Effects of Oropharyngeal Strengthening on Dysphagia in Patients Post-stroke (StrokeStrong)
Effects of Device-Facilitated Isometric Progressive Resistance Oropharyngeal (I-PRO) Therapy on Dysphagia Related Outcomes in Patients Post-stroke
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Dysphagia is estimated to occur in up to 76% of acute stroke patients1,2 and by 2030 the prevalence of stroke is estimated to rise by 21%.3 Serious health complications may result from the presence of dysphagia following stroke, including the development of aspiration pneumonia, malnutrition, and mortality.4-6 Developing pneumonia post-stroke results in a significantly increased relative risk (2.99) of death within 30 days of hospital discharge.1 Compensatory approaches to intervention, including postures or diet modification, are commonly used but do not enact lasting change in swallowing function. Early and intensive therapy approaches are suggested for attainment of optimal swallowing outcomes.7 The tongue is the primary propulsive force for movement of the bolus through the oral cavity and pharynx and into the cervical esophagus during swallowing. Patients post-stroke demonstrate lower than normal maximum isometric lingual pressures, measured as pressures produced when the tongue is pushed as hard as possible against the palate.2 Progressive resistance training for the tongue and related oropharyngeal musculature has been shown to improve swallow physiology and quality of life for patients post-stroke.8 Previous studies have examined Isometric Progressive Resistance Oropharyngeal (I-PRO) therapy facilitated by the Iowa Oral Pressure Instrument (IOPI) for lingual strengthening. The recently developed SwallowSTRONG® device consists of a customized, adjustable mouthpiece that provides pressure readings from embedded sensors allowing for consistent tongue placement, immediate knowledge of performance levels, and automatic calculation of therapeutic strengthening targets. Results from a federally-funded Department of Veterans Affairs Clinical Demonstration Program that employed use of device-facilitated (DF) I-PRO therapy showed improved swallowing-related outcomes in a group of patients with oropharyngeal dysphagia resulting from a variety of medical etiologies.9 The effects of this therapy approach on various aspects of swallowing function and health status in a group of post-stroke patients have yet to be examined. In addition, ideal treatment duration for use with stroke patients is unknown.
The long term goal of this work is to develop more effective, evidence-based treatments that improve overall health status related to swallowing-specific changes for patients with dysphagia. The preliminary group data generated will provide the basis for a line of work dedicated to determination of effective treatments for patients post-stroke.
Specific Aims include: 1) determine differences in swallowing physiology and bolus flow measures a) between a group of unilateral ischemic stroke subjects undergoing DF I-PRO therapy and a control group and b) between two durations of treatment (8 and 12 weeks); 2) examine changes in level of oral intake and swallowing quality of life in post-stroke patients undergoing I-PRO therapy as compared to a control group and as they relate to treatment duration response at 8 weeks and 12 weeks; and 3) evaluate effects of DF I-PRO therapy on overall health status reflected by the number of pneumonia diagnoses and overall hospital readmission rates in post-stroke subjects undergoing DF I-PRO therapy compared to controls.
In order to address these aims, thirty patients who have suffered unilateral ischemic stroke will be recruited. Subjects will be randomized to receive either 1) 12 weeks of DF I-PRO therapy plus compensatory treatment or 2) compensatory treatment only. Assessments will take place at baseline, 8 and 12 weeks. The primary outcome measure will be changes in maximum isometric tongue pressures. Details regarding specific outcomes most influenced by this approach and dose response effects will inform the clinical practice of Speech-Language Pathologists and facilitate strengthening regimens to become more standard for the treatment of stroke related dysphagia.
Study Type
Enrollment (Actual)
Phase
- Not Applicable
Contacts and Locations
Study Locations
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Wisconsin
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Madison, Wisconsin, United States, 53562
- University of Wisconsin-Madison
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Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- clinical diagnosis of unilateral ischemic strokes by attending physician (according to the National Institute of Health Stroke Scale (NIHSS))
- within 6 months of acute stroke diagnosis
- a score of 3 or higher on the Penetration-Aspiration scale OR a score of 2 on the Residue scale at any location (oral cavity, valleculae, or pharynx) that is instrumentally documented by a participating SLP during a standardized videofluoroscopic swallowing study
- between the ages of 21 and 95
- ability to perform the strengthening protocol independently or with the assistance of a caregiver
- physician approval of medical stability to participate
- decision-making capacity to provide informed consent (confirmed through discussion with the subject's primary physician)
- phone access
- ability to return to the clinic for required follow-up appointments.
Exclusion Criteria:
- degenerative neuromuscular disease
- prior or current diagnosis of bilateral or hemorrhagic stroke
- prior surgery to the head and neck region that would affect muscles involved in swallowing
- history of radiotherapy or chemotherapy to the head and neck
- patient unable to complete the exercise program
- taking medications that depress the central nervous system
- allergy to barium (used in videofluoroscopic swallowing assessment)
- currently pregnant.
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: None (Open Label)
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
|---|---|
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Active Comparator: Compensatory
This group will receive standard swallowing intervention, which is identified by the SLP as appropriate to treat the patient's dysphagia and is common clinical practice.
Their therapy may include: 1) modifying their foods and fluids; 2) changing their posture when they eat or drink; or 3) having them eat more slowly or in a quiet environment to make swallowing easier and safer.
These compensatory approaches will ensure safety while swallowing foods and fluids.
Range of motion, vocal exercises, and other oromotor exercises, such as the Shaker Exercise, as well as any other potential strengthening regimens for swallowing or speech will be delayed until subjects have completed participation.
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Experimental: I-PRO + compensatory
The Device-Facilitated Isometric Progressive Resistance Oropharyngeal (D-F I-PRO) intervention will be completed using the SwallowSTRONG® device.
Tongue press exercises consist of pressing the tongue against the sensors located along the hard palate.
Isometric exercises will focus on the anterior and posterior sensor.
Subjects will take the SwallowStrong® device home with them and will complete 20 repetitions of the exercise (10 repetitions at the front sensor; 10 repetitions at the back sensor), three times per day on three days per week for twelve weeks.
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Isometric Progressive Resistance Oropharyngeal Therapy is an approach to oropharyngeal strengthening.
This particular use of I-PRO therapy will be facilitated by the Swallow Strong device.
Other Names:
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What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
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Lingual Pressures (Changes in the One Repetition Maximum Isometric Lingual Pressures)
Time Frame: After 8 weeks and 12 weeks
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Changes in the one repetition maximum isometric lingual pressures measured at the front and back sensors of the device
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After 8 weeks and 12 weeks
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Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
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Percent Residue
Time Frame: baseline, 8 and 12 weeks
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Measurement of Residue
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baseline, 8 and 12 weeks
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Swallowing-related Pressures (Videofluoroscopic Swallow Study)
Time Frame: After 8 and 12 weeks
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Pressures will be measured while the subject is swallowing during the videofluoroscopic swallow study
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After 8 and 12 weeks
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Dysphagia-related Quality of Life Scores (SWAL-QOL)
Time Frame: After 8 weeks and 12 weeks
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A quality of life questionnaire related to swallowing.
The scores range from 0-100, and a higher score indicates a higher quality of life related to swallowing.
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After 8 weeks and 12 weeks
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Functional Oral Intake Scale (FOIS) Scores
Time Frame: After 8 weeks and 12 weeks
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FOIS scores reflect level of nutritional intake.
Scores range from 1 to 7, with 1 being nothing by mouth and with 7 indicating a diet with no restrictions.
Qualitative assessment via interview.
Range of final scores is between 1 and 7. Average scores of each arm reported at 8 and 12 weeks.
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After 8 weeks and 12 weeks
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Pneumonia Diagnoses (Number of Pneumonia Diagnoses)
Time Frame: up to 9 months
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The number of pneumonia diagnoses within 9 months following completion of the program will be compared to the same pre-enrollment period.
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up to 9 months
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Hospital Admissions (Number of Hospital Admissions and Readmissions)
Time Frame: up to 9 months
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The number of hospital admissions and readmissions within 9 months following completion of the program will be compared to the same pre-enrollment period.
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up to 9 months
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Collaborators and Investigators
Sponsor
Investigators
- Principal Investigator: Nicole Pulia, PhD, University of Wisconsin, Madison
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Actual)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Estimate)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- 2014-0747
- A534255 (Other Identifier: UW- Madison)
- SMPH/MEDICINE/GER-AD DEV (Other Identifier: UW Madison)
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
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