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Functional Outcome in Acute Stroke Patients with

Oropharyngeal Dysphagia after Swallowing Therapy

Kun-Ling Huang,

MD,

*

Ting-Yuan Liu,

MD,

Yu-Chi Huang,

MD,

Chau-Peng Leong,

MD,

Wei-Che Lin,

MD, PhD,

and Ya-Ping Pong,

MD

Dysphagia after stroke is associated with mortality and increased pulmonary complications. Swallowing therapies may decrease pulmonary complications and improve patients’ quality of life after stroke. This study used clinical swal-lowing assessments and videofluoroscopy (VFS) to assess the functional recovery of acute stroke patients with dysphagia after different swallowing therapies. We enrolled 29 acute stroke patients with dysphagia and randomly divided them into 3 therapy groups: traditional swallowing (TS), oropharyngeal neuromuscular electrical stimulation (NMES), and combined NMES/TS. All patients were as-sessed using the clinical functional oral intake scale (FOIS), 8-point penetra-tion–aspiration scale (PAS), and functional dysphagia scale (FDS) of VFS before and after treatment. There were no differences in the clinical parameters and swallowing results of the FOIS and VFS before swallowing treatment among the 3 groups (P . .05). TS therapy and combined therapy both had significant swallowing improvement after therapy according to the FOIS and 8-point PAS (P , .05). When comparing the results of the VFS among the 3 groups, we found significant improvements in patients eating cookies and thick liquid after bined NMES/TS therapy (P , .05). In acute stroke patients with dysphagia, com-bined NMES/TS therapy is the most effective swallowing therapy in taking solid diets and thick liquids. Key Words: Dysphagia—stroke—neuromuscular electrical stimulation—swallowing therapy—videofluoroscopy.

Ó 2014 by National Stroke Association

Introduction

Dysphagia is one of the most common morbidities

after stroke, with a reported incidence of 29%-81%.1-4

Poststroke dysphagia increases the risk for dehydration, malnutrition, pulmonary complications, and mortality,

all of which lead to a poor prognosis.1,2

Stroke-associated pneumonia is Stroke-associated with risk factors of dysphagia, National Institute of Health Stroke Scale (NIHSS) greater than or equal to 10, nonlacunar basal ganglia infarction, and any other infection present on

admission.5 For patients with poststroke dysphagia,

aspiration pneumonia occurs in 43%-50% of patients

dur-ing the first year, with a mortality of up to 45%.6,7

Additionally, it is associated with increased long-term

in-stitutionalization.8Some patients with severe dysphagia

require a percutaneous feeding tube for nonoral feeding

to sustain adequate nutrition and/or water intake.9

How-ever percutaneous feeding tube such as nasogatric tube From the *Department of Otolaryngology-Head and Neck surgery,

Chang Gung Memorial Hospital, Chiayi; †Department of Physical Medicine and Rehabilitation, Kaohsiung Chang Gung Memorial Hos-pital and Chang Gung University College of Medicine, Kaohsiung; and ‡Department of Radiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaoh-siung, Taiwan.

Received April 25, 2014; revision received May 28, 2014; accepted May 29, 2014.

K.-L. H. and T.-Y.L. contributed equally to this article.

This study was supported by grants from the National Science Council, Taiwan (99-2314-B-182A-021-MY3). The authors thank the co-workers in Chang Gung Memorial Hospital.

Address correspondence to Yu-Chi Huang, MD, Department of Physical Medicine and Rehabilitation, Kaohsiung Chang Gung Me-morial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, No 123, Dapi Rd, Niaosong Dist, Kaohsiung City 833, Taiwan. E-mail:hyuchi@gmail.com.

1052-3057

Ó 2014 by National Stroke Association

http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2014.05.031

Journal of Stroke and Cerebrovascular Diseases, Vol. 23, No. 10 (November-December), 2014: pp 2547-2553 2547

Open access under CC BY-NC-ND license.

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provided limited protection against aspiration-associated

pneumonia in poststroke patients with dysphagia.10

The enteral feeding tubes also cause nasopharyngeal discomfort, impairs the patients’ body image, and

affects their quality of life.11 Therefore, early diagnosis

and intervention for poststroke dysphagia is important

and recommended to prevent stroke-associated

pneumonia.12,13

There are several practical methods for decreasing complications associated with dysphagia, including postural adjustments, viscosity changes to food and liquids, oropharyngeal exercises, swallowing maneuvers, thermal stimulation, and enteral feeding, to manage

swallowing dysfunction.9,14-20 Traditional swallowing

(TS) therapy involves compensation strategies, such as postural adjustment or diet modification, strengthening weak oropharyngeal musculature through oral exercise, swallowing maneuvers for the augment impaired aspects of oropharyngeal swallowing, and heightening sensory input through thermal–tactile stimulation. Severe poststroke dysphagia is more likely to develop aspiration pneumonia or other potentially complications during prolonged treatment. However, effective swallowing therapies are limited for stoke patients with severe

dysphagia, which requires long-term treatment.14

Recently, neuromuscular electrical stimulation

(NMES) has become a possible intervention for re-storing swallowing function. The VitalStim (Chatta-nooga Group, Hixson, TN) therapy is a type of transcutaneous NMES, which was approved by the Food and Drug Administration in 2001 for treatment of dysphagia. This therapy bypasses the injured central swallowing circuitries such as stroke and delivers an electrical current via electrodes that are placed on the neck muscles to create a contraction of the swallowing muscles. NMES may create more laryngeal elevation and increase the strength of the associated muscles, which leads to better swallowing motion in dysphagic

patients.21-28Bulow et al29reported positive therapy

ef-fects for both NMES and TS therapy combined on more than 3 months hemispheric stroke patients with oral

and pharyngeal dysfunction. Kushner et al30presented

that NMES with traditional dysphagia therapy/pro-gressive resistance training is significantly more effec-tive than traditional dysphagia therapy/progressive resistance training only for reducing tube-dependent dysphagia in acute stroke patient. However, there is still a lack of more objective evidence about the efficacy of NMES for treating poststroke dysphagia at acute phase.

We aimed to evaluate the functional recovery in acute stroke patients with orophyaryngeal dysphagia after TS, oropharyngeal NMES, and combined NMES/TS, by us-ing clinical swallowus-ing assessments and objective video-fluoroscopy (VFS).

Materials and Methods

Participants

Between January 2011 and July 2013, we enrolled 29 acute stroke patients with dysphagia (20 men, 9 women) who were admitted to a rehabilitation unit of the Chang Gung Memorial Hospital-Kaohsiung Medical Center in Taiwan. All the patients’ strokes occurred less than 3 months before enrollment (mean, 22.4 days; range, 5-50 days). The strokes were diagnosed by neurologists according to the clinical neurologic deficits relating to their brain damage and the findings on brain computed tomography or magnetic resonance imaging scans. Their swallowing disorders were impressed by physiatrists tak-ing the history of choktak-ing or cough durtak-ing swallowtak-ing or wet voice after conducting a 100-mL water test. Further-more, a formal swallowing condition was assessed by 1 speech–language therapist.

The inclusion criteria were recent cerebral hemispheric stroke with swallowing difficulty with functional oral intake scale (FOIS), which was equal to or less than level 4 while admission to the rehabilitation unit. The exclusion criteria were as follows: (1) impaired communication abil-ity due to cognitive deficit, aphasia, or serious psycho-logic disorders; (2) other systemic neuropsycho-logic disorders leading to swallowing difficulty; (3) swallowing disorders caused by structural lesions, such as an oropharyngeal tumor or extensive surgery or radiotherapy of the head and neck region; (4) use of an electrically sensitive biomedical device (eg, cardiac pacemaker); and (5) pneu-monia or acute medical conditions at the time of enroll-ment. The study was reviewed by the institutional ethics committee at our hospital, and after understanding of all procedures in this study, informed consent was obtained from each patient.

Procedures

Clinical parameters, including age, gender, stroke type, stroke location, duration since stroke onset, the Mini-Mental State Examination (MMSE), and the National Institute of Health Stroke Scale (NIHSS), were recorded when the participants were admitted to our rehabilitation unit. We randomly divided the patients into 3 groups. There were 11 patients in the TS group, 8 patients in the NMES group, and 10 patients in the combined NMES/ TS group.

In the TS group, the therapies included oral exercise, compensatory techniques (eg, chin tuck, head tilt, and head rotation), faucial thermal–tactile stimulation, and swallowing therapeutic maneuvers (eg, supraglottic swal-lowing, effortful swalswal-lowing, and the Mendelsohn ma-neuver). These dysphagia therapies are commonly used in rehabilitation departments. The TS therapies were per-formed by 1 qualified and experienced speech–language therapist. The choice of specific and compensatory

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techniques and swallowing maneuvers was based on the findings of VFS and the clinical evaluation of swallowing. This group of patients was treated 3 times per week (60 mi-nutes per treatment), and 10 sessions were performed for each patient.

In the NMES group, we used the VitalStim therapeutic device, which consists of a dual channel with 2 bipolar electrodes for each channel. The parameters of electrical

stimulator are a pulse width of 700 ms, frequency of

80 Hz, and wave amplitude of 0-25 mA. A licensed phys-iatrist with 10 years of clinical experience and certified training in using the VitalStim electrical stimulator administered the NMES. Each patient’s anterior neck skin was cleaned using an alcohol swab to remove sub-stances that might interfere with the electrode contact, and the 2 sets of electrodes were placed on the patients’ anterior neck. The placement of the dual-channel elec-trodes was located in 1 vertical line with channel 1 above the thyroid notch and channel 2 below the thyroid notch. The wave amplitude of the treatment was set according to the patient’s tolerance level, and it gradually increased in a stepwise increment of .5 mA from 0 mA until the patient felt a tingling sensation on the neck and a muscle contrac-tion. The tolerance wave amplitude was different among individuals. The current intensity of the electrical stimu-lation was determined and fixed during the treatment session. Patients were not instructed to perform any oropharyngeal exercises or swallowing training during NMES treatment. These patients were treated 3 times per week (60 minutes per session), and 10 sessions of NMES were performed per patient.

In the combined NMES/TS group, another licensed physiatrist with experienced and certified training in using the VitalStim device administered the therapy. These partic-ipants accepted combined TS therapies from the same phys-iatrist while receiving NMES therapy. The treatment occurred 3 times per week (60 minutes per treatment), and each patient had 10 sessions.

Outcome Measurement

Three quantifiable methods were used to evaluate the swallowing function before and after treatment. The

FOIS was reported by Crary et al31for assessing the oral

intake of food and liquid in stroke patients. The FOIS is a statistically validated scale that reflects the functional

oral intake of poststroke patients with dysphagia.31An

ordinal series of 7 swallowing function levels was used (1-7). The level ranged from nothing by mouth (level 1) to total oral diet with no restriction (level 7). One speech–language therapist who was blinded to all proce-dures evaluated the FOIS for each patient before and after swallowing treatments.

The VFS is a standard tool for observation and identifi-cation of swallowing abnormalities. The 8-point penetra-tion–aspiration scale (PAS) and functional dysphagia

scale (FDS) based on VFS provided a quantitative and

objective measurement for swallowing disorders.32,33

The 8-point PAS describes the severity of respiration compromise and is a validated and reliable index of

aspi-ration.32,34 Penetration was defined as any material

entering the laryngeal vestibule but remaining at or above the vocal folds. Aspiration was defined as any material entering the larynx below the vocal folds. In the 8-point PAS, the scores ranged from normal swallow-ing without material enterswallow-ing the airway (score 1) to se-vere airway compromise with material entering the airway and passing below the vocal folds (score 8). The

11-item FDS reported by Han et al33in 2001 is a sensitive

and specific method for quantifying swallowing function in stroke patient. The FDS is composed of 11 items that quantitatively measure oral function (lip closure, bolus formation, residual in oral cavity, and oral transit time) and pharyngeal function (triggering of pharyngeal swal-lowing, laryngeal elevation and epiglottis closure, nasal penetration, triggering, residue in valleculae and pyri-form sinus, pharyngeal coating, and pharyngeal transit time) during VFS. A total 100 points was scored according to the findings of VFS. The lower the FDS score, the better swallowing function. The FDS was measured during 4 di-ets (soft diet, cookies, thick liquid, and thin liquid). Both the 8-point PAS and FDS were interpreted and scored before and after each therapy by another well-experienced speech–language therapist who was also blinded to all 3 interventions.

Data Analysis

SPSS software, version 12.0 (SPSS, Chicago, IL) was used to analyze all collected data. The Kruskal–Wallis test was used to compare differences in age, MMSE, NIHSS among the TS, NMES, and combined NMES/TS groups at admission. The differences in gender, stroke type, and stroke location among the TS, NMES, and com-bined NMES/TS groups at admission were calculated

us-ingc2test. The FOIS, FDS, and 8-point PAS scales were

assessed among the 3 groups before and after treatment and were compared using the Kruskal–Wallis test. The

statistical significance was set asP , .05.

Results

Twenty-nine acute stroke patients with dysphagia were included in this study. All clinical parameters are shown inTable 1. Eleven patients were in the TS group (5 women and 6 men; median age, 67.0 years), 8 patients were in the NMES group (3 women and 5 men; median age, 64.5 years), and 10 patients were in the combined NMES/TS group (1 woman and 9 men; median age, 68.9 years). There were no significant differences in age, gender, stroke type, NIHSS, MMSE, and stroke duration among the 3 groups. In the TS group, there were 6 pa-tients (55%) without oral intake (FOIS, 1) and 5 papa-tients

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(45%) with minimal to total oral intake (FOIS, 2-4). Three patients (38%) with FOIS 1 and 5 patients (62%) with FOIS 2-4 were in the NMES group. Five patients (50%) with FOIS 1 and 5 patients (50%) with FOIS 2-4 were in the combined NMES/TS group. No significant difference was noted in FOIS subgroup among these 3 groups.

The median FDS during VFS before therapy while on a soft diet, cookies, and thick and thin liquid were 21.1, 19.2, 26, and 18.9 in the TS group, 11.4, 17.8, 18.9, and 12.4 in the NMES group, and 25.4, 30, 32.6, and 22.3 in

the combined NMES/TS group, respectively (Table 2).

The median 8-point PAS during VFS in the TS, NMES, and combined NMES/TS groups were 3.8, 3.0, and 3.5, respectively. The median FOIS in the TS, NMES, and com-bined NMES/TS groups were 1.6, 2.3, and 1.8, respectively. There were no statistically significant differences in the swallowing evaluations, including the median FOIS, 8-point PAS, and FDS during VFS, among the 3 groups before therapy. The median FDS scales while on a soft diet, cookies, and thick and thin liquid were 21.1, 19.2, 26, and 18.9 before treatment and 15.7, 24.8, 23.4, and 16.2 after treatment in the TS group, respectively. The me-dian FDS scales in the 4 kinds of diet were 11.4, 17.8, 18.9, and 12.4 before treatment and 18.3, 22.5, 22.6, and 11.9 after treatment in the NMES group, respectively. The median FDS scales while on a soft diet, cookies, and thick and thin liquid were 25.4, 30, 32.6, and 22.3 before treatment and 16.4, 10.6, 24.7, and 16.8 after treatment in the com-bined NMES/TS group, respectively. In the TS group, the median 8-point PAS scales were 3.8 and 2.4, and the median FOIS scales were 1.6 and 4.6 before and after treat-ment, respectively. In the NMES group, the median 8-point PAS were 3.0 and 1.8, and the median FOIS were 2.3 and 4.9 before and after therapy, respectively. In the combined

NMES/TS group, the median 8-point PAS were 3.5 and 2.5, and the median FOIS were 1.8 and 5.5 before and after therapy, respectively. There were significant differences in FOIS before and after therapy in all 3 groups (P , .05). There were significant differences in the PAS before and af-ter therapy in TS and combined NMES/TS groups (P , .05). Significant differences were found between the me-dian FDS before and after therapy while on a soft diet in the combined NMES/TS group (P 5 .01).

InTable 3, the change of FDS during VFS after therapy while on a soft diet, cookies, and thick and thin liquid

were25.4, 7.6, 22.6, and 22.7 in the TS group, 6.9, 4.8,

3.8, and2.5 in the NMES group, and 29.0, 216.3, 27.9,

and25.5 in the combined NMES/TS group, respectively.

Significant differences were found in the changes of FDS while on a cookie (P 5 .03) and thick liquid (P 5 .04) after treatment among the 3 groups. There were no significant differences in the changes of FDS while on a soft diet and thin liquid after therapy among the 3 groups (P ..05). The

changes of the 8-point PAS after intervention were21.5,

21.3, and 21.0 in the TS, NMES, and combined NMES/ TS groups, respectively. The changes of the FOIS were 3.0, 2.6, and 3.7 in the TS, NMES, and combined NMES/TS groups, respectively. No significant differences were found in the changes of the 8-point PAS and FOIS among the 3 groups (P . .05).

Discussion

We are the first in this field to investigate the effect of NMES, TS therapy, and combined NMES and TS ther-apy in acute stroke with oropharyngeal dysphagia by both FOIS and VFS with 8-point PAS and FDS. The results in this study showed that TS, NMES, and combined Table 1. Comparison of clinical characteristics in stroke patients among the 3 groups

Characteristics TS group, N5 11 NMES group, N5 8 Combined NMES/TS group, N5 10 P value

Age, y, median (IQR) 67.0 (10.1) 64.5 (14.4) 68.9 (9.8) .77

Female/male, n 5/6 3/5 1/9 .25 Stroke type, n (%) Infarction 9 (81.8) 6 (75.0) 9 (90) .75 Hemorrhage 2 (18.2) 2 (25.0) 1 (10) Hemiplegic side, n (%) Left 6 (54.5) 3 (37.5) 6 (60) .30 Right 5 (45.5) 4 (50) 4 (40) Bilateral 1 (12.5)

MMSE, median (IQR) 17.9 (6.4) 23.4 (3.7) 22.6 (5.0) .10

NIHSS, median (IQR) 10.7 (5.1) 9.0 (2.8) 7.6 (3.9) .30

Duration, median (IQR) 25.2 (16.0) 16.6 (6.6) 23.5 (13.9) .61

Abbreviations: IQR, interquartile range; MMSE, Mini-Mental State Examination; NIHSS, National Institute of Health Stroke Scale; NMES, neuromuscular electrical stimulation; TS, traditional swallowing.

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NMES/TS therapy had a significant improvement on the clinical FOIS score and TS, and combined NMES/TS ther-apy had a significant improvement on the 8-point PAS during VFS. However, no statistically significant differ-ences were found among these 3 therapies. In the NMES therapy, we also found an improvement tendency after treatment on 8-point PAS, but it was not statistically significant. The study indicated that all 3 treatments might provide some positive therapeutic effects for acute stroke patients with dysphagia. The results were consis-tent with previous studies in chronic stroke. Bulow

et al29 reported statistically significant positive effects

for both NMES and TS therapy in chronic stroke patients with dysphagia, but there was no statistically significant difference in therapy effect between the groups.

We demonstrated that a combined NMES/TS therapy could result in better swallowing performance in FDS scores than NMES or TS therapy alone while on a cookies and thick liquid during VFS. In the combined therapy group, we also found a tendency for the FDS to improve while on soft diet or thin liquid, but the difference before and after therapy was not statistically significant. This

result is similar to that of previous studies. Lim et al35

re-ported that NMES combined with thermal–tactile stimu-lation is a better treatment for patients with swallowing disorders after stroke than thermal-tactile stimulation

alone. Kushner et al30found significant improvement in

FOIS in the NMES group with traditional dysphagia ther-apy/progressive resistance training; therefore, they sug-gest that this combined therapy is more effective than traditional dysphagia therapy/progressive resistance training only for reducing tube-dependent dysphagia in acute stroke patients. The application of NMES for dysphagia associated with oropharyngeal dysfunction is for improving sensation input of oropharyngeal cavity, facilitating or restoring the oral or pharyngeal motor function, and achieving adequate laryngeal elevation. Therefore, concurrent NMES could further augment or enhance the contraction of paralyzed oropharyngeal mus-cles with volitional control. Although the TS therapy is a mainstay for the management of dysphagia after stroke by strengthening the weakened oropharyngeal muscles under voluntary oral or swallowing exercise, these find-ings supported that NMES could be used as an alternative therapy for acute stroke patients with dysphagia.

We consider that NMES can be an adjunctive therapy to the general swallowing therapy. First, with moderate-to-severe dysphagia, there is little or no muscle contraction of oropharyngeal muscles under voluntary swallowing ac-tion. The NMES can avoid the disuse of muscle dystrophy and strengthen contraction of paralyzed oropharyngeal muscles. Second, the order of the muscle recruitment of voluntary muscle contraction and that of electrical stimula-tion are different. During normal muscle contracstimula-tion, the type I muscle fibers are recruited first and followed by the recruitment of type II muscle fibers. The recruitment of

Table 2. Videofluoroscopy and FOIS results in TS, NMES, and combined NMES/TS groups before and after therapy Group TS group, N 5 11 P value NMES group, N 5 8 P value Combined NMES/TS group, N 5 10 P value P 1 value Before treatment After treatment Before treatment After treatment Before treatment After treatment FDS Soft diet, median (IQR) 21.1 (14.9) 15.7 (13.5) .14 11.4 (8.4) 18.3 (12.9) .17 25.4 (13.0) 16.4 (17.6) .03 * .06 Cookie, median (IQR) 19.2 (18.0) 24.8 (11.7) .16 17.8 (7.0) 22.5 (9.3) .40 30.0 (17.0) 10.6 (8.0) .08 .73 Thick liquid, median (IQR) 26.0 (13.5) 23.4 (10.0) .26 18.9 (13.6) 22.6 (12.7) .32 32.6 (11.9) 24.7 (11.4) .05 .11 Thin liquid, median (IQR) 18.9 (11.6) 16.2 (4.5) .72 12.4 (11.1) 11.9 (9.1) 1.0 22.3 (13.6) 16.8 (13.8) .06 .06 8-point PAS, median (IQR) 3.8 (2.6) 2.4 (1.9) .04 * 3.0 (2.1) 1.8 (1.8) .07 3.5 (2.5) 2.5 (2.1) .04 * .66 FOIS, median (IQR) 1.6 (.8) 4.6 (1.8) .03 * 2.3 (1.4) 4.9 (2.3) .01 * 1.8 (1.1) 5.5 (2.0) .005 * .60 Abbreviations: IQR, interquartile range; FDS, functional dysphagia scale; FOIS, functional oral intake scale; NMES, neuromuscular electrical st imulation; PAS, penetration–aspiration scale; TS, traditional swallowing. Kruskal–Wallis test for FDS, 8-point PAS, and FOIS. * P , .05, P 5 Comparison between before and after treatment, P 1 5 Comparison among different groups before treatment.

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NMES, reverse of normal voluntary recruitment, involves

type II fibers first followed by slow type I fibers.25,36The

synchronous recruitment of both types I and II muscle fibers during combined therapy can generate larger swallowing muscle force and enhance the therapeutic effect than NMES or TS exercise alone in dysphagia treatment. Third, the electrical stimulation combined with swallowing task training and exercise can increase swallowing excitability and facilitate motor learning. Park

et al37reported that effortful swallowing coupled with

elec-trical stimulation increased the degree of hyoid elevation in

healthy volunteers. Ludlow et al38observed that hyoid bone

depression occurred with stimulation at rest, and stimula-tion may have acted to resist the patient’s hyoid elevastimula-tion during swallowing. Fourth, the NMES can heighten the pharyngeal sensory feedback pathway and stimulate

pharyngeal cortical reorganization. Oh et al21 reported

that the swallowing function improvement after electrical stimulation is correlated with cortical reorganization measured by corticobulbar output maps, which suggests that multiple sessions of electrical stimulation applied to the neck muscles improve swallowing function via a mech-anism involving long-term cortical reorganization. Howev-er, the exact mechanism of NMES remains unclear. Further study is needed to investigate the possible cortical mecha-nism of NMES on poststroke dysphagic patients.

The following are the several limitations to our study: (1) we collected a small patient group limited to 1 rehabil-itation unit in 1 medical center in Taiwan, which may impede smaller significant differences among groups; (2) because of an ethical issue, we did not have stroke pa-tients with dysphagia receive any treatment in a control group to exclude the effect of a spontaneous recovery of a swallowing deficit; (3) there was no standard NMES therapy protocol for the current intensity, frequency, the duration of the intervention; and (4) there was a lack of long-term follow-up to assess the swallowing function re-covery after completing the 3-week therapy.

In summary, TS therapy and combined therapy both have therapeutic effects on improving the swallowing function based on the clinical FOIS and 8-point PAS dur-ing VFS in acute stroke patients with dysphagia. Howev-er, among the 3 therapies, the combined NMES with TS therapy may result in more positive effects, because it showed a significant improvement in FDS when the pa-tients were on a solid diet and thick liquid during VFS.

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Table 3. Change of videofluoroscopy and FOIS results in TS, NMES, and combined NMES/TS groups after therapy

Group TS group, N5 11 NMES group, N5 8

Combined NMES/TS group,

N5 10 P value

FDS

Soft diet, median (IQR) 25.4 (11.3) 6.9 (13.4) 29.0 (10.4) .43

Cookie, median (IQR) 7.6 (11.9) 4.8 (12.6) 216.3 (18.4) .03*

Thick liquid, median (IQR) 22.6 (6.8) 3.8 (9.5) 27.9 (11.2) .04*

Thin liquid, median (IQR) 22.7 (10.3) 2.5 (13.9) 25.5 (7.7) .31

8-point PAS, median (IQR) 21.5 (2.0) 21.3 (1.6) 21.0 (1.6) .87

FOIS, median (IQR) 3.0 (1.4) 2.6 (1.5) 3.7 (1.6) .31

Abbreviations: IQR, interquartile range; FDS, functional dysphagia scale; FOIS, functional oral intake scale; NMES, neuromuscular electrical stimulation; PAS, penetration–aspiration scale; TS, traditional swallowing.

Kruskal–Wallis test for FDS, 8-point PAS, and FOIS.

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efficacy in acute stroke feeding tube-dependent dysphagia during inpatient rehabilitation. Am J Phys Med Rehabil 2013;92:486-495.

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33.Han TR, Paik NJ, Park JW. Quantifying swallowing func-tion after stroke: A funcfunc-tional dysphagia scale based on videofluoroscopic studies. Arch Phys Med Rehabil 2001;82:677-682.

34.Robbins J, et al. Differentiation of normal and abnormal airway protection during swallowing using the penetration-aspiration scale. Dysphagia 1999;14:228-232. 35. Lim KB, et al. Neuromuscular electrical and thermal-tactile stimulation for dysphagia caused by stroke: a ran-domized controlled trial. J Rehabil Med 2009;41:174-178. 36. Carnaby-Mann GD, Crary MA. Adjunctive neuromus-cular electrical stimulation for treatment-refractory dysphagia. Ann Otol Rhinol Laryngol 2008;117: 279-287.

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References

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