Dysphagia After Different Swallowing Therapies

Study Overview
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Brief Summary
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Dysphagia after stroke is associated to increased pulmonary complications and mortality. The swallowing therapies could decrease the pulmonary complications and improve the quality of life after stroke. The swallowing therapies include dietary modifications, thermal stimulation, compensatory positions, and oropharyngeal muscle stimulation. Most researchers used clinical assessments and videofluoroscopy to evaluate the effect of the swallowing therapies. Some authors performed functional magnetic resonance imaging (fMRI) to investigate the brain neuroactivity during swallowing with tasks in normal adults and unilateral hemispheric stroke patients. The aim of this study is to explore the effect of swallowing therapies not only in clinical swallowing function but also brain plasticity of acute stroke patients with dysphagia by videofluoroscopy and fMRI.

Detailed Description
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In the study, 10 healthy controls and 48 patients with a single and acute hemispheric or brain stem stroke will be enrolled. Both 24 hemispheric and 24 brain stem stroke patients will be divided into 3 groups. General swallowing therapy, oropharyngeal neuromuscular electrical stimulation (NMES), and combined general and NMES therapies will be randomly provided for the 3 groups. Each patient will receive clinical assessment of food oral intake scale, functional dysphagia scale of videofluoroscopy, and brain neuroactivity in fMRI. The investigators hope to find the benefit of the swallowing therapies both in clinical swallowing function and in brain functional neuroactivity/reorganization after acute stroke. While comparing the 3 swallowing therapies, different functional neuroactivity may be facilitated by different swallowing therapies. Finally, the investigators could also find out the most effective swallowing therapy among the 3 therapies in acute stroke patients with dysphagia according to the findings of videofluoroscopy and fMRI.

Official Title
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Acute Stroke Patients With Dysphagia After Different Swallowing Therapies: Videofluoroscopy Findings and Brain Plasticity in Magnetic Resonance Imaging

Conditions
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Videofluoroscopy, Stroke, Dysphagia

Intervention / Treatment
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* Other: general swallowing therapy
* Other: NMES therapy


Participation Criteria
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Eligibility Criteria
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Inclusion criteria of normal controls: normal neurological examination no history of stroke no active neurological disorder Inclusion criteria of hemispheric stroke patients: a single cerebral hemispheric stroke swallowing difficulty: detected by bedside swallow assessment by a physician while admitting to the rehabilitation unit. Inclusion criteria of these brain stem stroke patients: a single brain stem stroke without prior stroke history swallowing difficulties: detected by bedside swallow assessment by a physician while admitting to the rehabilitation unit Exclusion criteria: multiple brain lesions due to one episode of stroke impaired communication ability due to cognition deficit other central or peripheral neurological deficit leading to swallowing difficulty. use of an electrically sensitive biomedical device (eg. cardiac pacemaker) metal clip in the brain pneumonia at the time of enrollment.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 80 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Other: general swallowing therapy<br>including: oral exercises tactile stimulation compensatory techniques swallowing maneuvers | Other: general swallowing therapy<br>* including a session of oral exercises, tactile stimulation, compensatory techniques, swallowing maneuvers that are taught to the participants by a speech therapist.<br>|
| Experimental: the NMES therapy with VitalStim therapeutic device<br>The placement of 2-channel electrodes is depended on the dysphagic types and the findings on VFS | Other: NMES therapy<br>* he NMES therapy with VitalStim therapeutic device will be done by one physician who is licensed practitioner and certified in use of the VitalStim device. The placement of 2-channel electrodes is depended on the dysphagic types and the findings on VFS.<br>|
| Active Comparator: : the combined NMES and general swallowing therapies<br> | Other: general swallowing therapy<br>* including a session of oral exercises, tactile stimulation, compensatory techniques, swallowing maneuvers that are taught to the participants by a speech therapist.<br>Other: NMES therapy<br>* he NMES therapy with VitalStim therapeutic device will be done by one physician who is licensed practitioner and certified in use of the VitalStim device. The placement of 2-channel electrodes is depended on the dysphagic types and the findings on VFS.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The functional oral intake scale | Clinical swallowing evaluations: The functional oral intake scale (FOIS) was reported by Crary et al. for presenting the functional oral intake of food and liquid in stroke patients. One physician who is blinded to the therapies will evaluate the FOIS for each participant before and after swallowing treatments. | baseline (before intervention), changes from baseline FOIS at 4 weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| 8-point penetration-aspiration scale (PAS) | VFS is a standard tool for swallowing disorders. A 8-point penetration-aspiration scale (PAS) is used for observing the event of penetration or aspiration on VFS. | baseline (before intervention), changes from baseline PAS score at 4 weeks | 
| 11-item functional dysphagia scale (FDS) | A 11-item functional dysphagia scale (FDS) of VFS is a sensitive and specific method for quantifying swallowing function in stroke. | baseline (before intervention), changes from baseline FDS score at 4weeks | 
| 3-Dimensional (3D) structural MRI | MR images are obtained using a 3.0-T whole body magnet with a 50- and 23-mT/m gradient strength, and an echo-planar-capable receiver (GE SIGNA EXCITE HD, GE Medical Systems, Milwaukee, US). A 3-dimensional (3D) structural MRI is acquired for each subject using a T1-weighted gradient echo magnetization prepared rapid gradient echo sequence yielding 124 sagittal slices with a defined voxel size of 1 x 1 x 1.5 mm. | baseline (before intervention), changes from baseline result of 3-Dimensional (3D) structural MRI at 4 weeks | 
| Function MRI | MR images are obtained using a 3.0-T whole body magnet with a 50- and 23-mT/m gradient strength, and an echo-planar-capable receiver (GE SIGNA EXCITE HD, GE Medical Systems, Milwaukee, US). The functional images are obtained using an EPI sequence with the following parameters: 33 axial slices, image resolution = 3.75*3.75*4, and TR= 2000 ms. | baseline (before intervention), changes from baseline result of fMRI at 4 weeks | 
| Diffusion tensor imaging | MR images are obtained using a 3.0-T whole body magnet with a 50- and 23-mT/m gradient strength, and an echo-planar-capable receiver (GE SIGNA EXCITE HD, GE Medical Systems, Milwaukee, US). An 8 channels diffusion tensor imaging (DTI) acquisition protocol will be used to acquire high resolution DTI, i.e. 2 x 2 x 2 mm3 voxel size. With 13 diffusion encoding directions and number of average of 4, whole brain DTI and high resolution eigenvector field can be acquired within 20 mins. | baseline (before intervention), changes from baseline result of diffusion tensor imaging at 4 weeks | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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stroke, dysphagia, magnetic resonance imaging, videofluoroscopy