N. Vilardell

Post-stroke dysphagia: progress at last.

Oropharyngeal Dysphagia (OD) is both underestimated and underdiagnosed as a cause of malnutrition and respiratory complications following stroke. OD occurs in more than 50% of stroke patients. Aspiration pneumonia (AP) occurs in up to 20% of acute stroke patients and is a major cause of mortality after discharge. Systematic screening for OD should be performed on every patient with stroke before starting oral feeding, followed, if appropriate by clinical and instrumental (videofluroscopy and/or fiberoptic endoscopy) assessment. Bolus modification with adaptation of texture and viscosity of solids and fluids and postural adjustments should be part of the minimal treatment protocol, but they do not change the impaired swallow physiology nor promote recovery of damaged neural swallow networks in stroke patients. To this purpose, two new neurostimulation approaches are being developed to stimulate cortical neuroplasticity to recover swallowing function: (i) those aimed at stimulating the peripheral oropharyngeal sensory system by chemical, physical or electrical stimulus; and (ii) those aimed at directly stimulating the pharyngeal motor cortex, such as repetitive transcranial magnetic stimulation (rTMS). The study of Park et al. in this issue of Neurogastroenterology and Motility evaluated the effect of rTMS in dysphagic stroke patients and showed a marked improvement in swallow physiology. Other studies also using rTMS showed plastic changes in pharyngeal motor cortical areas relevant to swallowing function. If further randomized controlled trials confirm these initial results, the neurorehabilitation strategies will be introduced to clinical practice sooner rather than later, improving the recovery of dysphagic stroke patients. Progress at last.

Neurorehabilitation strategies for poststroke oropharyngeal dysphagia: from compensation to the recovery of swallowing function

Oropharyngeal dysphagia (OD) is very prevalent among poststroke patients, causing severe complications but lacking specific neurorehabilitation treatment. This review covers advances in the pathophysiology, diagnosis, and physiologically based neurorehabilitation strategies for poststroke OD. The pathophysiology of oropharyngeal biomechanics can be assessed by videofluoroscopy, as delayed laryngeal vestibule closure is closely associated with aspiration. Stroke may affect afferent or efferent neuronal circuits participating in deglutition. The integrity of oropharyngeal–cortical afferent pathways can be assessed by electroencephalography through sensory‐evoked potentials by pharyngeal electrical stimulation, while corticopharyngeal efferent pathways can be characterized by electromyography through motor‐evoked potentials by transcranial magnetic stimulation. Dysfunction in both cortico‐mediated evoked responses is associated with delayed swallow response and aspiration. Studies have reported hemispherical asymmetry on motor control of swallowing and the relevance of impaired oropharyngeal sensitivity on aspiration. Advances in treatment include improvements in compensatory strategies but are mainly focused on (1) peripheral stimulation strategies and (2) central, noninvasive stimulation strategies with evidence of their clinical benefits. Characterization of poststroke OD is evolving from the assessment of impaired biomechanics to the sensorimotor integration processes involved in deglutition. Treatment is also changing from compensatory strategies to promoting brain plasticity, both to recover swallow function and to improve brain‐related swallowing dysfunction.

Spatiotemporal characteristics of the pharyngeal event-related potential in healthy subjects and older patients with oropharyngeal dysfunction.

Oropharyngeal dysphagia (OD) is a highly prevalent symptom in older people. Appropriate oropharyngeal sensory feedback is essential for safe and efficient swallowing. However, pharyngeal sensitivity decreases with advancing age and could play a fundamental role in the physiopathology of swallowing dysfunction associated with aging. We aimed to characterize pharyngeal sensitivity and cortical response to a pharyngeal electrical stimulus in healthy volunteers (HV) and older patients with and without OD.

Neuogenic and oropharyngeal dysphagia

Oropharyngeal dysphagia (OD) is a swallowing disorder caused by congenital abnormalities and structural damage and disease‐associated damage of the oral cavity, pharynx, and upper esophageal sphincter. Patients with OD lack the protective mechanisms necessary for effective swallowing, exhibiting difficulty controlling food in the mouth and initiating a swallow, leading to choking, coughing, and nasal regurgitation. OD is a major risk factor for malnutrition, dehydration, and aspiration pneumonia. The following on OD includes commentaries on the application of simulation of oropharyngeal transient receptor potential vanilloid 1 (TRPV1) and maneuvers like the Shaker exercise to improve the safety and efficacy of swallow in OD patients; the prevalence of esophageal pathologies in OD patients and the need to evaluate the esophagus, esophagogastric junction, and stomach; and strategies for clinical screening to detect OD and aspiration among high‐risk patients and to improve oral health care, maintain nutrition and hydration, and prevent aspiration pneumonia.

Cough reflex attenuation and swallowing dysfunction in sub-acute post-stroke patients: prevalence, risk factors, and clinical outcome.

Cough and swallowing impairments in post‐stroke patients (PSP) have been associated with increased risk for respiratory complications.

Videofluoroscopic assessment of the pathophysiology of chronic poststroke oropharyngeal dysphagia

Oropharyngeal dysphagia (OD) is a major complaint following stroke, associated with poor clinical outcome and high mortality rates. We aimed at characterizing the kinematics of swallow response associated with unsafe swallowing in chronic poststroke patients with OD.

Neurogenic [corrected] and oropharyngeal dysphagia.

Oropharyngeal dysphagia (OD) is a swallowing disorder caused by congenital abnormalities and structural damage and disease‐associated damage of the oral cavity, pharynx, and upper esophageal sphincter. Patients with OD lack the protective mechanisms necessary for effective swallowing, exhibiting difficulty controlling food in the mouth and initiating a swallow, leading to choking, coughing, and nasal regurgitation. OD is a major risk factor for malnutrition, dehydration, and aspiration pneumonia. The following on OD includes commentaries on the application of simulation of oropharyngeal transient receptor potential vanilloid 1 (TRPV1) and maneuvers like the Shaker exercise to improve the safety and efficacy of swallow in OD patients; the prevalence of esophageal pathologies in OD patients and the need to evaluate the esophagus, esophagogastric junction, and stomach; and strategies for clinical screening to detect OD and aspiration among high‐risk patients and to improve oral health care, maintain nutrition and hydration, and prevent aspiration pneumonia.

Oropharyngeal Dysphagia and Swallowing Dysfunction

Oropharyngeal dysphagia (OD) is a disorder causing difficulty to form or move the alimentary bolus safely from the mouth to the esophagus. The three main populations at risk for OD are the elderly, patients with neurological diseases, and patients with head and neck diseases. OD may cause severe complications such as malnutrition and/or dehydration, choking and tracheobronchial aspiration which results in aspiration pneumonia with high mortality rates. OD may be caused by inability to mix the bolus and position it on the tongue in the oral phase. In the pharyngeal phase, OD is caused by delayed, prolonged or uncoordinated arrangement of oropharyngeal structures from a respiratory to a digestive pathway, and/or impaired transfer of the bolus from the mouth to the esophagus with reduced bolus propulsion and/or impaired upper esophageal sphincter (UES) relaxation. The sequential diagnostic procedure for patients at risk for OD includes: (a) screening of symptoms; (b) bedside clinical assessment, and (c) instrumental diagnosis. Videofluoroscopy can assess signs of safety and efficacy of deglutition, measure the swallow response and select therapeutic strategies. The Fiberoptic endoscopic evaluation of swallowing test studies pharyngeal/laryngeal anatomy, sensitivity and movement, aspirations, secretions, and the effect of treatments. Pharyngo-UES high-resolution manometry measures pharyngeal contraction and UES relaxation, and pharyngeal impedance detects postswallow residue and determines risk of aspirations. Therapeutic strategies for the treatment of OD include behavioral treatments, such as bolus modification (volume, viscosity), postural adjustment, motor behavioral techniques, swallow maneuvers, and sensory and neurophysiologic interventions. Alternative therapeutic strategies include surgical procedures at the UES, tube feeding and percutaneous endoscopic gastrostomy. New peripheral and central neuromodulation techniques have the potential to induce plastic changes in pharyngeal motor cortical areas that can be relevant for swallowing function.

Prevalence, risk factors and complications of oropharyngeal dysphagia in stroke patients: A cohort study

Oropharyngeal dysphagia (OD) is a prevalent poststroke condition with severe complications and increased mortality. Poststroke OD prevalence varies among studies and there is little evidence of its related risk factors and associated complications. Objective: to evaluate the prevalence of OD after stroke and the risk factors and associated complications.

Neuogenic and oropharyngeal dysphagia: Neuogenic and oropharyngeal dysphagia

Oropharyngeal dysphagia (OD) is a swallowing disorder caused by congenital abnormalities and structural damage and disease‐associated damage of the oral cavity, pharynx, and upper esophageal sphincter. Patients with OD lack the protective mechanisms necessary for effective swallowing, exhibiting difficulty controlling food in the mouth and initiating a swallow, leading to choking, coughing, and nasal regurgitation. OD is a major risk factor for malnutrition, dehydration, and aspiration pneumonia. The following on OD includes commentaries on the application of simulation of oropharyngeal transient receptor potential vanilloid 1 (TRPV1) and maneuvers like the Shaker exercise to improve the safety and efficacy of swallow in OD patients; the prevalence of esophageal pathologies in OD patients and the need to evaluate the esophagus, esophagogastric junction, and stomach; and strategies for clinical screening to detect OD and aspiration among high‐risk patients and to improve oral health care, maintain nutrition and hydration, and prevent aspiration pneumonia.