|Year : 2015 | Volume
| Issue : 3 | Page : 201-205
The influence of physical therapy on oropharyngeal dysphagia in acute stroke patients
Mohamed S El-Tamawy1, Moshera H Darwish PhD 2, Hatem S El-Azizi3, Ahmed M Abdelalim1, Shereen I Taha2
1 Department of Neurology, Faculty of Physical Therapy, Cairo University, Cairo, Egypt
2 Department of Neuromuscular Disorders and its Surgery, Faculty of Physical Therapy, Cairo University, Cairo, Egypt
3 Department of Radiology, Faculty of Medicine, Cairo University, Cairo, Egypt
|Date of Submission||15-Jan-2015|
|Date of Acceptance||20-Feb-2015|
|Date of Web Publication||13-Aug-2015|
Moshera H Darwish
Department of Neuromuscular Disorders and its Surgery, Faculty of Physical Therapy, Cairo University, Cairo, 12624
Source of Support: None, Conflict of Interest: None
Dysphagia occurs in 65% of acute stroke patients, resulting in airway obstruction, malnutrition, and chest infection.
The aim of this study was to evaluate the effect of a designed physical therapy program that consists of therapeutic physical exercises in addition to neuromuscular electrical stimulation on severe swallowing disorders (oropharyngeal dysphagia) in acute ischemic cerebrovascular stroke patients.
Thirty stroke patients suffering from severe dysphagia were assigned randomly to two equal groups: the study group (G1) and the control group (G2). The patients in the study group (G1) received medical treatment in addition to a designed physical therapy program mainly directed at strengthening and stimulating the elevator muscles of the larynx above and below the hyoid bone, whereas the patients in the control group (G2) were under medical treatment only. Digital fluoroscopy was used to assess the following variables: oral transit time, laryngeal elevation, hyoid elevation, esophageal sphincter opening, and aspiration or penetration. Assessment was carried out before and at the end of treatment after 6 weeks.
Before treatment, there were no significant differences in different variables between G1 and G2. After treatment there was significant improvement in all variables in G1 compared with G2, as measured by digital fluoroscopy.
The suggested physical therapy program could be an effective and safe method for improving and restoring the normal swallowing mechanism in ischemic stroke patients suffering from severe dysphagia.
Keywords: digital fluoroscopy, dysphagia, electrical stimulation, ischemic stroke, physical rehabilitation
|How to cite this article:|
El-Tamawy MS, Darwish MH, El-Azizi HS, Abdelalim AM, Taha SI. The influence of physical therapy on oropharyngeal dysphagia in acute stroke patients. Egypt J Neurol Psychiatry Neurosurg 2015;52:201-5
|How to cite this URL:|
El-Tamawy MS, Darwish MH, El-Azizi HS, Abdelalim AM, Taha SI. The influence of physical therapy on oropharyngeal dysphagia in acute stroke patients. Egypt J Neurol Psychiatry Neurosurg [serial online] 2015 [cited 2017 Oct 19];52:201-5. Available from: http://www.ejnpn.eg.net/text.asp?2015/52/3/201/162046
| Introduction|| |
Dysphagia occurs in up to 65% of acute stroke patients, resulting in airway obstruction, malnutrition, chest infection, diminished quality of life, and death . Dysphagia is a result of inappropriate timed and coordinated upper orodigestive events or muscle weakness causing impairment of the oral, pharyngeal, and/or esophageal stages during swallowing ,.
Traditional swallowing exercise therapy improves only type I fibers, and subsequently type II muscle fibers may undergo disuse atrophy. Type II fibers are involved in the high-speed and forceful contraction of muscles involved in swallowing. The use of electrical stimulation in treating dysphagia was first reported by Park et al.  and later by Freed et al. . Neuromuscular electrical stimulation (NMES), termed Vital Stim therapy, is directed toward the rehabilitation of type II muscle. Therefore, a combination of NMES with swallowing exercise therapy directed toward both muscle fiber types would be rather more effective  and compensatory techniques are applied until improvement is achieved .
This study was conducted to determine the influence of a designed program of therapeutic exercise therapy and NMES on the management of severe swallowing disorders (oropharyngeal dysphagia) in acute cerebrovascular stroke patients.
| Patients and methods|| |
Thirty patients with acute ischemic cerebrovascular stroke were included in this randomized controlled open-labeled study. All patients were admitted to the Department of Neurology, Cairo University Hospitals, Egypt. Patients were included if they:
- Suffered from severe dysphagia according to Sitoh et al. ,
- Were able to ambulate,
- Had normal attention and communication skills,
- Were free from any other neurological problems, and
- Were able to perform a sitting to standing test.
The clinical diagnosis of stroke was confirmed by computed tomography and/or MRI. Patients with disturbed conscious level, dementia, psychiatric disorders, syncope, or with previous operation or injury in the neck were excluded from the study.
The patients were randomly assigned to two groups using block design randomization: group 1 (G1) and group 2 (G2). G1 included 15 patients treated by medical treatment in addition to a physical therapy program consisting of therapeutic exercises and NMES; G2 included 15 patients who received medical treatment only. This study was reviewed and approved for ethical considerations by the research committee of the Faculty of Physical Therapy, Cairo University. Signed consent was obtained from all patients.
All patients were subjected to digital fluoroscopic examination using a digital X-ray machine (Omni Diagnost Eleva; Philips Medical System, Best, The Netherlands). The examination was performed in the Department of Radiology, Cairo University Hospitals.
- Two digital fluoroscopic views were recorded for each patient, lateral and anteroposterior views, with the patient seated in upright standing position with the head, trunk, and pelvis supported to stimulate normal ingestion.
- Fifteen milliliter bolus of high-density barium suspension was administered. The patient was asked to hold it in the mouth and then swallow it while the field of view focused on the oral cavity and the pharynx from the lateral view.
- The patients who were able to swallow 15 ml of bolus were asked to swallow 30 ml of high-density barium with the field of view centered on the pharyngoesophageal segment.
- When susceptibility for aspiration was expected the study was started with 3 ml of thin liquid, nonionic iodinated contrast material. The size of the bolus was increased gradually to 5, 10, and 15 ml of high-density barium suspension according to the ability of each patient. Aspiration was diagnosed if contrast material entered the superior laryngeal inlet before, during, or after swallowing.
- All digital fluoroscopic studies were analyzed and reviewed in real time and frame-by-frame by a radiologist experienced in performing and interpreting digital fluoroscopic studies and blinded to patients' clinical data.
Physical therapy program
The physical therapy program consisted of a combination of NMES and a selected program of therapeutic physical exercises for 6 weeks at a frequency of three sessions per week. Each session lasted for about 70-75 min according to the ability of each patient.
- The therapeutic exercise program: The duration of the physical therapy program was 45 min. Each exercise was repeated for about 10 times according to the ability of each patient in every session. The patient was asked to repeat each exercise program three times a day as a home routine program.
Patients were asked to perform the following:
- Maintain correct normal position of the head and neck with the chin tucked toward the chest.
- Push the tongue for 1 s to each cheek against maximum resistance from the therapist's finger.
- Round the lips tightly (oh), and stretch them broadly (ee).
- Open the jaw widely, hold it for 1 s and move it to both sides (for 1 s) against maximum resistance from the therapist's finger.
- Open the mouth and elevate the tongue as high as possible; then hold the tongue for 1 s and release it.
- Tilt the head slightly forward to keep the food bolus in the anterior part of the mouth until initiating the swallowing action.
- Manipulate a large piece of bolus in the mouth.
- Put the tongue on the alveolar ridge and ask the patient to begin the swallowing action with an upward-backward push of the tongue.
- Extend the tongue as far as possible. Hold it for 1 s and finally pull it backward as far as possible. Hold it again for 1 s.
- Take a deep breath; hold it and then release the air through a cough. The therapist will use the palm of the hand to push downward on the sternum.
- Vibrate the laryngeal musculature from under the chin, downward on each side to the sternal notch.
- Push the neck and head in flexion, extension, and lateral flexion against the therapist's hand.
- Use sour bolus to reduce swallowing delay.
- Use cold bolus to accelerate oral transit time.
- Finally the therapist grasps the tongue wrapped in gauze and pulls it forward to the front teeth. He then strokes firmly down the middle of tongue with the edge of a tongue blade.
- Application of electrical stimulation: The NMES was applied to the anterior neck and laryngeal elevator muscles of the larynx above and below the hyoid bone by using four surface electrodes for about 30 min using a four-channel electrical stimulator device (OK Gymmy, Rome, Italy). The value of intensity set is displayed both numerically through the indication of the current in milliamperes and graphically through the darkening of the bar that progressively darkens in proportion to the greater intensity of the current being delivered.
- The skin of the submental region was shaven and cleaned with alcohol, and then two channels of bipolar electrical stimulation were applied: one was placed horizontally on the skin overlying the submental region 1 cm lateral to the midline above the hyoid bone and the other was placed 1 cm lateral and posterior to the midline just below the hyoid bone. Stimulation was automatically cycled 'on' for 59 s and 'off' for 1 s to prevent muscle fatigue. Adult-sized electrodes with a 2.1-cm round active area were used.
- The configuration of the stimulating voltage was twin-peak pulse with a frequency of 80 Hz. The amplitude was adjusted from 0 to 150 V according to the ability of each patient. The intensity of electrical stimulation adjusted independently between 0 and 25 mA. The intensity of electrical stimulation was raised gradually about 0.5 mA until the first tingling sensation. The intensity gradually increased until the patient reported a pulling sensation. The intensity level was increased until the patient could not tolerate any further increase (maximum tolerance level). This configuration has a particular property of deeper muscle stimulation, while sparing pain stimulation of the neck as sensory discomfort and muscle soreness are the major obstacles to the use of NMES.
SPSS statistical package (v17; SPSS Inc., Chicago, Illinois, USA) for Windows was used for data analysis. Descriptive statistics were presented as mean ± SD. The unpaired Student t-test was used for comparison between the mean values of the two groups, and the paired Student t-test was used for comparison between the mean pretreatment and post-treatment values within the same group. The χ2 -test was used for comparison of the categorical data. P values less than 0.05 were considered statistically significant.
| Results|| |
The patient ages ranged from 49 to 70 years. The mean age of G1 was 61.53 ± 7.259 years and that of G2 was 61.33 ± 6.565 years (P > 0.05).
The oral transit time was significantly improved in G1 compared with pretreatment results (P = 0.001), but not in G2 (P > 0.05).
There were no significant differences in swallowing variables (oral transit time, hyoid elevation, laryngeal elevation, esophageal sphincter opening, and aspiration or penetration) between G1 and G2 before starting treatment (P > 0.05) [Table 1].
|Table 1: The different components of digital fluoroscopic examination before treatment in both groups (group 1 and group 2)|
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At the end of the treatment period, there was significant decrease in the mean oral transit time (P<0.01) in G1 compared with G2. There was a significantly higher proportion of patients in G1 compared with G2 who had lower aspiration and penetration rate (P = 0.008), significant hyoid elevation (P = 0.002), and laryngeal elevation (P = 0.001), but no significant differences were found in esophageal sphincter open (P > 0.05) [Table 2].
|Table 2: The different components of digital fluoroscopic evaluation after treatment in both groups (group 1 and group 2)|
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| Discussion|| |
The present study showed that a physical therapy program consisting mainly of NMES and physical exercise had a significant effect on the treatment of oropharyngeal dysphagia in acute stroke patients. We demonstrated significant improvement in all swallowing variables in the study group (G1) compared with the control group (G2). This improvement could be attributed to the effect of the designed physical therapy program, which consists of a combination of NMES and therapeutic physical exercise.
The results of this study are consistent with those reported by Shaw et al. , who found that the combination of NMES with swallowing therapy improved forceful contractions of several muscles involved in swallowing as it was directed at rehabilitation of both muscle fiber types I and II. Permsirivanich et al.  reported that NMES is more effective in treating oropharyngeal dysphagia.
The significant post-treatment improvement in hyolaryngeal elevation and aspiration in G1 compared with G2 is believed to be related to activation of the mylohyoid and thyrohyoid muscles, which raise the hyoid bone. The thyrohyoid muscle was selected in this study as a stimulating site because of the higher magnitude of infrahyoid compartment shortening for laryngeal excursion during swallowing compared with that of the suprahyoid group. Burnett et al.  observed that 50% of the laryngeal elevation that occurs during normal swallowing is due to paired stimulation of the mylohyoid and thyrohyoid muscles. The authors concluded that combined stimulation of suprahyoid muscles and the thyrohyoid muscle may have complementary actions on the hyoid bone and laryngeal suspension from the hyoid bone. Mylohyoid and thyrohyoid muscles have reciprocal attachments to the hyoid bone, which gives the greatest synergistic effect on laryngeal elevation. Thus, the entire larynx is elevated when the hyoid is raised by muscle contraction and the initial opening of the relaxed upper esophageal sphincter (UES) is achieved by laryngeal lifting.
The results of the present study contradicted the finding of Humbert et al. . The authors concluded that surface stimulation caused significant hyoid and laryngeal descent at rest, and reduced hyoid and laryngeal peak elevation during swallowing in healthy adults. Kiger et al.  further showed that the exercise group experienced greater improvement in both the oral and pharyngeal phases compared with the NMES group. These inconsistent results compared with the results of the present study may be attributed to different treatment conditions and to the number of stimulated muscles, as in the study by Humbert et al.  only suprahyoid muscles were stimulated, whereas in our study we stimulated two main sites: suprahyoid muscles in addition to thyrohyoid muscle.
In the present study, the twin-peak pulse was used according to the tolerance level of each patient at 80 Hz frequency. The NMES using the twin-peak pulse was well tolerated by patients. The results of the present study tend to be greatly consistent with those obtained by Leelamanit et al. , who found that treatment with NMES using the twin-peak pulse has potential for treating patients with reduced laryngeal elevation. Doeltgen et al.  reported that 5, 20 and 40 Hz frequency stimulation inhibited maximum evoked potentials amplitude, whereas 80 Hz frequency facilitated maximum evoked potentials amplitude on submental muscles. Freed et al.  also compared the effect of three different electrical stimulation frequencies on treatment of dysphagia (sensory, motor, and thermal stimulation). The authors found that electrical stimulation at the sensory and motor level had a success rate of submental muscle stimulation of 98.4% compared with 32.7% for thermal level. They added that lower frequencies are inhibitory when treating swallowing difficulties. In contrast to the results of the present study, Ludlow et al.  found that stimulation to both the submental and throat regions resulted in lowering of the hyoid in the neck. Aspiration and pooling were significantly reduced only with low sensory threshold levels of stimulation and not during maximum levels of surface electrical stimulation. Stimulation has acted to resist hyoid elevation during swallowing. This discrepancy between results from the study by Ludlow et al.  and the present study may be due to the difference in the type of the electrical stimulation current used.
The results of the current study revealed that laryngeal elevation helps to open the UES and improve laryngeal penetration and aspiration. This physiologic explanation is consistent with that of Leonard et al.  who found that larynx-to-hyoid approximation achieved its maximal value after UES opens and true vocal folds close and suggested that this gesture might be a secondary protective mechanism of the airway, sealing it more tightly during the time of greatest pressure in the pharynx. Yokoyama et al.  suggested that superior laryngeal movement protects the lower airway and prevents aspiration.
Leelamanit et al.  found that laryngeal elevation widens the pharynx and pulls forward the anterior wall of the UES. The UES is pulled open to accommodate the downward directed bolus. The authors attributed these results to the ability of the NMES to enhance the relearning process of the brain in controlling muscles involved in the swallowing mechanism to function properly. Oh et al.  also suggested that applying NMES to the laryngeal neck muscles improves swallowing function through a mechanism involving long-term cortical reorganization.
Mepani et al.  also reported a significant increase in UES opening and anterior excursion of larynx and hyoid during swallowing in patients with UES dysfunction, resulting in elimination of aspiration and resumption of oral intake. This effect is attributed to strengthening of the suprahyoid muscles, as evidenced by comparison of electromyographic changes in muscle fatigue before and after completion of the exercise regime. The results of the present study are in close agreement with those of Mepani et al. .
The results also revealed an improvement in bolus control and functional dietary intake by mouth on digital fluoroscopy. This may be attributed to improved tongue accuracy. Tongue training was beneficial for improving the functional aspects of swallowing. Similarly, Yeates et al.  concluded that improvement in tongue strength and tongue pressure generation following tongue pressure training was effective in improving swallowing function in dysphagic patients.
| Conclusion|| |
We conclude that a designed physical therapy program that combines exercise therapy with electrical stimulation has a significant beneficial effect on swallowing disorders (oropharyngeal dysphagia) in acute cerebrovascular stroke patients. The physical therapy program was safe and had a positive effect on the treatment of dysphagia in stroke patients, with no known adverse complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ney DM, Weiss JM, Kind AJ, Robbins J. Senescent swallowing: impact, strategies, and interventions. Nutr Clin Pract 2009; 24
Kendall KA, Leonard RJ, McKenzie S. Airway protection: evaluation with videofluoroscopy. Dysphagia 2004; 19
Rosenvinge SK, Starke ID. Improving care for patients with dysphagia. Age Ageing 2005; 34
Park CL, O'Neill PA, Martin DF. A pilot exploratory study of oral electrical stimulation on swallow function following stroke: an innovative technique. Dysphagia 1997; 12
Freed ML, Freed L, Chatburn RL, Christian M. Electrical stimulation for swallowing disorders caused by stroke. Respir Care 2001; 46
Shaw GY, Sechtem PR, Searl J, Keller K, Rawi TA, Dowdy E. Transcutaneous neuromuscular electrical stimulation (VitalStim) curative therapy for severe dysphagia: myth or reality? Ann Otol Rhinol Laryngol 2007; 116
Crary MA, Groher ME. Reinstituting oral feeding in tube-fed adult patients with dysphagia. Nutr Clin Pract 2006; 21
Sitoh YY, Lee A, Phua SY, Lieu PK, Chan SP. Bedside assessment of swallowing: a useful screening tool for dysphagia in an acute geriatric ward. Singapore Med J 2000; 41
Permsirivanich W, Tipchatyotin S, Wongchai M, Leelamanit V, Setthawatcharawanich S, Sathirapanya P, et al.
Comparing the effects of rehabilitation swallowing therapy vs. neuromuscular electrical stimulation therapy among stroke patients with persistent pharyngeal dysphagia: a randomized controlled study. J Med Assoc Thai 2009; 92
Burnett TA, Mann EA, Cornell SA, Ludlow CL. Laryngeal elevation achieved by neuromuscular stimulation at rest. J Appl Physiol 2003; 94
Humbert IA, Poletto CJ, Saxon KG, Kearney PR, Crujido L, Wright-Harp W, et al
. The effect of surface electrical stimulation on hyolaryngeal movement in normal individuals at rest and during swallowing. J Appl Physiol 2006; 101
Kiger M, Brown CS, Watkins L. Dysphagia management: an analysis of patient outcomes using VitalStim therapy compared to traditional swallow therapy. Dysphagia 2006; 21
Leelamanit V, Limsakul C, Geater A. Synchronized electrical stimulation in treating pharyngeal dysphagia. Laryngoscope 2002; 112
Doeltgen SH, Dalrymple-Alford J, Ridding MC, Huckabee ML. Differential effects of neuromuscular electrical stimulation parameters on submental motor-evoked potentials. Neurorehabil Neural Repair 2010; 24
Ludlow CL, Humbert I, Saxon K, Poletto C, Sonies B, Crujido L. Effects of surface electrical stimulation both at rest and during swallowing in chronic pharyngeal dysphagia. Dysphagia 2007; 22
Leonard RJ, Kendall KA, McKenzie S, Gonçalves MI, Walker A. Structural displacements in normal swallowing: a videofluoroscopic study. Dysphagia 2000; 15
Yokoyama M, Mitomi N, Tetsuka K, Tayama N, Niimi S. Role of laryngeal movement and effect of aging on swallowing pressure in the pharynx and upper esophageal sphincter. Laryngoscope 2000; 110
(Pt 1): 434-439.
Oh BM, Kim DY, Paik NJ. Recovery of swallowing function is accompanied by the expansion of the cortical map. Int J Neurosci 2007; 117
Mepani R, Antonik S, Massey B, Kern M, Logemann J, Pauloski B, et al
. Augmentation of deglutitive thyrohyoid muscle shortening by the Shaker Exercise. Dysphagia 2009; 24
Yeates EM, Molfenter SM, Steele CM. Improvements in tongue strength and pressure-generation precision following a tongue-pressure training protocol in older individuals with dysphagia: three case reports. Clin Interv Aging 2008; 3
[Table 1], [Table 2]