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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
of cerebellar rTMS. A case report (Vasant et al., 2019), a pseudo-RCT (Zhong
et al., 2021), and an RCT (Dong et al.,
2022) found that it may be beneficial for
poststroke dysphagia. Overall, several
recent systematic reviews and metaanalyses suggested that rTMS has treatment benefits for dysphagia (Cheng et
al., 2021; Chiang et al., 2019; Liao et al.,
2017; Pisegna et al., 2016; Speyer, Sutt,
Bergström, Hamdy, Pommée, et al., 2022;
Yang et al., 2015). Importantly, Cheng
et al. (2021) found that bilateral rTMS
showed the greatest benefits among all
rTMS protocols. Moreover, the effects
of rTMS were the most significant during the first 2 weeks posttreatment, and
they diminished after 3 months.
Other studies suggested that rTMS
may be beneficial for dysphagia associated with PD and old age. A pilot
RCT with a crossover design found
that three types of neurostimulation,
including 1 Hz rTMS, 5 Hz rTMS, and
PES, were well tolerated by PD patients
(Sasegbon et al., 2021). However, the
clinical effects remain uncertain given
the small sample size. In another RCT
study with 33 PD patients, Khedr et
al. (2019) reported improved timing
of hyoid bone elevation and pharyngeal transit time after 10-day bilateral
20 Hz rTMS applied over hand motor
cortex. In elderly patients with dysphagia, Park et al. (2017) found that 5 Hz
rTMS improved swallowing function
and increased cortical activation during swallowing.
tDCS
The neurophysiological effects of tDCS
in the pathological population are
less well explored compared to rTMS.
Functionally, studies showed that unilateral tDCS reduces dysphagia severity (Kumar et al., 2011; Mao et al., 2021;
Sawan et al., 2020; Shigematsu et al.,
2013; Suntrup-Krueger et al., 2018; Yang
et al., 2012) and improves nutritional
status (Mao et al., 2021). By contrast,
the effects of bilateral tDCS were less
consistent. Two studies reported no
treatment effects of bilateral tDCS (Ahn
et al., 2017; Pingue et al., 2018). However, a study found that bilateral anodal
tDCS combined with balloon dilation
therapy and conventional swallowing
therapy improved swallowing function and pharyngoesophageal segment
opening (Wang et al., 2020). Another
study found that unilateral contralesional anodal tDCS and bilateral
tDCS improved swallowing function
in patients with unilateral and bilateral hemispheric stroke, respectively
(Sawan et al., 2020). Overall, systematic
reviews and meta-analyses found that
tDCS has modest but promising beneficial effects for patients with poststroke
dysphagia (Cheng et al., 2021; He et al.,
2022; Lin et al., 2021; Marchina et al.,
2021; Speyer, Sutt, Bergström, Hamdy,
Pommée, et al., 2022). Some studies suggested that tDCS may also be beneficial
for patients with dysphagia associated
with multiple sclerosis (MS) (Cosentino
et al., 2018; Restivo et al., 2019).
PES
Several RCT studies have shown that
PES can reduce the risk of penetration
and aspiration and improve swallowing function in patients with poststroke
dysphagia (Cabib et al., 2020b; Dziewas
et al., 2018; Fraser et al., 2002; Jayasekeran et al., 2010; Michou et al., 2014;
10. THE TREATMENT PLAN: BEHAVIORAL APPROACHES
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255
Suntrup, Marian, et al., 2015), although
some reported no treatment effects
(Bath et al., 2016; Vasant et al., 2016).
Importantly, two large-scale studies
found that PES can facilitate decannulation in tracheostomized patients with
severe dysphagia (Dziewas et al., 2018;
Suntrup, Marian, et al., 2015). Overall,
current evidence suggested that PES is
beneficial for patients with poststroke
dysphagia, but its longer term (beyond
2 weeks) effects remain uncertain (Cheng
et al., 2021). Furthermore, studies suggested that PES may improve swallowing function in MS patients (Restivo et
al., 2013) and potentially in PD patients
(Sasegbon et al., 2021).
Limitations of Neuromodulation
Treatments
Despite their potential benefits for dysphagia, these neuromodulation techniques have not been widely adopted
in clinical practice due to some practical issues and limitations (Cheng &
Hamdy, 2021; Cheng, Sasegbon, et al.,
2022). Among these techniques, PES is
the only one that has received both EC
and (recent) FDA approval as a dysphagia treatment. For NIBS, small studies
and heterogeneous treatment protocols made drawing of definitive conclusions challenging, and their longterm (beyond 3 months) effects remain
poorly explored. Moreover, the operational costs can be high given that both
rTMS and tDCS require specialized
equipment and trained personnel to
operate (Cheng, Sasegbon, et al., 2022).
Finally, NIBS is limited by the response
variability. Studies have reported that
genetic predispositions (Hwang et al.,
2022; Raginis-Zborowska et al., 2019)
and neural activation before stimulation (Cheng et al., 2020) may contribute
to such variability. Response variability
may be minimized by preconditioning
the brain prior to stimulation (Cheng
et al., 2020), but further studies are
needed to fully elucidate the effects of
preconditioning in dysphagic patients.
CONCLUSION/FUTURE WORK
Neuromodulation treatments, including rTMS, tDCS, and PES, have shown
potential in facilitating dysphagia rehabilitation following stroke. Future work
should focus on the long-term treatment benefits and explore the treatment
effects in different pathological populations. Further studies should also identify strategies that maximize treatment
outcomes, for example, identification
of genetic biomarkers for treatment
responses or preconditioning of the
brain before treatment.
CONFLICTS OF INTEREST
SH is a board director, shareholder, and
chief scientific officer of Phagenesis
Ltd., a company that is involved in dysphagia treatment. IC and SH authored
some of the papers that were referenced
in this review.
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The Treatment Plan: Medical
https://t.me/medicina_free
and Surgical Therapies
Katherine A. Kendall
MEDICAL THERAPIES
Medical therapies designed specifically
for the treatment of dysphagia from
any cause have not been developed.
Rather, therapies designed to treat the
underlying medical condition resulting
in dysphagia are the mainstay of medical therapy. It is, therefore, extremely
important to identify the etiology of the
dysphagia in any given patient so that
appropriate medical therapy, aimed at
treating the underlying cause of the
dysphagia, can be instituted.
Neuromuscular Disease
When a neuromuscular disease is the
etiology of the dysphagia, it must be
ascertained if the medical therapy
appropriate for treating the condition
has been maximized. For any patient
with dysphagia, a review of other
medications prescribed for the patient
will help determine if any of them may
contribute to dysphagia. Many drugs
prescribed for neuromuscular disease
affect the cholinergic nervous system
and are known to have an effect on
swallowing (see Chapter 2). Therefore,
the same drugs prescribed to treat the
neuromuscular disease may have a deleterious effect on swallowing. A balance
between therapeutic benefit and side
effects of medications must be achieved.
In several types of neuromuscular
disease, cricopharyngeal achalasia, or
failure of the cricopharyngeus muscle
to relax, has been commonly identified.
In many of these patients, cricopharyngeal myotomy may be considered. (See
below for further discussion of cricopharyngeal myotomy.)
Gastroesophageal Reflux (GERD)
Gastroesophageal reflux (GERD) is the
result of the reflux of gastric contents
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