Oral neuromuscular training in patients with dysphagia after stroke: a prospective, randomized, open-label study with blinded evaluators

Patricia Hägglund, Mary Hägg, Eva Levring Jäghagen, Bengt Larsson, Per Wester, Patricia Hägglund, Mary Hägg, Eva Levring Jäghagen, Bengt Larsson, Per Wester

Abstract

Background: Oral and pharyngeal swallowing dysfunction are common complications in acute stroke patients. This primary aim of this study was to determine whether oral neuromuscular training improves swallowing function in participants with swallowing dysfunction after stroke. A secondary aim was to assess how well results of the timed water-swallow test (TWST) correspond with swallowing dysfunction diagnosed by videofluoroscopy (VFS).

Methods: This was an intention-to-treat two-centre prospective randomized open-label study with blinded-evaluators (PROBE) design. At 4 weeks after stroke onset, participants with swallowing dysfunction were randomized to 5 weeks of continued orofacial sensory-vibration stimulation with an electric toothbrush or additional oral neuromuscular training with an oral device (Muppy®). Participants were examined with TWST, a lip-force test, and VFS before (baseline), after 5 weeks' treatment (the end-of-treatment), and 12 months after treatment (follow-up). The baseline VFS results were compared with the TWST results. The primary endpoint was changes in swallowing rate assessed using TWST, from baseline to the end of training and from baseline to follow-up based on intention-to-treat analyses. The secondary endpoint was the corresponding changes in lip-force between baseline, the end of treatment, and follow-up.

Results: The participants were randomly assigned as controls (n = 20) or for intervention with oral neuromuscular training (n = 20). After treatment, both groups had improved significantly (intervention, P < 0.001; controls, P = 0.001) in TWST but there was no significant between-group difference in swallowing rate. At the 12-month follow-up, the intervention group had improved further whereas the controls had deteriorated, and there were significant between-group differences in swallowing rate (P = 0.032) and lip force (P = 0.001). A TWST < 10 mL/sec at baseline corresponded to VFS-verified swallowing dysfunction in all assessed participants.

Conclusion: The 5-week oral neuromuscular training improved swallowing function in participants with post-stroke dysphagia compared with the controls 12 months after intervention, but there was no between-group difference in improvement immediately after treatment. TWST results corresponded with VFS results, making TWST a feasible method for identifying persons with swallowing dysfunction after stroke. Larger randomized controlled trials are required to confirm our preliminary positive long-term results.

Trial registration: Retrospectively registered at ClinicalTrials.gov : NCT04164420 . Registered on 15 November 2019.

Keywords: Oral screen; Radiology; Rehabilitation; Swallowing capacity; Swallowing disorder; Videofluoroscopy.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
The oral device (Muppy®) (own image)
Fig. 2
Fig. 2
The lip force meter, LF100 (MHC1 AB Detector, Gothenburg, Sweden) (own image). LF100 is a device for measuring the force (in newtons) of the buccinators. The handle on the LF100 is connected to the oral device
Fig. 3
Fig. 3
Orofacial sensory-vibration stimulation using an electric toothbrush. (Left) Stimulation of (1) the buccinator mechanism that activates tongue retraction; (2) the muscles of the floor (m. digastricus anterior abdomen, m. mylohyoideus and m. geniohyoideus) that will lift the hyoid bone forward and upward and activate the swallow reflex; and (3) the lips, enhancing lip closure. (Middle) Stimulation of the front of the tongue that activates and raises the root of the tongue, thus passively activating the receptors in the anterior faucial arch to perform the swallowing reflex and indirectly lift the velum. (Right) Stimulation of the tip of the tongue by downward pressure improves the force of the tongue. All the different movements in the left, middle, and right images also provide sensory stimulation (through n trigeminus, afferent pathway) and feedback as a motor response (through n facialis, efferent pathway), that describe the sensory-motor reflex arc. Illustrations: Anna Jäghagen (own illustration/image)
Fig. 4
Fig. 4
Flowchart of the subject inclusion and data collection processes
Fig. 5
Fig. 5
Line plots indicating the individual changes in swallowing rate measured by the timed water-swallow test (TWST) and in lip force measured in newtons (N), from baseline (BL) to the end of treatment (EOT) and follow-up 12 months after completed treatment (FO) for the control group and the intervention group

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