Exercise‐based swallowing intervention (McNeill Dysphagia Therapy) with adjunctive NMES to treat dysphagia post‐stroke: A double‐blind placebo‐controlled trial

Abstract

Background Dysphagia following stroke is prevalent; however, dysphagia treatment is often applied haphazardly and outcomes unclear. Neuromuscular electrical stimulation (NMES) has received increased attention as a treatment for post‐stroke dysphagia; but application data remain conflicted. Objective This study investigated effectiveness and safety of an exercise‐based swallowing therapy (McNeill Dysphagia Therapy: MDTP) +NMES for dysphagia rehabilitation following stroke. Methods Stroke patients (n = 53, x̅ age: 66 [13.2], 47.2% male) with dysphagia admitted to sub‐acute rehabilitation hospital were randomised to MDTP + NMES [NMES], MDTP + sham NMES [MDTP] or usual care [UC] swallowing therapy groups. Patients were treated for 1 hour per day for 3 weeks and monitored to 3 months by a blinded evaluator. Outcomes included clinical swallowing ability, oral intake, weight, patient perception of swallow and occurrence of dysphagia‐related complications. Results Post‐treatment dysphagia severity and treatment response were significantly different between groups (P ≤ .0001). MDTP demonstrated greater positive change than either NMES or UC arms, including increase in oral intake (χ2 = 5, P ≤ .022) and improved functional outcome by 3 months post‐stroke (RR = 1.72, 1.04‐2.84). Exploratory Cox regression revealed the MDTP group conferred the greatest benefit in time to “return to pre‐stroke diet” of 4.317 [95% CI: 1.08‐ 17.2, P< .03]. Conclusion Greater benefit (eg reduction in dysphagia severity, improved oral intake and earlier return to pre‐stroke diet) resulted from a programme of MDTP alone vs NMES or UC.

Effectiveness of Different Application Parameters of Neuromuscular Electrical Stimulation for the Treatment of Dysphagia after a Stroke: A Systematic Review

“…A total of 21 articles were found, of which eleven were focused on experimental researchs [ 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 ] and nine were randomized-controlled trials [ 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 ]. The methodological characteristics of the analysed studies are shown in Table 2 and, in Table 3 , the characteristics of the interventions applied in them are presented.…”

“…The application of NMES was not conducted using the same parameters in the analysed investigations. Regarding the application frequency, the choice of 80 Hz was the most widely used [ 27 , 28 , 29 , 30 , 31 , 32 , 33 , 35 , 36 , 37 , 39 , 40 , 41 , 42 , 45 ], although, in several cases, this parameter was not mentioned [ 34 , 38 , 44 , 46 ] and in another two studies the authors selected lower frequencies (60 [ 47 ] and 30 Hz [ 43 ]). In all cases, the results were statistically significant; even those studies which used lower frequencies obtained significant reductions in oral and pharyngeal transit time [ 47 ], significant decreases in the severity of penetration and aspiration [ 43 ] and significant increases in the level of oral intake and quality of life [ 43 ].…”

“…Regarding the intensity of the application, most of the obtained studies were aimed at reaching the motor threshold as the patient’s tolerance to the current increased with the sessions [ 28 , 29 , 30 , 35 , 42 , 43 , 45 , 46 , 47 ]. In contrast, other studies reached the pain threshold of the patient [ 31 ] or aimed to reach a certain level of intensity as the patient’s tolerance increased with each session: up to 7 [ 37 , 38 ], 8.5 [ 32 ], 12.5 [ 41 ], 20 [ 36 ], 25 [ 40 ] and 28 mA [ 37 ].…”

“…The electrodes were preferentially placed in the anterior side of the neck: suprahyoid [ 27 , 31 , 32 , 33 , 36 , 37 , 38 , 39 , 42 , 43 , 44 , 45 , 46 , 47 ] or infrahyoid area [ 35 ], thyroid muscles [ 28 , 41 , 44 ], and lateral regions of the pharynx [ 40 ], although some authors also applied NMES in the cranium: in the paretic facial area [ 29 ], orbicularis orbis muscle [ 30 ] and masseters [ 37 ]. Two of the analysed articles were focused on comparing the effects of different application areas.…”

Capsaicin combined with ice stimulation improves swallowing function in patients with dysphagia after stroke: A randomised controlled trial

“…Patients with mild dysphagia may present with coughing when drinking water, which affects patients' confidence in eating, and repetitive fever 10 . Severe patients are prone to aspiration pneumonia and asphyxia, malnutrition, etc, and it seriously impairs the quality of life of patients, and sometimes even endanger the lives of patients 11 . Therefore, early assessment of swallowing function after stroke, active and effective rehabilitation treatment based on the specific conditions of patients, has significant effects on shortening the course of disease, reducing the mortality and the burden of patients and society, and improving the quality of life 12 …”