Arquivo da categoria: Stroke

Failed Deglutitive Upper Esophageal Sphincter Relaxation Is a Risk Factor for Aspiration in Stroke Patients with Oropharyngeal Dysphagia.

J Neurogastroenterol Motil. 2016 Aug 10. doi: 10.5056/jnm16028. [Epub ahead of print]



We attempted to examine the relationship between abnormal findings on high-resolution manometry (HRM) and videofluoroscopic swallowing study (VFSS) of the pharynx and upper esophageal sphincter (UES) and to identify the risk factors for aspiration.


We performed VFSS and HRM on the same day in 36 ischemic stroke patients (mean age, 67.5 years) with dysphagia. Pressure (basal, median intra bolus, nadir), relaxation time interval of the UES, and mesopharyngeal and hypopharyngeal contractility (as a contractile integral) were examined using HRM. The parameters of VFSS were vallecular residue, pyriform sinus residue, vallecular overflow, penetration, and aspiration. The association between the parameters of VFSS and HRM was analyzed by the Student’s t test.


Three (8.3 %) and 4 (11.1 %) stroke patients with dysphagia had pyriform sinus residue and vallecular sinus residue, respectively, and 5 (13.8%) patients showed aspiration. Mesopharyngeal and hypopharyngeal contractile integrals in patients with residue in pyriform sinus were significantly lower than those in patients without residue in pyriform sinus (P < 0.05, respectively). Relaxation time intervals in patients with aspiration were significantly shorter than those in patients without aspiration (P < 0.05), and multivariate regression analysis revealed a shorter relaxation time interval as the main risk factor for aspiration (odds ratio, 0.025; 95% confidence interval, 0.001-0.652).


Manometric measurements of the pharynx and UES were well correlated with abnormal findings in the VFSS and a shorter relaxation time interval of the UES during deglutition is an important parameter for the development of aspiration.



Effects of neuromuscular electrical stimulation combined with effortful swallowing on post-stroke oropharyngeal dysphagia: a randomised controlled trial.

J Oral Rehabil. 2016 Jun;43(6):426-34. doi: 10.1111/joor.12390. Epub 2016 Mar 9.
Park JS1, Oh DH2, Hwang NK3, Lee JH4.


Neuromuscular electrical stimulation (NMES) has been used as a therapeutic intervention for dysphagia. However, the therapeutic effects of NMES lack supporting evidence. In recent years, NMES combined with traditional swallowing therapy has been used to improve functional recovery in patients with post-stroke dysphagia. This study aimed to investigate the effects of effortful swallowing combined with neuromuscular electrical stimulation on hyoid bone movement and swallowing function in stroke patients. Fifty stroke patients with mild dysphagia who were able to swallow against the resistance applied by using NMES and cooperate actively in training were included. This study was designed as a 6-week single-blind, randomised, controlled study. In the experimental group, two pairs of electrodes were placed horizontally in the infrahyoid region to depress the hyoid bone. The NMES intensity was increased gradually until the participants felt a grabbing sensation in their neck and performed an effortful swallow during the stimulation. In the placebo group, the same procedure was followed except for the intensity, which was increased gradually until the participants felt an electrical sensation. All participants underwent this intervention for 30 min per session, 5 sessions per week, for 6 weeks. Videofluoroscopic swallowing studies (VFSS) were carried out before and after the intervention and kinematics of the hyoid bone and swallowing function were analysed based on the VFSS. The experimental group revealed a significant increase in anterior and superior hyoid bone movement and the pharyngeal phase of the swallowing function. This intervention can be used as a novel remedial approach in dysphagic stroke patients.


Effect of the Masako maneuver and neuromuscular electrical stimulation on the improvement of swallowing function in patients with dysphagia caused by stroke.

J Phys Ther Sci. 2016 Jul;28(7):2069-71. doi: 10.1589/jpts.28.2069. Epub 2016 Jul 29.


[Purpose] The aim of this study was to compare improvements in swallowing function by the intervention of the Masako maneuver and neuromuscular electrical stimulation in patients with dysphagia caused by stroke. [Subjects and Methods] The Masako maneuver (n=23) and neuromuscular electrical stimulation (n=24) were conducted in 47 patients with dysphagia caused by stroke over a period of 4 weeks. Swallowing recovery was recorded using the functional dysphagia scale based on videofluoroscopic studies. [Results] Mean functional dysphagia scale values for the Masako maneuver and neuromuscular electrical stimulation groups decreased after the treatments. However, the pre-post functional dysphagia scale values showed no statistically significant differences between the groups. [Conclusion] The Masako maneuver and neuromuscular electrical stimulation each showed significant effects on the improvement of swallowing function for the patients with dysphagia caused by stroke, but no significant difference was observed between the two treatment methods.


Instrumentos de rastreio para disfagia orofaríngea no acidente vascular encefálico

Almeida, Tatiana Magalhães de;  Cola, Paula Cristina;  Pernambuco, Leandro de Araújo;  Magalhães Junior, Hipólito Virgílio;  Silva, Roberta Gonçalves da.

Audiology – Communication Research, Dez 2015, Volume 20  4 Páginas 361 – 370




Identificar os parâmetros presentes nos instrumentos de rastreio para a disfagia orofaríngea no acidente vascular encefálico, publicados na literatura.

Estratégia de pesquisa:

Para a seleção dos estudos, foram utilizados os descritores: transtornos de deglutição, acidente vascular cerebral, rastreio, screening, avaliação e disfagia. Foram consultadas as bases de dados MEDLINE, Embase, LILACS, SciELO e biblioteca Cochrane.

Critérios de seleção:

Foram selecionados artigos em inglês, português e espanhol, publicados até dezembro de 2014, cuja abordagem metodológica referisse instrumentos de rastreio para a disfagia orofaríngea, elaborados para indivíduos adultos com acidente vascular encefálico. Os parâmetros utilizados nos diferentes instrumentos de rastreio foram agrupados por igualdade e/ou semelhança. Foi realizada análise descritiva e calculada a frequência dos parâmetros encontrados.


Foram encontrados 688 artigos e, após consideração dos critérios de inclusão e exclusão, 23 artigos foram efetivamente analisados. Dos 20 instrumentos encontrados, 90% utilizaram algum tipo de oferta via oral no rastreio para a disfagia, sendo a maioria, a água. Foram encontrados 19 parâmetros distintos, não relacionados à oferta de alimento e 12 parâmetros relacionados à oferta de alimento.


Não há consenso, entre os estudos, sobre os parâmetros mais sensíveis e específicos para compor o método de rastreio para disfagia orofaríngea na população com acidente vascular encefálico.


Respiratory muscle strength training and neuromuscular electrical stimulation in subacute dysphagic stroke patients: A randomized controlled trial

Guillén-Solà A, Messagi Sartor M, Bofill Soler N, Duarte E, Barrera MC, Marco E.

Clin Rehabil. 2016 Jun 7. pii: 0269215516652446. [Epub ahead of print]



To evaluate the effectiveness of inspiratory/expiratory muscle training (IEMT) and neuromuscular electrical stimulation (NMES) to improve dysphagia in stroke.


Prospective, single-blind, randomized-controlled trial.


Tertiary public hospital.


Sixty-two patients with dysphagia were randomly assigned to standard swallow therapy (SST) (Group I, controls, n=21), SST+ IEMT (Group II, n=21) or SST+ sham IEMT+ NMES (Group III, n=20).


All patients followed a 3-week standard multidisciplinary rehabilitation program of SST and speech therapy. The SST+IEMT group’s muscle training consisted of 5 sets/10 repetitions, twice-daily, 5 days/week. Group III’s sham IEMT required no effort; NMES consisted of 40-minute sessions, 5 days/week, at 80Hz.


Dysphagia severity, assessed by Penetration-Aspiration Scale, and respiratory muscle strength (maximal inspiratory and expiratory pressures) at the end of intervention and 3-month follow-up.


Maximal respiratory pressures were most improved in Group II: treatment effect was 12.9 (95% confidence interval 4.5-21.2) and 19.3 (95% confidence interval 8.5-30.3) for maximal inspiratory and expiratory pressures, respectively. Swallowing security signs were improved in Groups II and III at the end of intervention. No differences in Penetration-Aspiration Scale or respiratory complications were detected between the 3 groups at 3-month follow-up.


Adding IEMT to SST was an effective, feasible, and safe approach that improved respiratory muscle strength. Both IEMT and NMES were associated with improvement in pharyngeal swallowing security signs at the end of the intervention, but the effect did not persist at 3-month follow-up and no differences in respiratory complications were detected between treatment groups and controls.

© The Author(s) 2016.




Rehabilitation of swallowing and cough functions following stroke: an expiratory muscle strength training trial

Hegland KW, Davenport PW, Brandimore AE, Singletary FF, Troche MS.

Arch Phys Med Rehabil. 2016 Apr 26. pii: S0003-9993(16)30078-8. doi: 10.1016/j.apmr.2016.03.027.




To determine the effect of expiratory muscle strength training on both cough and swallow function in stroke patients.


Prospective pre-post intervention trial with one participant group.


Two outpatient rehabilitation clinics PARTICIPANTS: Fourteen adults with a history of ischemic stroke in the preceding 3 – 24 months participated in this study.


Expiratory muscle strength training (EMST). The training program was completed at home and consisted of 25 repetitions per day, 5 days per week, for 5 weeks.


Baseline and post-training measures were: maximum expiratory pressure, voluntary cough airflows, reflex cough challenge to 200μM capsaicin, sensory perception of urge-to-cough, and fluoroscopic swallow evaluation. Repeated measures and one-way analyses of variance were used to determine significant differences pre/post training.


Maximum expiratory pressure increased in all participants by an average of 30cmH2O post training. At baseline, all participants demonstrated a blunted reflex cough response to 200 μM capsaicin. Following 5 weeks of training, measures of urge to cough and cough effectiveness increased for reflex cough, however voluntary cough effectiveness did not increase. Swallow function was minimally impaired at baseline, and there were no significant changes in the measures of swallow function post training.


Expiratory muscle strength training improves both expiratory muscle strength, reflex cough strength and urge-to-cough. Voluntary cough and swallow measures were not significantly different post training. It may be that stroke patients benefit from the training for up-regulation of reflex cough and thus improved airway protection.


Evolução de Pacientes com Disfagia Orofaríngea em Ambiente Hospitalar

Abdulmassih EMS, Filho EDM, Santos RS, Jurkiewicz AL. Evolution of Patients with Oropharyngeal Dysphasia in Hospital Environment.

Int. Arch. Otorhinolaryngol. 2009;13(1):55-62


Introdução: A disfagia orofaríngea de etiologia neurogênica pode causar risco clínico nutricional e comprometimento laringo traqueal por aspiração, podendo culminar em broncopneumonia aspirativa. Esta condição está presente na rotina das avaliações do fonoaudiólogo que atua em ambiente hospitalar junto a pacientes pós acidente vascular encefálico (AVE). Objetivo: O objetivo deste estudo foi avaliar a evolução de pacientes portadores de disfagia orofaríngea neurogênica pós AVE, durante o período de internação até o momento da alta hospitalar, analisando grau da disfagia no pré-tratamento; diagnóstico instrumental; condutas fonoaudiológicas; condições do paciente na alta hospitalar. Método: Foram estudados 39 pacientes no período de dezembro de 2003 a junho de 2004, com queixa de dificuldade de deglutição sugestiva de disfagia. Foi elaborado um protocolo padronizado para a coleta dos dados clínicos. Conclusão: Os resultados permitiram concluir que: houve prevalência da disfagia de grau moderado, seguida pelos graus leve e severo; no diagnóstico instrumental ocorreu à prevalência de aspiração laríngea, seguida de alteração na fase orofaríngea, penetração laríngea, alteração na fase oral da deglutição; nas condutas fonoaudiológicas a manipulação de alimentos apresentou excelente resultado seguida das manobras posturais e das manobras protetivas; na alta hospitalar a prevalência foi de sujeitos que apresentaram estado clínico de nível bom, alimentando-se por via oral, com algumas modificações posturais e/ou da consistência alimentar sem o uso de sonda, seguido pelos que apresentaram nível regular, iniciando com dieta via oral fazendo uso de sonda, mas com possibilidade de retirada entre 30 a 60 dias do período hospitalar.