. M. et al., 201624	United Kingdom	162	Stroke	Multicenter; Randomized; Controlled; Double-blind	VFSS (PAS)	GI - active PES GC - simulated PES	3 sessions/10 min	No GI improvements in relation to the GC	2,6 and 12 weeks
Vasant, D, H et al., 201625	United Kingdom	36	Stroke	Multicenter; Randomized; Controlled	DSR	GI - active PES GC - simulated PES	3sessions/10 min	In relation to the simulated group, a probability ratio (OR)> 1 indicated a favorable outcome for the active group in DSR punctuations.	2 weeks and 3 months
Essa, H., 201726	United Kingdom	38	Stroke	Randomized; Controlled; Double-blind	DRS	GI - active PES GC - simulated PES	3 sessions/10 min	In the GI, patients with the allele Met BDNF showed improvements in DERD after 3 months in relation to patients in the GC (P = 0.009)	2 weeks and 3 months
Moon, J. H et al., 201841	Korea	16	Stroke	Randomized; Controlled	IOPI; MASA	GI - TPSAT in the morning and TC in the afternoon GC - TC	80 sessions/30 min - 2 times a day, 5 times a week for 8 weeks	Anterior (P = 0.001) and posterior (P = 0.001) PMI improvement in the GI in relation to the GC; GI and GC MASA improvement (P = 0.012)	No follow-up
Kim, H. D. et al., 201635	Korea	35	Stroke	Randomized; Controlled	IOPI; VFSS (VDS and PAS)	GI - TPRT and TC GC - TC	20 sessions - 5 times a week	GI tongue strength improvement (anterior and posterior, p = 0.009, 0.015) and oral and pharynx phases punctuations improvement in VDS (p = 0.029, 0.007), but not in PAS (p = 0.471) in relation to the control group.	No follow-up

Reference	Country	Patients	Diagnosis	Study design	Outcomes	Intervention	Intervention time	Results	Follow-up
Gao, J.; Zhang, H.J., 201733	China	90	Ischemic stroke	Clinical; Random	VFSS (PAS)	GC - TC Shaker - TC and Shaker exercise CTAR - TC and CTAR	42 sessions - 3 times a day	A better swallowing improvement in the CTAR group when compared to the Shaker group	2, 4 and 6 weeks
Park, J. S. et al., 201832	Korea	22	Stroke	Randomized; Controlled	VFSS (PAS; FDS)	GI - CTAR and TC GC - TC	20 sessions/30 min - 5 times a week	Significant improvement in the PAS and FDS in the GI when compared to the GC	No follow-up
Choi, J. B. et al., 201737	Korea	31	Stroke	Randomized; Controlled; Double-blind	VFSS (PAS); FOIS	GI - TC and Shaker exercise GC - TC	20 sessions/30 min - 5 times a week	PAS and FOIS significantly improved the GI in relation to the GC	No follow-up
Park, J. S et al., 2019 34	Korea	37	Stroke	Randomized; Controlled	VFSS (PAS); FOIS	GI - Game-based CTAR GC - CTAR	20 sessions/30min - 5 times a week	There were no differences in improvement between groups	No follow-up
Kim, H. H.; Park, J. S, 201935	Korea	30	Stroke	Clinical; Randomized	PAS; FOIS	GI - CTAR and TC GC - TC	30 sessions/30 min - 5 times a week	GI had a significant improvement in PAS and FOIS (P <0.001, both)	No follow-up

Reference	Country	Patients	Diagnosis	Study design	Outcomes	Intervention	Intervention time	Results	Follow-up
McCullough, G.H. et al., 2012 28	USA	18	Stroke	Randomized	VFSS (DOHME and DOHAME)	Group A - 2 weeks of treatment with the Mendelsohn maneuver and EMG with feedback and 2 weeks without treatment. Group B - 2 weeks without treatment and 2 weeks with treatment.	45 min sessions, 2 times a day	DOHME and DOHMAE significantly improved (P = 0.011 and 0.009) after treatment.	No follow-up
McCullough, G.H; Kim, Y., 2013 27	USA	18	Stroke	Randomized	VFSS (HME, HMAE, UES)	Group A - 2 weeks of treatment with the Mendelsohn maneuver and EMG with feedback and 2 weeks without treatment. Group B - 2 weeks without treatment and 2 weeks with treatment.	45 min sessions, 2 times a day	No significant improvement after treatment	1 month, 1 year
Xia, W. et al., 201538	China	124	Stroke	Clinical; Randomized; Double blind	SSA; DOSS	GI- TC and acupuncture GC - TC	24 sessions/30 minutes - 6 times a week	SSA and DOSS GI improvement in relation to the GC (P<0.01)	No follow-up
Mao, L. et al., 2016 39	China	98	Stroke	Prospective	VFSS; SSA	GI - TC and acupuncture GC - TC	20 sessions/30 minutes - 5 times a week	VFSS and SSA GI improvement in relation to the GC (P=0.007 and P=0.007)	No follow-up
Chen, L. et al., 2016 40	China	250	Stroke	Randomized; Double-blind; Controlled	NIHSS; VFSS; SSA	GI - TC and acupuncture GC - TC	18 sessions/30 minutes - 6 times a week	GI improvement in relation to the GC: NIHSS (p < 0.001), VFSS (p < 0.001) and SSA (p =0.037)	1, 3, 7 weeks

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[TFN1] DOSS: Dysphagia Outcome and Severity Scale; EE: Electrical Stimulation; NMES: Neuromuscular Electrical Stimulation ; FOIS: Functional Oral Intake Scale; GA: Group A; GB: Group B; GC: Control group; GI: Intervention group; MASA: Mann Assessment of Swallowing Ability; PAS: Penetration-Aspiration Scale; SSA: Standardized Swallowing Assessment; TC: Conventional therapy; TBI: Traumatic Brain Injury; VDS: videofluoroscopic dysphagia scale; UES: Upper esophageal sphincter; VFSS: Video Fluoroscopic Swallowing Study.