Mary Hägg

Lip muscle training in stroke patients with dysphagia

Conclusion. Training with an oral screen can improve lip force (LF) and swallowing capacity (SC) in stroke patients with oropharyngeal dysphagia, irrespective of the duration of pretreatment of dysphagia, and irrespective of the presence or absence of central facial paresis. It is more plausible that treatment results are attributable to sensory motor stimulation and the plasticity of the central nervous system than to the training of the lip muscles per se. Objectives. A close relationship has been demonstrated between LF and SC in stroke patients whether or not they are affected by facial paresis. It is not known how training of lip function can improve swallowing capacity. The present study was therefore designed to ascertain: (i) if training with an oral screen can improve the LF and SC of stroke patients with oropharyngeal dysphagia; to establish (ii) if improvement in LF and SC is connected with the presence or absence of central facial palsy, (iii) on the interval between stroke onset and initiation of treatment, (iv) on age, or (v) on sex. Subjects and methods. This was a retrospective study of 30 stroke patients, 49–88 years old, who were investigated with a Lip Force Meter, LF100 (LF100) and a swallowing capacity test (SCT) before and after a period of self-training lasting at least 5–8 weeks, using an oral screen. Initial central facial paresis was present in 24 patients. Results. The median LF was 7 Newtons (N) (range 0–27) before treatment and 18.5 N (range 7–44) after treatment (p<0.001). The median SC was 0 ml/s (range 0–9.1) before treatment and 12.1 ml/s (range 0–36.7) at follow-up (p<0.001). There was no significant difference in swallowing improvement between patients with versus those without facial paresis. The interval between stroke attack and start of treatment, ranging from a few days up to 10 years, had no significant influence on the treatment results, nor did age or sex. The facial paresis was improved or at least ameliorated in all patients after the lip training period.

Effects of Motor and Sensory Stimulation in Stroke Patients with Long-Lasting Dysphagia

Dysphagia is a common poststroke symptom with negative effects on recovery and rehabilitation. However, the orofacial regulation therapy, developed by Castillo Morales, comprising body regulation and orofacial regulation in combination with a palatal plate application has shown promising results in stroke patients. This therapy is based not only on muscle exercises but also on an improvement of the entire sensory-motor reflex arc involved in normal deglutition, and on the knowledge that the function of face and oropharynx at deglutition is closely interrelated with the entire body posture as well as with appropriate breathing. The treatment concept is relatively unknown to caregivers, partly due to lack of scientific evaluation of treatment results. The present investigation aimed to assess the effect of motor and sensory stimulation in stroke patients with dysphagia persisting for more than six months. Seven patients were evaluated with respect to orofacial and pharyngeal motility and sensory function before and two weeks after a five-week treatment period. The evaluation comprised a swallowing capacity test, a meal observation test, clinical examination of oral motor and sensory function, a velopharyngeal closure test, and videofluoroscopy. In addition, the symptoms were scored by the patients. An overall single-blind estimation showed objective and self-assessed swallowing improvement in all seven patients. Kappa coefficients are calculated on all reliability data, both inter- and intrarater reliabilities. Sensory and motor stimulation seems to be a promising therapy in stroke patients with long-lasting and persistent oropharyngeal dysphagia.

Influence of lip force on swallowing capacity in stroke patients and in healthy subjects.

Abstract Conclusion: In spite of no clinical signs of facial paresis, a pathological lip force (LF) will strongly influence swallowing capacity (SC). Stroke patients with impaired SC suffer a subclinical facial paresis. The results support earlier findings that LF training can be used to treat dysphagia. Objectives: Lip muscle training with an oral screen can improve both LF and SC in stroke patients, irrespective of the presence or absence of facial palsy. The aim was therefore to study the influence of LF on SC. Methods: This prospective study included 22 stroke patients, aged 38–90 years, with dysphagia, 12 with initial unilateral facial paresis and 45 healthy subjects, aged 25–87 years. All were investigated with a Lip Force Meter (LF100), and with an SC test. Results: A significant correlation was found between LF/SC (p = 0.012) in stroke patients but not in healthy subjects. LF/SC was not age-related in stroke patients. LF was not age-dependent in healthy subjects, but SC decreased with increasing age (p < 0.0001). However, SC did not reach a pathological value and a regression analysis showed that 73% of the variation in SC is attributable to LF and age.

Four-Quadrant Facial Function in Dysphagic Patients after Stroke and in Healthy Controls

This study aims to examine any motility disturbance in any quadrant of the face other than the quadrant innervated by the lower facial nerve contralateral to the cortical lesion after stroke. Thirty-one stroke-afflicted patients with subjective dysphagia, consecutively referred to a swallowing centre, were investigated with a facial activity test (FAT) in all four facial quadrants and with a swallowing capacity test (SCT). Fifteen healthy adult participants served as FAT controls. Sixteen patients were judged to have a central facial palsy (FP) according to the referring physician, but all 31 patients had a pathological FAT in the lower quadrant contralateral to the cortical lesion. Simultaneous pathology in all four quadrants was observed in 52% of stroke-afflicted patients with dysphagia; some pathology in the left or right upper quadrant was observed in 74%. Dysfunction in multiple facial quadrants was independent of the time interval between stroke and study inclusion. All patients except two had a pathological SCT. All the controls had normal activity in all facial quadrants. In summary the majority of poststroke patients with dysphagia have subclinical orofacial motor dysfunction in three or four facial quadrants as assessed with a FAT. However, whether subclinical orofacial motor dysfunction can be present in stroke-afflicted patients without dysphagia is unknown.

Longstanding Effect and Outcome Differences of Palatal Plate and Oral Screen Training on Stroke-Related Dysphagia

Aim: This study aimed at evaluating (1) if the oral training effect on stroke related dysphagia differs between two different oral appliances, a palatal plate (PP) and an oral screen (OS), and (2) if the training effect remains at a late follow-up. Methods: We included patients with stroke-related dysphagia at two different time periods: the first group of 12 patients studied in 1997- 2 002 had to train with a PP, the other one of 14 patients studied in 2003-2008 had to train with an OS. All patients were evaluated by a swallowing capacity test (SCT), and by a self-assessed visual analogue scale (VAS) of water swallowing capacity at entry of the study, after 13 weeks of training, and at a late follow-up. Results: At end of treatment the SCT had normalized in 33% of PP patients and in 71% of OS patients. There was a significant SCT improvement difference between the PP and OS groups in the period from baseline to late follow-up (p < 0.002) in favor of the OS group. VAS as tested at baseline and at end of treatment did not differ significantly between the two groups. Training with PP and with OS produced remaining improvement of SCT and of VAS as assessed at a late follow-up. Conclusion: The outcome of OS training on SCT in patients with stroke-related dysphagia seems to be superior to PP training. The improvement as assessed with VAS did not differ between the two groups. Training with PP or OS gives a longstanding improvement of SCT and VAS.

Effects on facial dysfunction and swallowing capacity of intraoral stimulation early and late after stroke

BACKGROUND Most patients with post-stroke dysphagia are also affected by facial dysfunction in all four facial quadrants. Intraoral stimulation can successfully treat post-stroke dysphagia, but its effect on post-stroke facial dysfunction remains unknown. OBJECTIVE This study aimed to investigate whether intraoral stimulation after stroke has simultaneous effects on facial dysfunction in the contralateral lower facial quadrant and in the other three facial quadrants, on lip force, and on dysphagia. METHODS Thirty-one stroke patients were treated with intraoral stimulation and assessed with a facial activity test, lip force test, and swallowing capacity test at three time-points: before treatment, at the end of treatment, and at late follow-up (over one year after the end of treatment). RESULTS Facial activity, lip force, and swallowing capacity scores were all improved between baseline and the end of treatment (P < 0.001 for each), with these improvements remaining at late follow-up. Baseline and treatment data did not significantly differ between patients treated short and late after stroke. CONCLUSIONS Treatment with intraoral stimulation significantly improved post-stroke dysfunction in all four facial quadrants, swallowing capacity, and lip force even in cases of long-standing post-stroke dysfunction. Furthermore, such improvement remained for over one year after the end of treatment.

Esophageal dysphagia and reflux symptoms before and after oral IQoro(R) training.

AIM To examine whether muscle training with an oral IQoro(R) screen (IQS) improves esophageal dysphagia and reflux symptoms. METHODS A total of 43 adult patients (21 women and 22 men) were consecutively referred to a swallowing center for the treatment and investigation of long-lasting nonstenotic esophageal dysphagia. Hiatal hernia was confirmed by radiologic examination in 21 patients before enrollment in the study (group A; median age 52 years, range: 19-85 years). No hiatal hernia was detected by radiologic examination in the remaining 22 patients (group B; median age 57 years, range: 22-85 years). Before and after training with an oral IQS for 6-8 mo, the patients were evaluated using a symptom questionnaire (esophageal dysphagia and acid chest symptoms; score 0-3), visual analogue scale (ability to swallow food: score 0-100), lip force test (≥ 15 N), velopharyngeal closure test (≥ 10 s), orofacial motor tests, and an oral sensory test. Another twelve patients (median age 53 years, range: 22-68 years) with hiatal hernia were evaluated using oral IQS traction maneuvers with pressure recordings of the upper esophageal sphincter and hiatus canal as assessed by high-resolution manometry. RESULTS Esophageal dysphagia was present in all 43 patients at entry, and 98% of patients showed improvement after IQS training [mean score (range): 2.5 (1-3) vs 0.9 (0-2), P < 0.001]. Symptoms of reflux were reported before training in 86% of the patients who showed improvement at follow-up [1.7 (0-3) vs 0.5 (0-2), P < 0.001). The visual analogue scale scores were classified as pathologic in all 43 patients, and 100% showed improvement after IQS training [71 (30-100) vs 22 (0-50), P < 0.001]. No significant difference in symptom frequency was found between groups A and B before or after IQS training. The lip force test [31 N (12-80 N) vs 54 N (27-116), P < 0.001] and velopharyngeal closure test values [28 s (5-74 s) vs 34 s (13-80 s), P < 0.001] were significantly higher after IQS training. The oral IQS traction results showed an increase in mean pressure in the diaphragmatic hiatus region from 0 mmHg at rest (range: 0-0 mmHG) to 65 mmHg (range: 20-100 mmHg). CONCLUSION Oral IQS training can relieve/improve esophageal dysphagia and reflux symptoms in adults, likely due to improved hiatal competence.

Effect of oral IQoro R and palatal plate training in post-stroke, four-quadrant facial dysfunction and dysphagia: A comparison study

Abstract Conclusion: Training with either a palatal plate (PP) or an oral IQoroR screen (IQS) in patients with longstanding facial dysfunction and dysphagia after stroke can significantly improve facial activity (FA) in all four facial quadrants as well as swallowing capacity (SC). Improvements remained at late follow-up. The training modalities did not significantly differ in ameliorating facial dysfunction and dysphagia in these patients. However, IQS training has practical and economic advantages over PP training. Objectives: This study compared PP and oral IQS training in terms of (i) effect on four-quadrant facial dysfunction and dysphagia after a first-ever stroke, and (ii) whether the training effect persisted at late follow-up. Methods: Patients were included during two periods; 13 patients in 2005–2008 trained with a PP, while 18 patients in 2009–2012 trained with an IQS. Four-quadrant facial dysfunction was assessed with an FA test and swallowing dysfunction with a SC test: before and after a 3-month training period and at late follow-up. FA and SC significantly improved (p < 0.001) in both groups. FA test scores after training and at late follow-up did not differ significantly between the groups, irrespective of whether the interval between stroke incidence and the start of training was long or short.

Effect of IQoro R training in hiatal hernia patients with misdirected swallowing and esophageal retention symptoms

Abstract Conclusion: Misdirected swallowing can be triggered by esophageal retention and hiatal incompetence. The results show that oral IQoroR screen (IQS) training improves misdirected swallowing, hoarseness, cough, esophageal retention, and globus symptoms in patients with hiatal hernia. Objectives: The present study investigated whether muscle training with an IQS influences symptoms of misdirected swallowing and esophageal retention in patients with hiatal hernia. Methods: A total of 28 adult patients with hiatal hernia suffering from misdirected swallowing and esophageal retention symptoms for more than 1 year before entry to the study were evaluated before and after training with an IQS. The patients had to fill out a questionnaire regarding symptoms of misdirected swallowing, hoarseness, cough, esophageal retention, and suprasternal globus, which were scored from 0–3, and a VAS on the ability to swallow food. The effect of IQS traction on diaphragmatic hiatus (DH) pressure was recorded in 12 patients with hiatal hernia using high resolution manometry (HRM). Results: Upon entry into the study, misdirected swallowing, globus sensation, and esophageal retention symptoms were present in all 28 patients, hoarseness in 79%, and cough in 86%. Significant improvement was found for all symptoms after oral IQS training (p < 0.001). Traction with an IQS resulted in a 65 mmHg increase in the mean HRM pressure of the DH.

Effect of IQoro® training on impaired postural control and oropharyngeal motor function in patients with dysphagia after stroke

Abstract Conclusion All patients with dysphagia after stroke have impaired postural control. IQoro® screen (IQS) training gives a significant and lasting improvement of postural control running parallel with significant improvement of oropharyngeal motor dysfunction (OPMD). Objectives The present investigation aimed at studying the frequency of impaired postural control in patients with stroke-related dysphagia and if IQS training has any effect on impaired postural control in parallel with effect on OPMD. Method A prospective clinical study was carried out with 26 adult patients with stroke-related dysphagia. The training effect was compared between patients consecutively investigated at two different time periods, the first period with 15 patients included in the study more than half a year after stroke, the second period with 11 patients included within 1 month after stroke. Postural control tests and different oropharyngeal motor tests were performed before and after 3 months of oropharyngeal sensorimotor training with an IQS, and at a late follow-up (median 59 weeks after end of training). Result All patients had impaired postural control at baseline. Significant improvement in postural control and OPMD was observed after the completion of IQS training in both intervention groups. The improvements were still present at the late follow-up.