An overview of dysphagia rehabilitation for stroke patients

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.

A Comprehensive Review on Mouth Dissolving Tablet

Oral drug delivery system of Mouth Dissolving Tablets (MDTs) is using a new concept that have been mostly accepted in the pharmaceutical industry in recent days. This system is the most comfortable, safest and inexpensive of drug delivery system, enhancing the patient compliance and extending the patient life. Mouth dissolving formulations using an important ingredient or active agent due to allow release of drug is rapidly after that produce faster dissolution process. The mouth dissolving tablets contain a unique property of tablets like quickly disintegrating or easily dissolving and releasing the active drug within a few minutes and its contact with saliva. In pediatric, geriatric, bed ridden, psychic, dysphagic patients are using the MDTs because of these tablets are easily engulfing or swallowing is most convenient and patient compliance is better to compared than other Delivery systems. The tablets are formulated with an aid of super disintegrant. It's more reliable because of better compliance in patients. There are several technologies used in the MDTs manufacturing process such as patented technology & conventional technology. The important patented technologies are Durasolve Technology, Orasolve Technology, Zydis Technology, Wow Tab Technology, Flash Dose Technology, Flash Tab Technology and Quick Solv Technology. The MDTs are improving the demand for rapidly growing areas in the pharmaceutical industry and other fields are also in demand on these formulations. The recent progress of pharmaceutical fields is allowing the improvement of a better route of health care management with avoidance of numerous difficulties are connected to the other Drug Delivery System (DDS).

Reduction of Sniff Nasal Inspiratory Pressure (SNIP) as an Early Indicator of the Need of Enteral Nutrition in Patients with Amyotrophic Lateral Sclerosis

Percutaneous endoscopic gastrostomy (PEG) is the standard procedure for feeding severely dysphagic patients with amyotrophic lateral sclerosis (ALS). It is associated with prolonged survival and improvement in quality of life. Nasal inspiratory pressure during a sniff (SNIP) is a respiratory test used extensively in ALS for the assessment of inspiratory muscle strength. In this study, we aimed to investigate the role of SNIP at baseline to predict PEG placement in ALS. Data from a clinical incident cohort of 179 ALS cases attending the multidisciplinary ALS unit of the University of Bari between April 2006 and December 2012 were retrospectively analysed. At baseline, patients underwent detailed neurological, nutritional and respiratory assessments, including measurements of SNIP and forced vital capacity (FVC). Patients were therefore followed up approximately every three to six months until they were able to attend the centre. The censoring date for the survival analysis was 15 April 2014, with PEG placement as the main outcome. Cox proportional hazard regression models were used to examine the association between SNIP and PEG placement, adjusted for possible confounders. During the follow-up period, 75 participants (42%) received PEG implant. PEG placement was more frequent (57% vs. 31%; p = 0.001) and earlier (after 11.6 ± 14.0 months from the first visit, vs. 23.3 ± 15.5 months; p < 0.0001) in the group of patients with baseline SNIP ≤ 40 cm H2O. Baseline SNIP was a predictor of PEG placement even after correction for multiple potential confounders (HR 0.98; 95% CI: 0.96–0.99; p = 0.02). To conclude, the present study showed that SNIP at baseline is an early indicator of disease progression and therefore of the need for enteral nutrition in ALS.

Applications of Alginates in the Design and Preparation of Orodispersible Dosage Forms

Orodispersible dosage forms are attractive and innovative drug delivery systems that can fulfill individual patient needs, especially in children, elderly and among dysphagic patients. Indeed, they rapidly disperse in the mouth upon contact with the saliva without the need for water or munching. Examples of such dosage forms include orodispersible tablets (ODT), and orodispersible films (ODF). The ability to obtain ODF with different dimensions (sizes and thicknesses) makes them a suitable for personalized dosing of single or a fixed-dose combination of drugs in special patient populations. Several biopolymers are currently being exploited in the development of orodispersible dosage forms including alginates due to their versatility, availability, naturally occurring, and biosafety profile. This chapter provides an appraisal on the various applications of alginates in the preparations and their role on the properties of orodispersible dosage forms and highlights future perspectives of this very versatile biopolymer for these innovative drug delivery systems.

The role of the Sapienza GLObal Bedside Evaluation of Swallowing after Stroke (GLOBE-3S) in the prevention of stroke-associated pneumonia (SAP)

Background and purpose Stroke-associated pneumonia (SAP) affects 10 to 38% of patients in the acute phase of stroke. Stroke patients diagnosed with dysphagia have an 11-fold higher risk of developing SAP. Thus, identifying dysphagic patients through a highly accurate screening tool might be crucial in reducing the incidence of SAP. We present a case–control study designed to evaluate efficacy in reducing the risk of SAP between two swallowing screening tools, the classic water swallow test (WST) and a recently validated tool such as the GLOBE-3S (the Sapienza GLObal Bedside Evaluation of Swallowing after Stroke), which is a highly sensitive swallowing screening tool particularly accurate in detecting silent aspiration as well. Methods We analyzed the occurrence of dysphagia in 100 acute stroke patients distributed in two groups: half were screened with WST and the other half with GLOBE-3S. Results Dysphagia was diagnosed in 28 patients. The main result is that, among patients who passed the dysphagia screenings, none of those screened with the GLOBE-3S method developed pneumonia compared to 31.82% in the WST group. Discriminant function analysis (DFA) showed that NIH Stroke Scale (NIHSS) score and the dysphagia screening method (i.e., GLOBE-3S vs. WST) were the two main factors in the SAP’s predicting model and the only significant ones per se. Conclusions The new GLOBE-3S screening test can reduce the risk of SAP compared to WST.

Coordination of Respiration, Swallowing, and Chewing in Healthy Young Adults

Examining the coordination of respiration and swallowing is important for elucidating the mechanisms underlying these functions and assessing how respiration is linked to swallowing impairment in dysphagic patients. In this study, we assessed the coordination of respiration and swallowing to clarify how voluntary swallowing is coordinated with respiration and how mastication modulates the coordination of respiration and swallowing in healthy humans. Twenty-one healthy volunteers participated in three experiments. The participants were asked to swallow 3 ml of water with or without a cue, to drink 100 ml of water using a cup without breathing between swallows, and to eat a 4-g portion of corned beef. The major coordination pattern of respiration and swallowing was expiration–swallow–expiration (EE type) while swallowing 3 ml of water either with or without a cue, swallowing 100 ml of water, and chewing. Although cueing did not affect swallowing movements, the expiratory time was lengthened with the cue. During 100-ml water swallowing, the respiratory cycle time and expiratory time immediately before swallowing were significantly shorter compared with during and after swallowing, whereas the inspiratory time did not differ throughout the recording period. During chewing, the respiratory cycle time was decreased in a time-dependent manner, probably because of metabolic demand. The coordination of the two functions is maintained not only in voluntary swallowing but also in involuntary swallowing during chewing. Understanding the mechanisms underlying respiration and swallowing is important for evaluating how coordination affects physiological swallowing in dysphagic patients.

Validation and Inter-rater Reliability of the Modified Videofluoroscopic Dysphagia Scale (mVDS) in Dysphagic Patients with Multiple Etiologies

Background: the Videofluoroscopic Dysphagia Scale (VDS) is used to interpret and predict the long-term prognosis of patients with dysphagia. However, the inter-rater agreement of the VDS was shown to be lower in a previous study. To overcome the mentioned limitation of the VDS, a modified version (mVDS) was created and applied clinically. We aimed to validate its usefulness in determining the appropriate feeding method and predicting the prognosis of dysphagia. Methods: the videofluroscopic swallowing study (VFSS) data of 50 patients with dysphagia were collected retrospectively. The VFSS data were evaluated using the mVDS, and the inter-rater reliability was calculated. We also evaluated the association between the mVDS and type of feeding method selected, and between the mVDS and presence of aspiration pneumonia in patients with dysphagia. Results: among the different parameters of mVDS, “aspiration” showed the highest reliability (k = 0.767), followed by “mastication” and “lip closure” (k = 0.648 and k = 0.634, respectively). Conversely, “triggering pharyngeal swallow” and “pyriformis residue” demonstrated the lowest reliabilities (k = 0.312 and k = 0.324, respectively). The intraclass correlation coefficient (ICC), which is used as a measure of the reliability of the total mVDS score, was 0.876. In all patients with dysphagia, the mVDS score correlated significantly with the type of feeding method selected (p < 0.05), and the presence of aspiration pneumonia (p < 0.05). Conclusion: the ICC of the total mVDS score was 0.876. Therefore, the mVDS could be a useful tool for quantifying the severity of dysphagia. It could be helpful in the analysis of the VFSS findings among patients with dysphagia in clinical settings and research.

The Contribution of Dysphagia to Acute Stroke Morbidity and Mortality in Nigeria: A Prospective Study

Background: The assessment of time-trend morbidity and mortality in acute stroke is critical to clinical policy decisions and resource allocation. Objectives: To determine the prevalence of dysphagia in acute stroke and the impact of dysphagia on short term stroke outcome (30 days post-stroke). Methods: This was a prospective longitudinal study. Bedside screening for dysphagia modified Rankin score (MRS) and Barthel Index (BI) were performed on acute stroke patients on day 1, day 7, day 14 and day 30 after stroke to determine the frequency of dysphagia. Patients with dysphagia were then compared with age- and gender-matched controls (stroke patients without dysphagia) in terms of stroke characteristics and 30-day outcome. Results: Of the recruited 200 patients, 99 (49.5%) had dysphagia. Patients with intracerebral haemorrhagic stroke had a significantly higher prevalence of dysphagia (64% vs 36%; p<0.001). At baseline, dysphagic patients had more severe (Mean NHISS score, 22.81 Vs 8.92; p=0.01) and subcortical strokes (57.1% vs 42.9%, p = 0.015). At 30 days after stroke, the mean MRS was significantly higher in the dysphagic stroke patients (3.8±1.02) compared to those without dysphagia (2.5±1.3), (p = 0.001)]. Case fatality was higher among the dysphagic (79.8% vs 15.84%; p = 0.001) and the mean survival time was lower (12.21 days) among the dysphagic group (p = 0.001) Conclusion: Severe stroke, subcortical stroke and haemorrhagic stroke types were significantly associated with dysphagia at baseline. Dysphagia adversely influenced 30-days morbidity and case fatality in this cohort of acute stroke patients.