Dysphagia rehabilitation following acquired brain injury, including cerebral palsy, across the lifespan: a scoping review protocol

Background Swallowing impairment (dysphagia) following brain injury can lead to life-threatening complications such as dehydration, aspiration pneumonia and acute choking episodes. In adult therapeutic practice, there is research and clinical evidence to support the use of swallowing exercises to improve swallowing physiology in dysphagia; however, the use of these exercises in treating children with dysphagia is largely unexplored. Fundamental questions remain regarding the feasibility and effectiveness of using swallowing exercises with children. This review aims to outline the published literature on exercise-based treatment methods used in the rehabilitation of dysphagia secondary to an acquired brain injury across the lifespan. This will allow the range and effects of interventions utilised to be mapped alongside differential practices between adult and child populations to be formally documented, providing the potential for discussions with clinicians about which rehabilitative interventions might be appropriate for further trial in paediatrics. Methods This study will use a scoping review framework to identify and systematically review the existing literature using Joanna Briggs Institute (JBI) and Preferred Reporting Items for Systematic Reviews (PRISMA) scoping review guidelines. Electronic databases (MEDLINE, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Allied and Complementary Medicine Database (AMED)), grey literature and the reference lists of key texts including systematic reviews will be searched. Information about the rehabilitation design, dosage and intensity of exercise programmes used as well as demographic information such as the age of participants and aetiology of dysphagia will be extracted. The number of articles in each area and the type of data source will be presented in a written and visual format. Comparison between the literature in adult and child populations will be discussed. Discussion This review is unique as it directly compares dysphagia rehabilitation in adults with that of a paediatric population in order to formally identify and discuss the therapeutic gaps in child dysphagia rehabilitation. The results will inform the next stage of research, looking into the current UK-based speech and language therapy practices when working with children with acquired dysphagia. Systematic review registration Open science framework osf.io/ja4dr

Swallowing Exercise During Head and Neck Cancer Treatment: Results of a Randomized Trial

The diagnosis and treatment of head and neck cancer (HNC) can have substantial impact on swallowing function, nutritional balance, physical function and quality of life (QoL). Early initiated swallowing exercises are hypothesized to improve swallowing function in HNC patients. The aim was to investigate the effects of swallowing exercises and progressive resistance training (PRT) during radiotherapy on swallowing function, physical function and QoL in patients with pharynx-, larynx-, oral cavity cancer or unknown primary compared to usual care. In a multi-centre RCT participants were assigned to (a) twice-weekly PRT and daily swallowing exercises throughout treatment or (b) usual care. Outcomes were measured at end of treatment and 2, 6 and 12 months after. Primary outcome was penetration aspiration score (PAS). Data were analysed on an “intention-to-treat” basis by GEE logistic regression model, linear mixed effects model and cox regression. Of 371 invited HNC patients, 240 (65%) enrolled. Five participants were excluded. At 12 months follow-up, 59 (25%) participants were lost. Analyses showed significant effect on mouth opening, QoL, depression and anxiety at 12 months when comparing intervention to non-active controls. The trial found no effect on swallowing safety in HNC undergoing radiotherapy, but several positive effects were found on secondary outcomes when comparing to non-active controls. The intervention period may have been too short, and the real difference between groups is too small. Nevertheless, the need to identify long-lasting intervention to slow down or avoid functional deteriorations is ever more crucial as the surviving HNC population is growing.

Dysphagia Rehabilitation Following Acquired Brain Injury, Including Cerebral Palsy, Across The Lifespan: A Scoping Review Protocol

Background: Swallowing impairment (dysphagia) following brain injury can lead to life-threatening complications such as dehydration, aspiration pneumonia and acute choking episodes. In adult therapeutic practice, there is research and clinical evidence to support the use of swallowing exercises to improve swallowing physiology in dysphagia, however, use of these exercises in treating children with dysphagia is largely unexplored. Fundamental questions remain regarding the feasibility and effectiveness of using swallowing exercises with children. This review aims to outline the published literature on exercise-based treatment methods used in the rehabilitation of dysphagia secondary to an acquired brain injury across the lifespan. This will allow the range and effects of interventions utilised to be mapped alongside differential practices between adult and child populations to be formally documented, providing the potential for discussions with clinicians about which interventions might be appropriate for further trial in paediatrics.Methods: This study will use a scoping review framework to identify and systematically review the existing literature using the Joanna Briggs Institute (JBI) and Preferred Reporting Items for Systematic Reviews (PRISMA) scoping review guidelines. Electronic databases (Medline, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED) and Cochrane Database of Systematic Reviews), grey literature and the reference lists of key texts will be searched. Information about the rehabilitation design, dosage and intensity of exercise programmes used as well as demographic information such as the age of participants and aetiology of dysphagia will be extracted. The number of articles in each area and the type of data source will be presented in written and visual format. Comparison between literature in adult and child populations will be discussed. Discussion: If therapy protocols from the adult literature are to be developed for use in paediatrics, it is important to have a clear understanding of the scope and effectiveness of interventions described in both adults and children. This review is unique as it directly compares dysphagia rehabilitation in adults with that of a paediatric population in order to formally identify and discuss the therapeutic gaps in child dysphagia rehabilitation. The results will inform the next stage of research, looking into current UK based Speech and Language Therapy practices when working with children with an acquired dysphagia. Systematic review registration: Not registered.

Targeting Chemosensory Ion Channels in Peripheral Swallowing-Related Regions for the Management of Oropharyngeal Dysphagia

Oropharyngeal dysphagia, or difficulty in swallowing, is a major health problem that can lead to serious complications, such as pulmonary aspiration, malnutrition, dehydration, and pneumonia. The current clinical management of oropharyngeal dysphagia mainly focuses on compensatory strategies and swallowing exercises/maneuvers; however, studies have suggested their limited effectiveness for recovering swallowing physiology and for promoting neuroplasticity in swallowing-related neuronal networks. Several new and innovative strategies based on neurostimulation in peripheral and cortical swallowing-related regions have been investigated, and appear promising for the management of oropharyngeal dysphagia. The peripheral chemical neurostimulation strategy is one of the innovative strategies, and targets chemosensory ion channels expressed in peripheral swallowing-related regions. A considerable number of animal and human studies, including randomized clinical trials in patients with oropharyngeal dysphagia, have reported improvements in the efficacy, safety, and physiology of swallowing using this strategy. There is also evidence that neuroplasticity is promoted in swallowing-related neuronal networks with this strategy. The targeting of chemosensory ion channels in peripheral swallowing-related regions may therefore be a promising pharmacological treatment strategy for the management of oropharyngeal dysphagia. In this review, we focus on this strategy, including its possible neurophysiological and molecular mechanisms.

Abstract TMP46: Fostering Eating After Stroke (FEAST) Trial: A Randomized Controlled Trial of Non-Invasive Brain Stimulation for Improving Dysphagia After Stroke

Background: Effective therapy for dysphagia recovery after stroke is currently lacking. We conducted a phase-2 RCT to investigate the effects of anodal transcranial direct current stimulation (atDCS) in reducing aspiration risk, improving diet, and analyzed its safety in the acute-subacute stroke phase. Hypothesis: Since swallowing has bi-hemispheric representation targeted atDCS to the unaffected hemisphere combined with swallowing exercises may improve dysphagia from a unilateral hemispheric infarction [UHI]. Methods: This phase-2, double-blind, RCT enrolled subjects with dysphagia [penetration and aspiration (PAS) score ≥ 4], from an acute-subacute UHI [day 2-day 6 after stroke onset] and randomized them into 3 groups: low-dose atDCS [2 mA atDCS alternating with sham twice daily], high-dose atDCS [2 mA atDCS twice daily] or sham [twice daily]. All sessions were performed with standardized swallowing exercises for 20 minutes over 5 days. Major safety outcomes were incidence of seizures, worsening of neurological and swallowing functions and mortality; primary efficacy outcome was a change in PAS scores between day 1 and 5 of intervention; main dietary outcome was a change in dietary intake at 1 month using the Functional Oral Intake scale (FOIS). Results: Of the planned 99 subjects, 42 could be enrolled in the funding period. No group differences in pre-defined safety outcomes were observed. Mean (SD) change in PAS score from baseline to final session was -0.8 (±1.6) in sham, -0.8 (±1.5) in low-dose and -0.4 (±1.2) in high dose groups. Adjusting for baseline PAS, NIHSS scores and age, means (SE) were -0.96 (0.33) in sham, -0.81 (0.36) in low-dose and -0.34 (0.35) in high dose; there were no significant pairwise differences (p>0.40). Mean (SD) changes in FOIS scores from baseline to 1 month were: 2.1 (±1.7) in sham, 2.5 (±1.7) in low-dose and 2.9 (±1.2) in high dose. Adjusted means (SE) were 2.07 (0.35) in sham, 2.46 (0.38) in low dose and 3.05 (0.38) in high dose (pairwise p > 0.15). Conclusion: Application of atDCS to the unaffected hemisphere is safe in the acute-subacute stroke phase but did not decrease aspiration risk in this phase-2 RCT. Higher doses of atDCS were associated with better dietary scores but group differences were not statistically significant.

Adherence to a Dysphagia Exercise Program by Oropharyngeal Cancer Survivors

Introduction: Adherence to a swallowing exercise protocol and a common compliance barrier, oral pain, was evaluated and described. Methods: A four-week dysphagia exercise program was completed by 12 individuals with a history of base of tongue cancer who were experiencing latent dysphagia. Adherence to a dysphagia exercise program was quantified. Focused outcome measures on oral pain related to dysphagia exercises and exercise related sense of effort were also included. Results: Moderate to strong adherence was reported by 75% of participants. Overall, 78.9% of exercise sessions were completed. Individuals reported little to no pain associated with dysphagia exercises throughout protocol participation. Conclusions: Routine reminders and establishment of a tracking method supported adherence with a dysphagia exercise protocol. Oral pain and sense of effort associated with completing oral and dysphagia exercises were not demonstrated to be barriers to participation in a dysphagia exercise program in people who are several years post radiation therapy completion. Keywords: dysphagia, oropharyngeal cancer, latent dysphagia, swallowing exercises