Study On Surface Electromyographic Characteristics Of Patients With Post-stroke Pharngeal Dysphagia And Intensive Deglutition Therapy

Dysphagia is one of the common complications after stroke and an independent risk factor for stroke prognosis,often causing serious consequences such as malnutrition,dehydration and aspiration pneumonia.After entering the recovery period of stroke,a considerable number of patients still have difficulty in swallowing,which hinders the recovery of other functions,and even causes depression,which seriously reduces the quality of life.Therefore,timely and effective targeted treatment for patients with dysphagia after stroke has important clinical and social value.In recent years,many studies have confirmed the effects of eating factors on the swallowing process and the therapeutic effects of neuromuscular electrical stimulation(NMES)on dysphagia.However,how to combine the two in the clinic and complete the swallowing treatment more efficiently and safely is a problem worth exploring.Part1 Contrast study on surface electromyographic characteristics of patients with post-stroke pharyngeal dysphagia and healthy adultsObjectiveTo compare the surface electromyographic(SEMG)characteristics of submental muscles(SMs)and infrahyoid muscles(IMs)in patients with post-stroke pharyngeal dysphagia and healthy adults of the same age when swallowing the boluses with different viscosity;To analyze the possible pathophysiological mechanisms of pharyngeal stage of dysphagia and to provide theoretical basis for clinical formulation and implementation of swallowing therapy.Methods76 subjects who comply with experiment standard in our hospital were divided into two groups.Among them,38 patients with post-stroke dysphagia were assigned to health group,and the remaining 38 healthy volunteers were assigned to patient group.Video fluoroscopy and surface electromyography were used to evaluate two groups of subjects.The swallowing duration(SD)?mean amplitude(MA)and sequence difference values of SMs and IMs were used to observe the swallowing activity of swallowing muscles during swallowing 5 ml nectar,water and pudding respectively.Result1.Both SD and MA of SMs?SD of IMs were the highest and the longest in two groups(P<0.05);The MA of the IMs during swallowing the pudding-bolus were the highest in health group(P<0.01);The differences weren't significant among MA of IMs in patient group when swallowing three kinds of viscous boluses(P>0.05).2.The MA and SD of SMs and SD of IMs in patient group were significantly higher than those in health group during swallowing three kinds of viscous boluses(P<0.05),especially when swallowing pudding-boluses,there were significant differences in MA and SD of SMs between groups(P<0.001).3.Comparing the time sequence difference value of initiation of SMs and IMs between the two groups,Most SMs were preferentially activated in health group,and most IMs activated in advance in patient group.Conclusion1.For the patients with post-stroke pharyngeal dysphagia and healthy adults,the change of viscous boluses has a significant effect on swallowing muscle group activity;Among the three viscous boluses,the pudding-boluses can maximize the activation of SMs and prolong the duration of activity;2.Patients with post-stroke pharyngeal dysphagia needed to took longer swallowing duration and was more difficult to complete swallowing than healthy adults during swallowing three kinds of boluses;The pudding-boluses has a greater impact on the submental muscles in patient group;3.Compared with healthy adults,the IMs of most of the patients with post-stroke pharyngeal dysphagia started earlier than the SMs during the swallowing process,which reflected the disorder of sequence in swallowing activity.Part2 Effect of Intensive Deglutition Therapy for Patients with Post-stroke Pharyngeal DysphagiaObjectivesThe intensive deglutition therapy is formulated according to the preliminary experimental results,and its safety and effectiveness are discussed based on the prospective randomized control experiment,so as to provide the effective and safe therapy for the post-stroke pharyngeal dysphagia in clinical.MethodsEighty-three patients with post-stroke pharyngeal dysphagia who met the screening criteria were randomly divided into three groups:28 patients in the conventional deglutition treatment group(RT Group);28 patients in the group of regular treatment combined with the ingestion training(IA+RT Group);27 patients in the group of regular treatment combined with intensive deglutition treatment(ingestion training is synchronized with neuromuscular electrical stimulation,NMES+IA+RT Group).Intensive deglutition therapy:the patient swallowed 150ml pudding-bolus in 30min,every 5ml for each time,and neuromuscular electrical stimulation was applied synchronously to the submental muscles,30min each time,once a day,5 days a week and 6 weeks each course of treatment,adding up to 30 times.Dysphagia Outcome and Severity Scale(DOSS),Subjective Global Assessment(SGA)nutritional scores,cases of tube feeding,overall response rate(ORR)after treatment,cases of stroke associated pneumonia(SAP)and moist voice assessment were used as indicators.The effectiveness and safety of the above three therapies were observed and compared before treatment and at the end of 6 weeks of treatment.Results1)Effectiveness indicator:There were no significant differences in DOSS,SGA,cases of tube feeding among the three groups(P>0.05);Compared with before treatment,the DOSS?SGA scores and cases of tube feeding of the three groups after treatment were significantly improved(P<0.05);NMES+IA+RT Group showed the best effectiveness in improving the function of deglutition,nutritional status and ORR and reducing dependence on tube feeding(P<0.05);2)Safety indicator:There weren't acute SAP patients before treatment in the three groups.New SAP patients in IA+RT Group were obviously the most(P<0.05),the other groups were not significant difference(P>0.05);No statistical significance was found in the number of cases with moist voice at the end of the first treatment in three groups(P>0.05).The number of cases with moist voice at the end of the 30th treatment in IA+RT Group were the most than the other Groups(P<0.05);The incidence rate of moist voice in IA+RT Group was the highest in 6 weeks,RT Group secondly,NMES+IA+RT Group was the lowest.Conclusions1.All the three therapies can improve the deglutition function and nutritional status of patients with post-stroke pharyngeal dysphagia.Among them,the intensive deglutition treatment group has the best efficacy,which is most beneficial for patients to get rid of the tube feeding as soon as possible;2.The intensive deglutition treatment group may reduce the occurrence of stroke-related pneumonia by reducing the occurrence of deglutition aspiration and leakage,so its treatment safety is better than the other two therapies;3.In the direct ingestion training alone,the choice of treatment intensity should be very careful.Part3 Effects of neuromuscular electrical stimulation with synchronous deglutition training in patients with dysphagia poststroke:a Meta-analysisObjectiveTo examine the effects of neuromuscular electrical stimulation with synchronous deglutition training in patients with dysphagia poststroke.MethodsWe searched Cochrane Library,PubMed,China National Knowledge Infrastructure and Wanfang Database for randomized controlled trials of investigating the effects of neuromuscular electrical stimulation(NMES)with synchronous deglutition training in stroke patients with dysphagia published before April 2018.The patients in training group was treated with NMES and swallowing at the same time.The stimulation site included supraglottic muscles and/or subhyoid muscles.The stimulation intensity was set as motor threshold stimulus.Synchronous deglutition training included swallowing saliva without effort,effortful swallowing and swallowing with food.The conventional swallowing training was manipulation,adjustment of food and position.The control group received conventional swallowing training with NMES without synchronous deglutition training,or conventional swallowing training only.The outcome indicators included water drinking test,dysphagia severity scale,penetration-aspiration scale(PAS),the superior and anterior excursion distance of the hyoid and larynx,dysphagia outcome and severity scale(DOSS),videofluoroscopic dysphagia scale.Two researcher independently carried out literature retrieval and data extraction,using Physiotherapy Evidence Database and standard data extraction forms adapted from Cochrane Collaboration model to evaluate the studies quality.The Meta-analysis was performed using Review Manager Version 5.3.ResultsSeven studies met the study criteria with a total number of 203 stroke patients,101 patients in training group,and 102 patients in control group,respectively.The Meta-analysis showed that NMES with synchronous deglutition training improves dysphagia severity scale(95%CI=1.21?3.22)and PAS(95%CI=-1.17?-0.20).The advantages of NMES without synchronous deglutition training have not been found in improving the superior and anterior excursion distance of the hyoid and larynx.ConclusionThe implementation of NMES with synchronous deglutition training combined with conventional swallowing training can improve the swallowing function(with dysphagia severity scale)and reduce aspiration.There is not enough evidence to prove that NMES with synchronous swallowing deglutition training is superior to conventional swallowing training in improving the superior and anterior excursion distance of the hyoid and larynx.