Dysphagia - Authors

NOTE: When reviewing the findings of randomized clinical trials (RCTs), repeated measures studies, crossover studies, cohort studies and quasi-experimental studies in the results table, it is important to note that a ‘+’ is indicated only if there was a significant post treatment difference between the treatment group and the control group. For pre-post study designs, a ‘+’ indicates a significant difference from pre to post intervention assessment.

Author, year, PEDro score

Sample size

Intervention

Outcome and significance :
(+) significant (-) not significant

Bulow et al., 2008 
PEDro score: 5

25 patients with chronic stroke and dysphagia

Neuromuscular electrical stimulation (NMES) (n=12)
vs.
Traditional swallowing therapy (n=13)
Treatment details:
60-minutes/sessions, 5 days/week for 3 weeks.

NMES: two electrodes were placed just at or above the level of the thyroid notch over the thyrohyoid muscle. Stimulation amplitude ranged from 4.5 – 25 mA.

At 3 weeks (immediately post-treatment): 
(-) Self-evaluation of dysphagia (Visual Analog Scale)
(-) Actual Nutrition Scale
(-) Oral Motor Function Test
(-) Videofluoroscopic Swallowing Evaluation  

Carnaby et al., 2006 
PEDro score: 8

306 patients with acute stroke and dysphagia

Usual care (n=102) (Group A)
vs. 
Standard low intensity treatment (n=102) (Group B)
vs.
Standard high intensity treatment (n=102) (Group C)

NOTE: due to lack of notable differences in results between Group B and C the authors combined these two groups so that the results reported here reflect Group A vs. Group B+C.

Treatment details:
Group A: patient management by the attending physician.

Group B: swallowing compensation strategies, environmental modification, safe swallowing advice, dietary modifications; 3 times/week for 1 month or for the duration of hospitalization.

Group C: direct swallowing exercises, dietary modifications; 5 days/week for 1 month or for the duration of hospitalization.

At 6 months (follow-up):
(-) Return to normal diet – time*
(-) Return to normal diet – number of patients
(+) Functional swallowing (i.e. return to pre-stroke diet without swallowing complications)
(+) Chest infection (aspiration pneumonia)
(+) Swallowing-related medical complications (dehydration, calorie-nitrogen deficit)
(-) Barthel Index
(-) Modified Ranking Scale
(+) Death or institutionalization
(-) Death or dependency
* Between-group difference was found in favor of Group A vs. Group B+C

Chipps et al., 2014
PEDro score: 5

51 patients with acute stroke and dysphagia

Timed oral care delivered by trained nurse (n=29)
vs.
Standard oral care as per hospital policy (n=22)

Treatment details:
2 times/day for 10 days.
Timed oral care consisted of providing patients with an “oral care box” containing necessary supplies. Performed care included timed tooth brushing with a battery powered toothbrush, tongue brushing, flossing, mouth rinse, and lip care.

At 10 days (immediately post-treatment):
(
-) Growth of S. aurcus
(-) Functional Oral Intake Scale
(-) Mann Assessment of Swallowing Ability
(-) Revised-THROAT

DePippo et al., 1994 
PEDro score: 6

115 patients with subacute stroke and dysphagia

Group A: Self-management of diet and swallowing techniques (n=38)
vs.
Group B: Diet chosen by dysphagia therapist; self-management of swallowing techniques (n=38)
vs.
Group C: Intensive diet management and swallowing techniques by dysphagia therapist (n=39)

 Treatment details:
All patients were also given a thorough explanation of diagnostic results, recommendations for specific diets, and written swallowing techniques.

Until end point during the inpatient stay (post-treatment) and at 1 year post-stroke (follow-up):
 
(-) Pneumonia – frequency
(+) Pneumonia – onset
(-) Dehydration
(-) Calorie-nitrogen deficit*
Note: Group B developed pneumonia sooner than group A
 *Calorie-nitrogen deficit was defined as serum albumin < 2.5 or sustained ketonuria without glycosuria over 2 weeks.

Ebihara et al., 2006 
PEDro score: 5

105 patients with stroke (stage of stroke recovery not specified) and dysphagia

Black pepper oil olfactory stimulation (n=35)
vs.
Lavender oil olfactory stimulation (n=35)
vs.
Nasal inhalation of distilled water (n=35)

Treatment details:
Nasal inhalation of 100 mL of black pepper oil or lavender oil or distilled water was administrated to the nostrils with a paper stick. Caregivers assisted with nasal inhalation of the nominated odorants by participants for 1 minute immediately before each meal for a period of 30 days.

After 30 days (immediately post-treatment):
(+) Latency of swallowing reflex
(-) Cough-reflex sensitivity
(+) Serum substance P
(+) Number of swallowing movements
Significant differences in favour of black pepper oil vs. lavender oil and distilled water. 

El-Tamawy et al., 2015
PEDro score: 5

30 patients with stroke (stage of stroke recovery not specified) and dysphagia

Physical therapy + neuromuscular electrical stimulation (NMES) (n=15)
vs.
Standard medical care (n=15)

Treatment details:
PT program comprised a 45-minute session of strengthening and stimulation of the elevator muscle of the larynx above and below the hyoid bone.

NMES was applied for 30 minutes/session using two channels placed at the submental region (80Hz frequency, 0 -150 V amplitude, 0 – 25mA intensity).

PT+NMES was provided 3 times/week over 6 weeks.

At 6 weeks (immediately post-treatment):
(+) Videofluoroscopic Swallowing Study (VFSS) – Oral transit time
(+) VFSS – Hyoid elevation
(+) VFSS – Laryngeal elevation
(-) VFSS – Oesophageal sphincter opening
(+) VFSS – Aspiration/penetration

Huang et al., (2014)
PEDro score: 6

29 patients with acute stroke and dysphagia

Neuromuscular electrical stimulation (NMES) + traditional swallowing therapy (Group A) (n=10)
vs.
NMES alone (Group B) (n=8)
vs.
Traditional swallowing therapy alone (control) (n=11)

Treatment details:
All groups received their respective treatment over 10 60-minute sessions, 3 times per week for 3 weeks.

NMES was provided using VitalStim® device consisting of dual channel with 2 bipolar electrodes placed at the anterior neck (80Hz frequency, 0-25mA amplitude, 700 µs pulse width).

At 3 weeks (immediately post-treatment):
(-) Functional Oral Intake Scale
(+) Functional Dysphagia Scale (FDS)– Solids*
(+) FDS – Thick liquids*
(-) FDS – Soft diet
(-) FDS – Thick liquids
(-) Penetration-Aspiration Scale
*In favor of Group A vs. Group B and vs. control group. 

Jayasekeran et al., 2010
PEDro score : 8

28 patients with acute stroke and dysphagia

Active pharyngeal electrical stimulation (n=16)
vs.
Sham pharyngeal electrical stimulation (n=12)

Treatment details:
Stimulation delivered via electromyography catheter (0.2ms pulses, 280V, 5Hz frequency, 75% of maximum tolerated intensity, 10 minutes duration).

10-minute session, 1 time/day for 3 consecutive days.

At 2 weeks following the start of the treatment:
(+) Penetration-Aspiration Scale
(-) Temporal swallowing measures
(+) Dysphagia Severity Rating Scale
At discharge from the hospital:
(-) Barthel Index
(+) Length of hospitalization

Joo Yang et al., 2012 
PEDro score: 7

16 patients with acute stroke and dysphagia

Anodal transcranial direct current stimulation (tDCS) (n=9)
vs.
Sham tDCS (n=7)

Treatment details:
30-minutes/session, 5 days/week for 2 weeks.

Stimulation was applied to the pharyngeal motor cortex of the affected hemisphere during conventional swallowing training.

At 2 weeks (immediately post-treatment):
(-) Functional Dysphagia Scale
(-) Videofluoroscopic Swallowing Study (VFSS) – Oral transit time
(-) VFSS – Pharyngeal transit time
(-) VFSS- Total transit time
At 3 months (follow-up):
(+) Functional Dysphagia Scale
(-) VFSS – Oral transit time
(-) VFSS – Pharyngeal transit time
(-) VFSS – Total transit time

Khedr & Abo-Elfetoh, 2010 
PEDro score: 6

22 patients with acute and subacute stroke and dysphagia

Patients were differentiated according to location of lesion: lateral medullary infarction (n=11) or other brainstem infarction (n=11)

Active repetitive transcranial magnetic stimulation (rTMS)
(n=11)
vs.
Sham rTMS
(n=11)
Treatment details:

10-minutes/session for 5 days.

rTMS was applied to the provisional oesophageal cortical area of both hemispheres (3cm anterior and 6 cm lateral to the vertex), 3Hz stimulation lasting for 10 seconds and repeated every minute for 10 minutes.

At 5 days (immediately post-treatment): 
(+) Dysphagia Grade
(-) National Institutes of Health Stroke Scale
(-) Hemispheric Stroke Scale – grip strength
(+) Barthel Index*

At 1-month and 2-month follow-up: 
(+) Dysphagia Grade
(-) National Institutes of Health Stroke Scale
(-) Hemispheric Stroke Scale – grip strength
(+) Barthel Index*
* in patients with lateral medullary infarction only

Kumar et al., 2011 
PEDro score: 6

14 patients with acute stroke and dysphagia

Anodal Transcranial direct current stimulation (tDCS) (n=7)
vs.
Sham tDCS (n=7)

Treatment details:
30-minutes/session for 5 days.

tDCS was applied to the sensorimotor cortical representation of swallowing in the unaffected hemisphere; both groups received their respective intervention with standardised swallowing maneuvers; anodal tDCS was of 2mA amplitude.

At 5 days (immediately post-treatment):
(+) Dysphagia Outcome and Severity Scale

Lim et al., 2009 
PEDro score: 6

36 patients with subacute or chronic stroke and dysphagia

Neuromuscular electrical stimulation (NMES) + tactile-thermal stimulation (TTS) (n=18)
vs.
TTS alone (n=18)

Treatment details:
NMES was provided using VitalStim® device with electrodes placed to stimulation the digastric, myohyoid and thryrohyoid muscle (at 7mA amplitude, for 1 hour with on and off periods).

TTS involved using a cold mirror to stimulate the oral cavity and an ice stick to stimulate the side of the face.

5 trials of each treatment/week for 4 weeks.

At 4 weeks (immediately post-treatment):
(+) Swallow Function Scoring system
(+) Penetration-Aspiration Scale (semi-solids and liquids)
(+) Videofluorosocpic Swallowing Study – pharyngeal transit time (semi-solids and liquids)
NB: changes refer to changes in pre- to post-treatment scores.

Michou et al., 2014
PEDro score : 6

18 patients with subacute or chronic stroke and subsequent dysphagia

Pharyngeal electrical stimulation (PES) (n=6)
vs.
Paired associative stimulation (PAS) (n=6)
vs.
Repetitive transcranial electrical stimulation (rTMS) (n=6)
vs.
Sham application of each respective treatment (n=18)

Treatment details:
Each treatment and their respective sham treatment were provided once, in random order, on different days.

PES: 5Hz for 10 minutes.

PAS: pairing a pharyngeal electrical stimulus (0.2ms pulse) with single TMS pulse over the pharyngeal motor cortex, delivered repeatedly every 20 seconds, inter-stimulus interval of 100ms for 10 minutes.

rTMS: delivered to the pharyngeal motor cortex, 5Hz frequency, 90$ of resting thenar Motor Threshold intensity in train of 250 pulses, in 5 blocks of 50 with 10 seconds between-block pauses.

At 30 minutes post-intervention:
(+) Cortical excitability of the unaffected hemisphere *#
(+) Penetration-Aspiration Scale #
*
in favor of PES vs. PES sham, and PAS vs. PAS sham in the unaffected hemisphere.
#when responses for all 3 modalities were combined.  

Momosaki et al., 2013 
PEDro score: 8

20 patients with chronic stroke and dysphagia

Real functional magnetic stimulation over the suprahyoid muscle group (n=10)
vs.
Sham functional magnetic stimulation over the suprahyoid muscle group (n=10)

Treatment details:
1 x 10-minute session.

Stimulation was provided using the MagVenture MagProR30® parabolic coil (280 µs of active pulse width, 30Hz frequency, 2 seconds duration followed by 28 seconds of rest, repeated over 10 minutes; 1200 pulses in total).

At 1 session of 10 minutes (immediately post-treatment): 
(-) Timed Water-Swallow Test (TMT) – Interswallow interval  
(+) TMT – Speed 
(+) TMT – Capacity  

McCullough & Kim, 2013
PEDro score: 5 (crossover study)

18 patients with subacute or chronic stroke and dysphagia

Mendelsohn maneuver (n=9)
vs.
No treatment (control) (=9)

Treatment details:
45-60 minutes/sessions, 2 times/day for 2 weeks, using an AABB / BBAA study design.

At 2 weeks (immediately post-treatment) and at 3 months (follow-up):
(-) Videofluoroscopic Swallowing Study (VFSS) – Hyoid maximum elevation
(-) VFSS – Hyoid maximum anterior excursion
(-) VFSS – Extent of the upper esophageal sphincter opening
(-) Penetration-Aspiration Scale
(-) Dysphagia Outcome and Severity Scale

McCullough et al., 2012
PEDro score: 5 (cross-over study)

18 patients with subacute or chronic stroke and dysphagia

Mendelsohn maneuver (n=9)
vs.
No treatment (control) (n=9)

Treatment details:

45-60minutes/sessions, 2 times/week for 2 weeks.

At 2 weeks (immediately post-treatment):
(-) Videofluoroscopic Swallowing Study (VFSS) – Duration of hyoid maximum anterior excursion
(-) VFSS – Duration of hyoid maximum elevation
(-) VFSS- Pharyngeal response duration
(-) VFSS – Duration of upper esophageal sphincter opening
(-) Penetration-Aspiration Scale
(-) Dysphagia Outcome and Severity Scale

Park et al.,. 2016 
PEDro score: 6

61 patients with chronic stroke and dysphagia

Neuromuscular motor electrical stimulation combined with effortful swallow (n=31)
vs.
Neuromuscular sensory electrical stimulation (n=30)

Treatment details:
30 x 30-minutes sessions over 6 weeks; both groups received conventional dysphagia therapy.

NMES provided using the VItalStim® with electrodes placed at the infrahyoid area targeting sternohyoid muscle (80Hz pulse rate, 700µs duration, 9-14mA intensity).

At 6 weeks (immediately post-treatment): 
(+) Videofluoroscopic Dysphagia Scale (VDS) – Total
(-) VDS – Oral phase
(+) VDS – Pharyngeal phase
(+) Horizontal displacement of the hyoid bone
(+) Vertical displacement of the hyoid bone
(+) Penetration-Aspiration Scale

Park et al., 2013 
PEDro score: 8

18 patients with subacute or chronic stroke and dysphagia

Repetitive transcranial magnetic stimulation (rTMS) (n=9)
vs.
Sham rTMS (n=9)

Treatment details:
10-minutes sessions/weekday for 2 weeks, applied over the pharyngeal hotspot of the intact hemisphere, 10 trains of 5Hz stimulations, lasting 10sec, repeated every minute.

At 2 weeks (immediately post-treatment): 
(+) Videofluoroscopic Dysphagia Scale
(-) Penetration-Aspiration Scale

At 4 weeks (follow-up): 
(+) Videofluoroscopic Dysphagia Scale 
(-) Penetration-Aspiration Scale
Note: Results indicate within-group differences for the rTMS group only; no between group analyses were performed.

Park et al., 2012 
PEDro score: 5

20 patients with stroke (phase of stroke recovery not specified) and dysphagia

Effortful swallow with infrahyoid motor electrical stimulation (n=10)
vs.
Effortful swallow with infrahyoid sensory electrical stimulation (control) (n=10)

Treatment details:
20-minutes sessions, 3 times/week for 4 weeks using VitalStim® consisting of 2 sets of electrodes placed at the infrahyoid area targeting the sternohyoid muscle (80Hz pulse rate, 700µs duration).  

At 4 weeks (immediately post-treatment):
(+) Videofluoroscopic Swallowing Study (VFSS) – maximal vertical displacement of the larynx
(-) VFSS – maximal vertical and anterior displacement of the hyoid bone
(-) VFSS – maximal anterior displacement of the larynx 
(-) VFSS – maximal width of the upper esophageal sphincter opening 
(-) Penetration-Aspiration Scale
Note: Results indicate significant within-group differences for motor electrical stimulation only; there were no significant changes from baseline to post-treatment following sensory electrical stimulation.

Power et al., 2006 
PEDro score: 7

16 patients with acute stroke and dysphagia

Oral electrical stimulation (n=8) 
vs.
Sham electrical stimulation (n=8)

 Treatment details:
1 x 60 minutes session.
Stimulation of the anterior faucial pillar for 10 minutes (0.2-Hz frequency stimulation or sham stimulation).

At 1 session of 60 minutes (immediately post-treatment): 
(-) Oral transit time
(-) Pharyngeal transit time
(-) Swallow response time
(-) Laryngeal closure duration
(-) Cricopharyngeal opening duration
(-) Penetration-Aspiration scale

Shigematsu et al., 2013 
PEDro score: 8

20 patients with subacute or chronic stroke and dysphagia

Anodal transcranial direct stimulation (tDCS) (n=10)
vs.
Sham tDCS (n=10)

Treatment details:
20-minutes session/weekday for 2 weeks

tDCS: 1-mA anodal tDCS to the ipsilesional pharyngeal motor cortex;

sham stimulation applied to the ipsilesional pharyngeal motor cortex;

Intensive swallowing therapy: blowing, ice massage, pushing exercises, supraglottic swallowing, Shaker exercise, effortful swallow, K-point stimulation.

At 2 weeks (immediately post-treatment):
(+) Dysphagia Outcome and Severity Scale
At 1-month follow-up:
(+) Dysphagia Outcome and Severity Scale

Terre & Mearin, 2015
PEDro score : 8

20 patients with subacute acquired brain injury (n=14 with stroke) and dysphagia

Neuromuscular electrical stimulation (NMES) + conventional swallowing therapy (n=7/10 patients with stroke)
Shame NMES + conventional swallowing therapy (n=7/10 patients with stroke)

Treatment details:
NMES: provided using VitalStim® device with 2 sets of electrodes placed over mylohyoid muscle above the hyoid, and the thyroid cartilage over the thyrohyoid muscle (80Hz frequency, 300 µs duration, 2.5-25.0mA apmplitude).

60-minute sessions, 5 times/week for 4 weeks.

Conventional swallowing therapy: changes in diet and active maneuvering, motor control exercises.

At 4 weeks (immediately post-treatment):
(+) Functional Oral Intake Scale (FOIS)
(+) Satisfaction with treatment (7-Point Likert Scale)
(+) Bolus viscosity at which aspiration appeared
(-) Pharyngo-esophageal manometry – basal pressure, relaxation, pharyngeal contraction *
At 3 months (follow-up):
(-) Functional Oral Intake Scale (FOIS)
(-) Satisfaction with treatment (7-Point Likert Scale)
(-) Bolus viscosity at which aspiration appeared
(-) Pharyngo-esophageal manometry – basal pressure, relaxation, pharyngeal contraction *
*significant improvements from pre- to post-treatment scores within NMES + conventional swallowing therapy group were noted.

Woo Lee et al., 2014 
PEDro score: 5

67 patients with acute stroke and dysphagia

Neuromuscular electrical stimulation (NMES) combined with traditional swallowing therapy (n=35)
vs.
Traditional swallowing therapy (control) (n=32)

Treatment details:
NMES: 30-minutes/weekday for 3 weeks. NMES was provided using electrodes placed at the infrahyoid area, targeting sternohyoid muscle (80Hz pulse rate, 700 µs duration, starting at 3mA and gradually increased by 1mA of amplitude).

Traditional swallowing therapy included thermal-tactile stimulation with any combination of lingual-strengthening exercise, laryngeal adduction-elevation exercises, effortful swallow maneuver, Mendelsohn maneuver, Masako maneuver, and Shaker exercises, provided for 60 minutes/day, every day for 15 days.

At 3 weeks (immediately post-treatment):
(+) Functional Oral Intake Scale

At 6-week and 12-week (follow-up): 
(+) Functional Oral Intake Scale

Xia et al., 2011 
PEDro score: 5

120 patients with acute stroke and dysphagia

Neuromuscular electrical stimulation (NMES) with traditional swallowing therapy (intervention 1) (n=40)
vs.
NMES (intervention 2) (n=40)
vs.
Traditional swallowing therapy (control) (n=40)

Treatment details:
NMES: VitalStim® surface electrical stimulation system was used (700 µs wave width, 80 Hz frequency, and 0-25 mA amplitude), 2 channels each equipped with 2 electrodes placed on the surface of swallowing muscles.

30-minute sessions 2 times/weekday for 4 weeks.

At 4 weeks (immediately post-treatment): 
(+) Standardized Swallowing Assessment*
(+) Surface Electromyography*
(+) Videofluoroscopic Swallowing Study*
(+) Swallowing-related Quality of Life Questionnaire*
 *in favor of intervention 1 vs. intervention 2 and vs. control

Xia et al., 2016
PEDro score : 6

124 patients with acute stroke and dysphagia

Acupuncture combined with standard swallowing training (n=62)
vs.
Standard swallowing training (n=62)

Treatment details:
30-minute sessions, 6 times/week for 4 weeks.

At 4 weeks (immediately post-treatment):
(+) Standardized Swallowing Assessment
(+) Dysphagia Outcome Severity Scale
(+) Modified Barthel Index
(+) Swallowing-Related Quality of Life Scale

Zhang et al., 2016 
PEDro score: 5

90 patients with acute stroke and dysphagia

Neuromuscular electrical stimulation (sensory approach) + traditional swallowing therapy (Group A) (n=30)
vs.
Neuromuscular electrical stimulation (motor approach) + traditional swallowing therapy (Group B) (n=30)
vs.
Traditional swallowing therapy (control) (n=30)

Treatment details:
Motor approach: 2 electrodes placed in parallel on the skin of the anterior belly of the digastric muscle in the submental region above the hyoid bone. NMES provided using a

multifunctional nerve rehabilitation and treatment system (100µs pulse width, 120Hz frequency)

Sensory approach: cathode placed on the submental region, anode placed on the occipital skin. NMES provided using vocaSTIM-Master® (0.25Hz frequency, 0-15mA intensity with gradual increase to stimulate swallowing)

Both therapies provided for 20-minutes sessions, 2 times/day, 5 days/week for 4 weeks.

At 4 weeks (immediately post-treatment): 
(+) Water Swallow Test *
(+) Standardized Swallowing Assessment *
(+) Functional Oral Intake Scale *
(+) Swallowing-Related Quality of Life Scale *
*In favor of the Group A vs. Group B and vs. control therapy.
*In favor of the Group B vs. control therapy.

Zhao et al., 2015
PEDro score : 4

120 patients with acute stroke and dysphagia

Combined acupuncture and neuromuscular electrical stimulation (n=62)
vs.
Acupuncture alone (n=58)

Treatment details:
NMES + Acupuncture:
NMES provided using stimulation therapy device (50-100Hz frequency, over nerves and muscles of the throat and neck); Acupuncture provided using reinforcing-reducing manipulation of 8 acupoints.

30-minute sessions, 2 times/day for 2 weeks.

Acupuncture alone: Provided using uniform reinforcing-reducing manipulation of 6 acupoints.

30-minute sessions, 1 time/day for 2 weeks.

At 2 weeks (immediately post-treatment):
(+) Kubota’s water test*
* This refers to a change score from pre- to post-treatment.

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