Methods
Results
Level of evidence | Data analysis | Reference (Literature) | Subjectsa/etiology | Evaluation techniques | Treatment(s)/groups (G)b
| Authors’ conclusions /key findings |
---|---|---|---|---|---|---|
A (randomized controlled trial) | Statistical analysis | Groher [12] | 46 Chronic dysphagia Excluding: N = 5 (dead), N = 5 (PEG), N = 10 (?) | Clinical evaluation, Other (chest X-ray) Blinding? | Viscosity modulation G1 pureed foods and nonaltered liquids (N = 23) G2 soft mechanical diet with altered/thickened liquids (N = 23) | Prior to inclusion, all subjects were on pureed diet plus fluids and had experienced at least one period of aspiration pneumonia. During the 6-month period of intervention, significantly more episodes of pneumonia were experienced in G1 (28 incidences) compared to G2 (five incidences). |
B (non-randomized controlled trial) | Statistical analysis | Bhattacharyya et al. [14] | 31 Unilateral vocal fold paralysis with aspiration and/or penetrationc
| Videofluoroscopy Blinding | Viscosity modulation: liquid versus paste (single session) | 25% (6/24) aspirated thin liquids, whereas none of these subjects aspirated paste boluses. Liquid versus paste boluses penetrated in, respectively, 79% (19/24) and 50% (12/24).The results indicate that thicker food consistencies are likely to be safer for oral intake in patients with unilateral vocal fold paralysis due to decreases in the risk of laryngeal penetration and aspiration despite a higher prevalence of pharyngeal residue. |
Bisch et al. [16] | 18 acute stroke | Videofluoroscopy Blinding? | Bolus temperature, volume, and viscosity modulation (single session) G1 Mild dysphagia, first-time stroke (N = 10) G2 Moderate to severe dysphagia, neurologically impaired (N = 8) | Both patient groups exhibited very few significant effects of temperature on swallowing disorders or swallow measures. Increases in bolus volume and viscosity decreased pharyngeal delay times in both groups. | ||
Clavé et al. [15] | 92 | Videofluoroscopy | Viscosity and volume modulation (single session) G1 Nonprogressive brain diseases (N = 46) G2 Neurodegenerative diseases (N = 46) | Increasing bolus viscosity from liquid to nectar and pudding significantly improved efficacy of swallowing and safety by reducing aspiration and penetration during swallowing in G1 and G2. Increasing the bolus viscosity did not affect the timing of swallow response or bolus kinetic energy, whereas increasing bolus volume significantly impaired efficacy and safety of swallowing in both groups. | ||
Hamdy et al. [18] | 12 acute stroke | Clinical evaluation (timed water swallow test) Blinding? | Thermal (cold) and/or chemical (citrus) application (single session) | Combined thermal and chemical modification of water substantially alters swallowing behavior in dysphagic stroke resulting in slowed swallowing and reduced swallow capacity. | ||
Logemann et al. [17] | 27 | Videofluoroscopy Blinding? | Sour and volume modulation (single session) G1 Stroke (N = 19) G2 Other neurological etiologies (N = 8) | Both groups of subjects revealed significantly improved onset of the oral swallow in response to sour boluses compared to nonsour boluses; G1 also exhibited reduced pharyngeal delay time, oral transit time, and improved swallow efficiency, whereas G2 exhibited reduced aspiration. Increasing bolus volume significantly increased oral residue and number of swallows and decreased the oral transit time, pharyngeal delay time, and pharyngeal transit time in both groups. | ||
Desciptive statistics | Groher and McKaig [13] | 212 Chronic dysphagia | Clinical evaluation (dietary level classification) No blinding | Evaluation/change of dietary level (single session) | 31% (212) of the 685 residents were on a consistency-modified diet. 87% (184/212) were on either pureed or tube feeding. After the therapists’ evaluation, 91% (192/212) were able to tolerate diets above the level of alimentation received before evalation, and they continued on these diets at a 30-day follow-up evaluation. 4% were at dietary levels higher than they could tolerate, and 5% were considered to be at the appropriate diet level. |
Level of evidence | Data analysis | Reference (literature) | Subjectsa/etiology | Evaluation techniques | Treatment(s)/groups (G)b
| Authors’ conclusions / key findings |
---|---|---|---|---|---|---|
A (randomized controlled trial) | Statistical analysis | Bülow et al. [19] | 25 Chronic dysphagia | Quality-of-life measure, videofluoroscopy, clinical evaluation (dietary level classification, oral motor function test) Blinding | G1 traditional swallowing therapy (N = 13) G2 Neuromuscular electrical stimulation: NMES (N = 12) | Statistically significant positive therapy effects were found for both NMES and traditional swallowing therapy combined but there was no statistically significant difference in therapy effect between the groups. The correlations between measurements were low. |
Power et al. [20] | 16 Acute stroke | Videofluoroscopy Blinding? | Surface electrical stimulation at anterior faucial pillars (single session) G1 Electrical stimulation (N = 8) G2 Sham stimulation (N = 8) | Compared with baseline, no significant differences were observed in oral transit time, swallow response time, pharyngeal transit time, laryngeal closure duration, cricopharyngeal opening duration, or aspiration severity within subjects or between G1 and G2. | ||
Rosenbek et al. [21] | 7 (male) Multiple stroke | Videofluoroscopy Blinding? | Thermal application at anterior faucial pillars A 1 week no therapy B 1 week thermal application G1 ABAB sequence (N = 1) G2 BABA sequence (N = 6) | 2/3 judges did report a treatment-related decrease in duration of stage transition for 2/7 patients, without any changes in the occurrence of aspiration or penetration. Overall, no strong evidence was found that dysphagia improved after 2 weeks of thermal application alternating with 2 weeks of no thermal application. | ||
Rosenbek et al. [22] | 22 ≥ 1 stroke Excluding: N = 1 (unable to complete protocol) | Videofluoroscopy Blinding | Thermal application at anterior faucial pillars A 10 swallows without therapy B 10 swallows with thermal application (30-min rest period between conditions) G1 ABAB sequence (N = 9) G2 BABA sequence (N = 13) | Thermal application significantly reduced duration of stage transition and total swallow duration compared to no treatment. | ||
B (non-randomized clinical trial) | Statistical analysis | Blumenfeld et al. [23] (retrospective design) | 80 Acute care patients Patient attrition? | Clinical evaluation (swallow severity scale) No blinding | G1 Surface electrical stimulation: pharyngeal/laryngeal musculature (N = 40) G2 Traditional therapy: exercises, compensatory maneuvers and diet-texture modifications (N = 40) | After therapy, both G1 and G2 showed significant improvement in severity score. Significantly more improvement was found in G1 compared to G2; G1 required fewer treatment sessions and displayed a trend toward a shorter length of hospitalization than G2. |
Ludlow et al. [24] | 11 Diverse neurological pathologies with chronic dysphagia | Videofluoroscopy Blinding | Surface electrical stimulation Different conditions: G1 Stimulation at sensory threshold level during swallow (N = 8) G2 Stimulation at motor threshold level during swallow (N = 10) G3 Stimulation at motor threshold level at rest (N = 10) G4 No therapy/no stimulation (N = 28 trials by N = 11?) | Only significant hyoid depression occurred during stimulation at rest. Aspiration and pooling were significantly reduced only with low sensory threshold levels of stimulation and not during maximum levels of surface electrical stimulation. Those patients who had reduced aspiration and penetration during swallowing with stimulation had greater hyoid depression during stimulation at rest. Stimulation may have acted to resist patients’ hyoid elevation during swallowing. | ||
Shaw et al. [25] (retrospective design) | 18 Diverse neurological pathologies, post laryngeal radiotherapy | Quality-of-life measure (N = 11), videofluoroscopy (N = 16), FEES (N = 2), clinical evaluation (dietary status) Blinding? | Surface electrical stimulation: anterior neck G1 Near-functional swallow (N = 2) G2 Limited swallowing requiring compensatory maneuvers (N = 4) G3 Enteral feedings, ability to swallow small amounts of certain consistencies (N = 7) G4 Tube feeding (N = 5) | Most patients improved with therapy. G2 improved significantly and G1 improved to normal. In G3 most patients (6/7) discontinued tube feeding, whereas in G4 no patient could stop tube feeding. In G4 only 2 patients out of 5 showed any improvement. | ||
Descriptive statistics | Lazzara et al. [27] | 25 Diverse neurological pathologies | Videofluoroscopy | Thermal stimulation at anterior faucial pillars (single session) | Thermal stimulation improved triggering of the swallowing reflex in 23/25 patients on swallows of at least one consistency (liquids or paste). Total transit time improved in 9/10 patients for liquids and 14/14 patients for paste. | |
Leelamanit et al. [26] | 22 Diverse neurological pathologies Excluding: N = 1 (broken device), N = 2 (failed treatment) | Videofluoroscopy, clinical evaluation, other (weight gain) Blinding? | Synchronous electrical stimulator treatment (SES treatment): thyrohyoid muscle | SES treatment was ended in 2 subjects because of failure to improve and indication for gastrostomy. The remaining 20 subjects showed improved swallowing function after SES. 6 patients relapsed after a first SES treatment but were successfully treated with an additional SES treatment. Stimulating synchronous contraction of the thyrohyoid muscle by synchronous electrical stimulation during swallowing improves dysphagia resulting from reduced laryngeal elevation. |
Level of evidence | Data analysis | Reference (literature) | Subjectsa/etiology | Evaluation techniques | Treatment(s)/groups (G)b
| Authors’ conclusions /key findings |
---|---|---|---|---|---|---|
A (randomized controlled trial) | Statistical analysis | Shaker et al. [28] | 27 Diverse neurological pathologies, post pharyngeal radiotherapy, diverse cardiovascular diseases | Videofluoroscopy, clinical evaluation (FOAMS: Functional Outcome Assessment of Swallowing Score) Blinding | G1 Sham exercise (N = 7) G2 Head-raising exercise program (N = 27c) | Pretreatment, all subjects suffered from abnormal UES opening. After treatment, G1 showed no significant changes in the measured biomechanical parameters. Following real exercise, both G2 and G1 (when crossed over to the real exercise group) exhibited a significant improvement in the anteroposterior diameter of the UES opening, in the anterior laryngeal excursion, and in the FOAMS scores. A significant decrease was found for postdeglutitive residue and resolution of aspiration. |
B (non-randomized clinical trial) | Statistical analysis | Bülow et al. [31] | 8 CVA, head and neck cancer | Videofluoroscopy, other (videomanometry) Blinding? | Supraglottic swallow, chin tuck, and effortful swallow (single session) | None of the techniques reduced the number of misdirected swallows, but effortful swallow and chin tuck significantly reduced the depth of contrast penetration into the larynx and pharyngeal retention. The swallowing techniques did not improve weak pharyngeal constriction. |
Logemann et al. [29] | 5 Acute brainstem stroke (unilateral dysphagia) | Videofluoroscopy | Head rotation (single session) | The fraction of the bolus swallowed and the UES opening diameter increased significantly with the head turned toward the paretic side. | ||
Logemann et al. [30] | 9 Head and neck cancer | Videofluoroscopy | Super-supraglottic swallow (single session) | With use of the super-supraglottic maneuver, fewer swallowing motility disorders were observed than without use of the maneuver. The maneuver contributed to the elimination or reduction of aspiration in three subjects. | ||
Descriptive statistics | Bogaert et al. [34] | 30 Diverse neurological pathologies | Videofluoroscopy | Chin tuck versus supraglottic swallow (single session) | Both head flexion and supraglottic swallow could improve the pharyngeal phase of swallowing (e.g., reduction of premature spilling, elimination or reduction of aspiration, or penetration), but a consistent effect could not be proven. | |
Lewin et al. [33] | 21 Esophagectomy with aspiration | Videofluoroscopy | Chin tuck (single session) | Aspiration was eliminated in 81% (17/21) of aspirators using the chin-tuck maneuver. | ||
Logemann et al. [36] | 32 Supraglottic laryngectomy, oral cancer resection, other resections | Videofluoroscopy | Postural techniques with or without supraglottic swallow (single session) | Postural techniques were effective in at least 60% of the patients with 1- and 3-ml volumes. If the patient first aspirated at 3-ml volumes, the posture was effective with 5-ml boluses in 80% of the patients. All patients who were able to swallow 10-ml boluses without aspiration using the posture were also able to swallow from a cup using the posture, an important step toward more normal eating. | ||
Logemann et al. [37] | 9 Post supraglottic laryngectomy | Videofluoroscopy Blinding? | Supraglottic swallow | 3/9 of the patients were able to eat orally at 2 weeks postoperatively, whereas 7/9 of the patients were successful oral feeders by 3 months. | ||
Shanahan et al. [32] | 30 Diverse neurological pathologies | Videofluoroscopy | Chin tuck (single session) | All subjects showed preswallow aspiration because of delayed pharyngeal swallow triggering. Use of chin tuck eliminated aspiration in 15 out of 30 subjects. | ||
Zuydam et al. [35] | 13? Tongue-base resection Patient attrition? | Videofluoroscopy Blinding? | Chin tuck; combination of chin tuck and supraglottic swallow G1 Tongue-base resection less than ¼ (N = 6?) G2 Tongue-base resection ¼ or more (N = 7?) | Compensatory procedures and therapy techniques were successful in a third of cases in the larger resection group and in all cases in the smaller resection group. |
Level of evidence | Data analysis | Reference (literature) | Subjectsa/etiology | Evaluation techniques | Treatment(s)/groups (G)b
| Authors’ conclusions / key findings |
---|---|---|---|---|---|---|
B (nonrandomized clinical trial) | Statistical analysis | El Sharkawi et al. [38] | 8 Idiopathic Parkinson’s disease | Videofluoroscopy Blinding | Lee Silverman Voice Treatment (LSVT) | LSVT improved neuromuscular control of the entire upper aerodigestive tract, improving oral tongue and tongue-base function during the oral and pharyngeal phases of swallowing: an overall 51% reduction in the number of swallowing motility disorders. For all swallow volumes and consistencies, oral transit time and oral residue were reduced and the oropharyngeal swallow efficiency was improved. |
Robbins et al. [39] | 10 Acute and chronic stroke | Quality-of-life measure, videofluoroscopy, clinical evaluation (dietary questionnaire), other (oral pressure measurements; MRI: N = 3) Blinding? | Isometric lingual exercise program (compressing air-filled bulb between tongue and hard palate) | Patients showed positive changes in lingual strength after 8 weeks of progressive resistance lingual exercises. Improved isometric strength corresponded with spontaneous increased pressure generation during swallowing. Patients showed significant improvement in swallowing function and dysphagia-specific quality-of-life measures, with reported changes in social life and dietary intake. |
Level of evidence | Data analysis | Reference (literature) | Subjectsa/etiology | Evaluation techniques | Treatment(s)/groups (G)b
| Authors’ conclusions /key findings |
---|---|---|---|---|---|---|
A randomized controlled trial) | Statistical analysis | Hwang et al. [40] | 33 Diverse etiologies (IC unit: ≥ 2 days intubation) | Videofluoroscopy Blinding | G1 Preemptive swallowing stimulation: thermal-tactile stimulation, oral stimulation and massage, digital manipulation, and cervical range of motion exercise (N = 15) G2 No therapy (N = 18) | Preemptive swallowing stimulation during intubation assists in the recovery of swallowing function in long-term intubated patients. Oral transit time, oral pharyngeal transit time, and oropharyngeal swallowing efficiency were significantly faster in G1. Differences between both groups in terms of percentage of aspiration and swallowed volume were not statistically significant. |
Robbins et al. [41] | 515 Dementia (N = 260), Parkinson disease (N = 154), Parkinson disease with dementia (N = 101) Patient attrition? | Other (chest X-ray, respiratory indicators: sustained fever, rhonchi, sputum gram stain, or sputum culture) Blinding? | Viscosity modulation & chin tuck G1 Chin tuck (N = 259) G2 Nectar-thickened liquids (N = 133) G3 Honey-thickened liquids (N = 123) | No definitive conclusions about the superiority of chin-down posture, nectar- or honey-thickened liquids on the 3-month cumulative incidence of pneumonia in patients with dementia and/or Parkinson’s disease can be made. | ||
Rosenbek et al. [41] | 45 Acute stroke (males) Including: N = 2 (?) | Videofluoroscopy Blinding? | Tactile-thermal application and effortful swallowing maneuver (during 2 weeks) G1 150 trials per week (N = 12) G2 300 trials per week (N = 10) G3 450 trials per week (N = 10) G4 600 trials per week (N = 13) | No single treatment intensity emerged as superior. Overall, improved severity of aspiration and/or penetration and decreased duration of stage transition did not reach clinical or statistical significance. | ||
Desciptive statistics | Carnaby et al. [43] | 303 Acute stroke (including 60 patients who died) Including: N = 60 (dead); Excluding: N = 3 (lost to follow-up) | Clinical evaluation (dietary status) Blinding | G1 Usual care: if treatment, mainly supervision of feeding, precautions for safe swallowing (e.g., positioning, slowed rate of feeding) (N = 102) G2 Standard low-intensity intervention (3x per week up to a month): compensation strategies, safe-swallowing advice, dietary modification (N = 101) G3 Standard high-intensity intervention (daily/every working day up to a month): direct swallowing exercises, dietary modification (N = 100) | After 6 months, 70% of the patients in G3, 64% in G2, and 56% in G1 returned to a normal diet. A functional swallow without swallowing complications was achieved by 32% of the patients in G1, 43% in G2, and 48% in G3. In patients with standard therapy (G2 and G3), medical complications, chest infections, and death or institutionalization were significantly decreased. | |
B (non-randomized clinical trial) | Statistical analysis | Carnaby-Mann et al. [50] | 6 Chronic dysphagia Including N = 1 (unrelated adverse advent) | Videofluoroscopy, clinical evaluation (Funcional Oral Intake Scale, Mann Assessment of Swallowing Ability), other (weight gain) Blinding | Neuromuscular Electrical Stimulation (NMES) and swallowing maneuver (fast, effortful swallow) | Significant change was demonstrated for clinical swallowing ability, functional oral intake, weight gain, and patient perception of swallowing ability. Hyoid and laryngeal elevation during swallowing demonstrated bolus-specific patterns of change. |
Crary et al. [49] (retrospective design) | 45 Patient attrition? | Clinical evaluation (Functional Oral Intake Scale) Blinding? | Swallowing instruction and surface electromyographic biofeedback (sEMG): anterior neck G1 Stroke (N = 25) G2 Head/neck cancer: postradiation and/or surgery (N = 20) | 87% of the patients increased their functional oral intake of food/liquid by at least one scale score subsequent to therapy, including 92% of stroke and 80% of head/neck cancer patients. Average change in functional oral intake scores reflected a trend toward statistical significance. The average number of therapy sessions per patient was significantly higher in G1 than in G2. | ||
Denk and Kaider [47] | 33 Oncology (post head and neck surgery) | Videofluoroscopy, FEES Blinding? | Videoendoscopic biofeedback in conventional therapy (thermal stimulation, oral motor exercises, compensatory techniques, and dietary measures) G1 Conventional therapy (N = 14) G2 Conventional therapy and videoendoscopic biofeedback (N = 19) Randomization? | Before therapy all patients suffered from aspiration. After therapy restoration of exclusively oral nutrition with food of all consistencies without moderate or severe aspiration was found in G1 for 71% (11/14) and in G2 for 73% (14/19) of the patients. In the first 40 days of therapy, G2 had a significantly better chance of therapeutic success, shortening the period of functional rehabilitation compared to G1. After this first period, no more significant difference in chance existed between G1 and G2. | ||
Elmståhl et al. [51] | 38 Acute stroke | Quality-of-life measure, videofluoroscopy, other (plasma protein levels, body composition) Blinding | Oral motor exercises, swallowing strategies (supraglottic swallowing, effortful swallowing, Mendelsohn maneuver, thermal stimulation), head and neck positioning, and diet modification | About 60% of all patients responded with better swallowing function and improved nutritional status at follow-up, thereby reducing the risk of developing a condition of malnutrition. Changes of subjective complaints did not correlate with swallowing function or nutritional improvements. | ||
Huckabee and Cannito [49] (retrospective design plus follow-up patient questionnaire) | 10 Brainstem injury (stroke, tumor) with chronic dysphagia Patient attrition? | Videofluoroscopy, clinical evaluation (nutritional intake scale, dichotomized respiratory symptomatology) Blinding? | Outpatient accelerated swallowing treatment programme surface electromyography biofeedback and cervical auscultation biofeedback in combination with effortful swallow, Mendelsohn maneuver, vocal adduction exercises, oral motor exercises, head-lifting maneuver, and compensatory mechanisms | After therapy significant improvements were observed in swallowing physiology as measured by severity ratings of videofluoroscopic swallowing studies, diet level, and pulmonary status. | ||
Kasprisin et al. [46] (retrospective design) | 69 Chronic dysphagia Patient attrition? | Pretreatment: Videofluoroscopy (N = 63) or clinical evaluation (N = 6); Post- treatment: other (radiographic and/or cytological analyses) Blinding? | Bolus modification and/or facilitation and/or compensatory techniques. G1 Therapy, no history of aspiration pneumonia (N = 48) G2 Therapy, history of aspiration pneumonia (N = 13) G3 No therapy (N = 8) | Within 1 year after treatment, 6% (3/48) of G1, 15% (2/13) of G2, and 100% (8/8) of G3 experienced aspiration pneumonia. No significant difference existed in the occurrence of aspiration between G1 and G2, but differences between G1 and G3 as well as between G2 and G3 did reach significance. | ||
Lin et al. [44] | 49 Stroke Excluding: N = 12 (moved, hospitalized, discharged, or withdrawn) | Clinical evaluation, other (e.g., timed swallowing test) Blinding? | Swallowing training protocol: (1) direct therapy: compensatory strategies like diet modification, environment arrangement, positioning, swallowing maneuvers; (2) indirect therapy: thermal stimulation, physical maneuvers like lip and lingual exercises. G1 Swallowing training protocol (N = 35) G2 No therapy (N = 14) Randomization? | After swallowing training, mean differences in volume per second, volume per swallow, mid-arm circumference, and body weight between pre- and post-training of the experimental group were significantly higher than for the control group, while mean differences in neurological examination and choking frequency during meals for the experimental group were significantly lower than for the control group. | ||
Martens et al. [45] | 31 Diverse neurological disorders | Clinical evaluation (e.g., Dysphagia Severity Rating Scale), other (chest X-rays) No blinding | Multidisciplinary management program: counseling and education, modification of diet, nonoral feeding, supervised trial feeds, oral motor exercises, supraglottic swallow, or thermal stimulation G1 Multidisciplinary dysphagia program (N = 16) G2 No therapy (N = 15) Randomization? | A significant improvement in weight gain and caloric intake was found when comparing G1 with G2. No incidence of aspiration was reported in either group. | ||
Nagaya et al. [53] | 10 Parkinson’s disease | Other (electromyography) Blinding? | Tongue motion and resistance exercises, exercises to increase the adduction of vocal folds, Mendelsohn maneuver, neck/shoulders/trunk motion exercises (single session) | After therapy, the premotor time was reduced significantly. No significant change in the duration of EMG burst was found. | ||
Prosiegel et al. [54] | 208 Diverse neurological pathologies | Videofluoroscopy and/or FEES (N = 204), clinical evaluation (functional feeding status) Blinding? | Functional swallowing therapy: restitution (89%: 186/208), compensation (89%: 186/208), adaptation (85%: 177/208) | 55% of all patients, initially dependent on tube feeding, were full oral feeders after therapy; functional feeding status showed significant improvement. | ||
Prosiegel et al. [55] | 43 Diverse neurological pathologies | Clinical evaluation (functional feeding status) No blinding | Functional swallowing therapy: adaptation, compensation, and restitution G1 Posterior fossa tumors and cerebellar hemorrhage (N = 8) G2 Wallenberg’s syndrome (N = 27) G3 Avellis’ syndrome and unilateral paresis of vagal nerve (N = 8) Randomization? | After therapy functional feeding status showed significant improvement in G1, G2, and G3. G3 had a significantly better functional outcome compared to G2, and G2 had a significantly better outcome compared to G1. More than 50% (5/8) of the patients in G1 and 30% of the patients in G2 were dependent on tube feeding, while no patients were dependent on tube feeding in G3. | ||
Seidl et al. [52] | 10 Head injury or cerebral hemorrhage (acute phase) Patient attrition? | FEES, clinical evaluation (swallowing frequency) Blinding? | Facio-oral tract therapy by Coombes (based on Bobath concepts) | The increase in swallowing frequency over the entire therapy period of 15 days (1 h per day) was statistically significant. Positive changes in swallowing ability and protection of the lower respiratory tract were statistically significant. | ||
Descriptive statistics | Barbiera et al. [66] | 36 Diverse neurological pathologies | Clinical evaluation (dietary status) Blinding? | Speech therapy and postural techniques G1 Normal swallowing: tracheostomy (N = 1), PEG tube (N = 1) G2 Minimal and mild dysphagia (N = 13) G3a Mild-moderate and moderate dysphagia (n = 11) G3b Moderate-severe and severe dysphagia (n = 10) (according to Dysphagia Severity Rating Scale) | G2: 10/13 patients returned to a free diet and 3/13 remained on a diet with some restrictions; G3a: 2/10 returned to a free diet and 1/10 was placed on tube feeding and died. The others remained on a diet with restrictions; G3b: 3/10 died and 1/10 went from tube feeding to a diet with restrictions. The others remained on tube feeding. | |
Bartolome and Neumann [60] | 28 Diverse neurological disorders causing cricopharyngeal dysfunction (including 5 subjects post surgery) | Clinical evaluation (dietary status), other (cineradiography) Blinding? | G1 Direct therapy: strategies to normalize impaired motor and sensory functions (N = 2) G2 Indirect therapy: Mendelsohn maneuver, supraglottic swallowing, dietary adjustments, and/or changes of head positioning (N = 3) G3 Direct and indirect therapy (N = 23, including 5 patients postsurgery) Randomization? | Overall, 90% of the patients improved after swallowing therapy, 65% by objective (type and/or safety of feeding) and 25% by subjective (ease of feeding and range of diet) criteria. Direct and indirect swallow methods are associated with improvement. | ||
Crary [70] | 6 Brainstem stroke (including 2 surgical myotomies) with chronic dysphagia | Clinical evaluation, other (sEMG assessment) Blinding? | Swallowing instruction (focused on bolus control and airway protection) and surface electromyographic biofeedback (sEMG): anterior neck | After 3 weeks of therapy, 3/6 patients were able to resume oral intake. Following completion of therapy, 5/6 patients returned to total oral feeding and maintained feeding tube removal. After therapy, sEMG evaluation demonstrated improved swallowing coordination, longer swallow durations, and increased effort. Functional benefit is long-lasting without related health complications. | ||
Denk et al. [64] | 32 Oncology (post head and neck surgery) | Videofluoroscopy, FEES | Conventional therapy (thermal stimulation, oral motor exercises, compensatory techniques, and dietary measures) Blinding? | Before therapy, all patients suffered from aspiration. After therapy 75% (24/32) of all patients regained full oral intake diet. | ||
Hägg and Larsson [67] | 7 Chronic dysphagia Stroke | Quality-of-life measure, videofluoroscopy, clinical evaluation Blinding | Orofacial regulation therapy by Morales: Motor and sensory stimulation | Therapy according to Morales can improve long-lasting oropharyngeal dysphagia in stroke patients. | ||
Horner et al. [57] | 22 Brainstem stroke Excluding: N = 1 (dead) | Videofluoroscopy,c clinical evaluation (dietary status) Blinding? | Diet modifications and chin tuck or lateral head postures (single session; mean period of follow-up = 97 days) | Before treatment 68% (15/22) of the patients took nothing by mouth. After treatment plus follow-up period, 9% (2/22) had oral plus gastrostomy feedings, while 86% (19/22) resumed full oral nutrition. No instances of pulmonary or nutritional compromise were found in any of the 19 successful subjects. | ||
Kiger et al. [69] | 22 Diverse neurological pathologies, respiratory failure/pneumonia, deconditioning, tongue tumor | Videofluoroscopy or FEES, clinical evaluation (dietary status) Blinding? | G1 VitalStimTM therapy (N = 11) G2 Traditional swallowing therapy, e.g., oral motor exercises, compensatory strategies, thermal stimulation via deep pharyngeal neuromuscular stimulation (N = 11) Randomization? | Raw positive change scores for oral and pharyngeal phases appeared stable in both groups (Run Chart analysis). Differences between G1 and G2 for changes in oral and pharyngeal phase dysphagia severity, dietary consistency restrictions, and progression from nonoral to oral intake were not statistically significant. | ||
Logemann et al. [56] | 711 Parkinson’s disease and/or dementia with aspiration Excluding: N = 2 (?), N = 29 (no or nonevaluable swallow) | Videofluoroscopy | Viscosity modulation (nectar- and honey-thickened liquid) and chin tuck (single session) G1 Parkinson’s disease (N = 228) G2 Dementia (N = 351) G3 Parkinson’s disease & dementia (N = 132) | Significantly more patients aspirated on thin liquids despite using chin-down posturing than when using nectar-thickened liquids (68% vs. 63%) or honey-thickened liquids (68% vs. 53%). About half of the patients received no benefit from any intervention. A significantly higher rate of benefit was observed in patients with Parkinson’s disease only compared with patients with dementia with or without Parkinson’s disease. Patients with the most severe dementia exhibited the least effectiveness on all interventions. | ||
Masiero et al. [63] | 16 Post carotid endarterectomy (acute phase) Excluding: N = 3 (?) | FEES, clinical evaluation (dietary level) Blinding? | Oral motor exercises, sensory stimulation, postural and compensatory techniques, dietary modifications, oral hygiene education, and family training | 10 and 6 patients recovered completely and returned to their preoperative diet within 1 and 6 months, respectively. | ||
Nagaya et al. [58] | 48 | Videofluoroscopy | Compensatory techniques (chin tuck, supraglottic swallow) and/or bolus modification (liquid, jelly); (single session) G1 Parkinson’s disease (N = 25) G2 Cerebellar ataxia (N = 23) | 52% (13/25) of G1 and 30% (7/23) of G2 aspirated on thin liquid. When using jelly boluses, aspiration was absent in all subjects, except for 2 subjects of G2. Subjects with aspiration (6 subjects of each group) were instructed to use chin tuck and supraglottic swallow. In 5/6 of G1 and 2/6 of G2 these techniques were not effective. | ||
Neumann [61] | 66 Diverse neurological pathologies | Clinical evaluation (dietary status), other (cineradiography) No blinding | Direct therapy: thermal stimulation, tapping, stretching, and exercises of the tongue, lips, jaw, palate, and larynx Indirect therapy (compensatory strategies): supraglottic swallowing, head and neck positioning, Mendelsohn maneuver, and modification of dietary consistencies G1 Indirect therapy (N = 8) G2 Direct therapy (N = 21) G3 Direct and indirect therapy (N = 37) Randomization? | After therapy, 84% of all patients improved as determined by type of feeding, ease of feeding, safety of feeding, and range of diet. Both direct and indirect methods were potentially useful. | ||
Neumann et al. [62] | 58 Diverse neurological pathologies Patient attrition? | Clinical evaluation (dietary status) No blinding | Direct therapy (compensatory strategies): head and neck positioning, supraglottic swallowing, and Mendelsohn maneuver Indirect therapy: stimulation, assisted isotonic or isometric exercises, and independent exercises G1 Indirect therapy (N = 29) G2 Direct therapy (N = 1) G3 Direct and indirect therapy (N = 28) Randomization? | Before therapy no patients exclusively achieved oral feeding, while after therapy 67% of the patients achieved oral feeding. | ||
Nguyen et al. [68] (retrospective design) | 41 Head and neck cancer Patient attrition? | Videofluoroscopy Blinding? | Individualized combination: diet modification, range of (orofacial) motion exercises, postural training, swallowing maneuvers, electrostimulation G1 Postoperative radiation (N = 17) G2 Postchemoradiation (N = 24) | Before therapy, 39% (16/41) and 61% (25/41) of all subjects showed, respectively, trace and severe aspiration. After therapy, 32% (13/41) of both groups combined had resolution of aspiration: 6 subjects of G1 and 7 subjects of G2. About 30% (7?/25) of the severe aspirators improved to trace or no aspiration, allowing discontinuation of gastrostomy tube: 50% (5/10) of G1 and 13% (2/15) of G2. | ||
Rasley et al. [59] | 165 Diverse neurological pathologies, head and neck cancer, Zenker’s diverticulum, generalized weakness, unknown (N = 2), Age 3-95 years | Videofluoroscopy | Bolus volume modulation (1, 3, 5, or 10 ml) and drinking from a cup combined with postural changes: head rotation, chin tuck, or side-lying (single session) | Changes in head or body position eliminated aspiration of at least 1 bolus of barium in 77% (127/165) of the subjects, and of all four boluses plus drinking barium from a cup in 25% (41/165). Chin tuck and head rotation resulted in elimination of aspiration for all volumes in 25% (21/84) and 26% (20/71) of the subjects, respectively. Using side-lying, 2 of 4 subjects showed elimination of aspiration for smaller swallows (1 or 3 ml). | ||
Schurr et al. [65] (retrospective design) | 24? Brain injury Patient attrition? | Clinical evaluation (dietary status) No blinding | Postural, dietary, and behavioral modifications | After therapy, 83% (20/24) of the patients returned to oral dietary intake. 4 patients remained on long-term gastrostomy tube feeding. |