Glottic insufficiency caused by vocal fold atrophy with or without sulcus: systematic review of outcome measurements.

PURPOSE: Identifying outcome measurements instruments (OMIs) to evaluate treatment efficacy in patients with vocal fold atrophy and/or sulcus. METHODS: Systematic review of records published before March 2021 by searching Pubmed and EMBASE. Included studies reported on adults (> 18 year) with dysphonia caused by glottic insufficiency due to vocal fold atrophy with or without sulcus, who were enrolled into a randomized controlled trial, a non-randomized controlled trial, a case-controlled study or a cohort study. All included studies described an intervention with at least one outcome measurement. RESULTS: A total of 5456 studies were identified. After removing duplicates, screening title and abstract and full text screening of selected records, 34 publications were included in final analysis. From these 50 separate OMIs were recorded and categorized according to the ELS protocol by DeJonckere et al. (Eur Arch Otorhinolaryngol 258: 77-82, 2001). With most OMIs being used in multiple studies the total number of OMIs reported was 265. Nineteen (19) individual OMIs accounted for 80% of reports. The most frequently used OMIs according to category were: VHI and VHI-10 (subjective evaluation); G of GRBAS (perceptual evaluation); F0, Jitter and Shimmer (acoustic evaluation); MPT and MFR (aerodynamic evaluation) and glottic closure and mucosal wave (endoscopic evaluation). Of these OMIs VHI had a high percentage of significance of 90%. CONCLUSION: This systematic review identifies the most used OMIs in patients with glottic incompetency due to vocal fold atrophy and/or sulcus as a step toward defining a Core Outcome Set (COS) for this population. PROSPERO REGISTRATION: 238274.

Multidimensional assessment of voice quality after injection augmentation of the vocal fold with autologous adipose tissue or calcium hydroxylapatite.

PURPOSE: The purpose of this study was to evaluate short- and long-term outcome of injection augmentation with autologous adipose tissue (AAT) and calcium hydroxylapatite injection (CAHA) in patients with a unilateral vocal fold paralysis (UVFP). DESIGN/METHODS: A retrospective cohort study was performed in patients diagnosed with UVFP, who had received injection augmentation with AAT or CAHA. Multidimensional voice analysis was performed before, 3 and 12 months after injection. This analysis included patient self-assessment (Voice Handicap Index-30), perceptual (overall dysphonia grade according to the GRBAS scale), aerodynamic (MPT, s/z ratio) and acoustic (fundamental frequency, dynamic range) parameters. Effects were assessed using a linear mixed model analysis. RESULTS: Forty-six patients were available for evaluation, with a total of 53 injection augmentations (AAT n = 39; CAHA n = 14). We found significant improvement of patient self-assessment and perceptive voice outcome at 3 months, which were maintained at 12 months. In the CAHA group, s/z ratio and dynamic range of extreme frequencies also improved significantly over time. No statistically significant differences were found between the two treatments (AAT vs. CAHA). No major complications were reported. CONCLUSION: This study, using a guide-line recommended panel of outcome parameters, shows a high success rate of injection augmentation with AAT or CAHA for patients with UVFP at 12 months with significant improvement in most voice outcome parameters, although voices do not completely normalize. There is no significant difference in outcome between the two materials.

Long-term voice outcomes of laryngeal framework surgery for unilateral vocal fold paralysis.

OBJECTIVE: To evaluate the short- and long-term voice outcomes after unilateral medialization thyroplasty (MT) and unilateral medialization thyroplasty with arytenoid adduction (MT + AA) in patients with unilateral vocal fold paralysis. METHODS: Voice outcomes were assessed preoperatively, and postoperatively at 3 and 12 months according to a standardized protocol. Voice assessment was performed using Voice Handicap Index (VHI), GRBAS Grade, Maximum Phonation Time (MPT), s/z-ratio and subjective numeric rating scales on voice quality, effort, performance and influence on life. RESULTS: Sixty-one patients were included (34 MT and 27 MT + AA). Significant pre- to postoperative improvements were seen in all voice outcome parameters. No significant differences in post-operative values were identified between the groups. CONCLUSION: Based on our findings, we conclude that patients with unilateral vocal fold paralysis who undergo MT and MT + AA achieve comparable and significant long time voice improvement, although voices do not completely normalize. We also conclude that this does not mean that AA is a superfluous procedure, but can indicate the accurate identification of patients in need of the additional AA procedure based on clinical parameters.

Prediction of aspiration in dysphagia using logistic regression: oral intake and self-evaluation.

OBJECTIVES: Oropharyngeal dysphagia (OD) has a major influence on health in general and health-related quality of life (HR-QoL) in particular. The gold standard assessments for OD, especially for aspiration in OD, are fiberoptic endoscopic evaluation of swallowing (FEES) and videofluoroscopy (VFSS), but not all patients have access to such procedures. Therefore, the current study built a prediction model to forecast aspiration in patients with OD on the basis of common self-evaluation questionnaires and oral intake status. METHODS: A consecutive series of 111 patients with confirmed diagnosis of OD was measured according to a standardised protocol using the following tools: the Swallowing Quality of Life Questionnaire (SWAL-QOL), the Dysphagia Handicap Index (DHI), two self-report visual analogue scales which measure the Severity and the Impairment of the swallowing problem on everyday social life as experienced by the patient, the Eating Assessment Tool 10 (EAT-10), the Functional Oral Intake Scale (FOIS) and subsequently FEES (the gold standard). Penalised logistic regression was carried out to predict aspiration. The performance of the resulting models was evaluated by constructing receiver operating characteristics (ROC) curves and computing areas under the curve (AUC). RESULTS: The final model showed an AUC of 0.92, indicating excellent performance. CONCLUSION: This study shows that it may be possible to accurately predict aspiration in oropharyngeal dysphagia by a non-invasive and non-instrumental assessment protocol including oral intake status and self-report questionnaires on functional health status and HR-QoL.

Bilateral medialization thyroplasty in patients with vocal fold atrophy with or without sulcus.

PURPOSE: To evaluate voice outcome after bilateral medialization thyroplasty in patients with non-paralytic glottic insufficiency due to vocal fold atrophy with or without sulcus. METHODS: Retrospective cohort study on 29 patients undergoing bilateral medialization thyroplasty for vocal fold atrophy (14 procedures) or atrophy with sulcus (15 procedures) between October 2012 and November 2017. Voice data were collected and analyzed for the preoperative and the 3- and 12-month postoperative time point according to a standardized protocol, including Voice Handicap Index (VHI)-30 and perceptual, acoustic and aerodynamic parameters. Failure rate was based on number of revisions within 12 months and non-relevant improvement (< 10 points) in VHI-30 at 12 months. RESULTS: There was a clinically relevant (≥ 15 points) and statistically significant improvement (p < 0.0001) in the VHI-30 (preoperative: 55.8 points; postoperative at 12 months: 30.9 points). Fundamental frequency for male subjects decreased significantly from 175 to 159 Hz (p = 0.0001). The pre- and post-operative grade of dysphonia was significantly lower in patients with atrophy compared to atrophy and sulcus (mean difference 0.70, p = 0.017). CONCLUSION: Bilateral medialization thyroplasty is a valid treatment option for patients with atrophy with or without sulcus. Outcomes are comparable to other methods reported in literature. However, there is a great need for larger, prospective studies with long-term follow-up to gain more insight into the comparative voice outcomes for the different forms of surgery for patients with glottic incompetence due to atrophy with or without sulcus.

Bilateral trial vocal fold injection with hyaluronic acid in patients with vocal fold atrophy with or without sulcus.

PURPOSE: To evaluate the outcome of bilateral trial vocal fold injection (VFI) with hyaluronic acid in patients with vocal fold atrophy ± sulcus and to assess the predictive value of trial VFI on the outcome of durable medialization procedure. METHODS: Voice data collected according to a standardized protocol before and one month after trial VFI of 68 patients with vocal fold atrophy (30) and atrophy with sulcus (38) were analyzed. Voice Handicap Index (VHI)-30 was compared to the outcome of a durable medialization at 3 and 12 months. RESULTS: The overall VHI-30 improvement was 16.8 points (from 49.9 to 33.1), which was statistically significant and clinically relevant. 57.8% of the patients experienced enough subjective benefit after trial VFI to undergo durable medialization. Of the patients that experienced subjective benefit 62% had a clinically relevant improvement in VHI-30. There was no relevant change in other parameters and no difference between ± sulcus. After durable medialization 90-94% of the patients had VHI-30 scores similar to or better than post-trial VFI. CONCLUSION: The majority of patients experience subjective improvement after bilateral trial VFI indicating that medialization is a valid treatment option for patients with vocal fold atrophy ± sulcus. The VHI-30 only partially overlaps with patients' subjective evaluation and does not predict which patients will experience subjective improvement. It is, however, predictive for VHI-30 outcome after durable medialization. The aerodynamic and acoustic parameters showed no relevant change. Further identification of voice assessment parameters accurately reflecting the subjective experience of these patients is warranted.

Quality of life and voice outcome of patients treated with transoral CO2 laser microsurgery for early glottic carcinoma (T1-T2): a 2-year follow-up study.

PURPOSE: Longitudinal studies in laryngeal cancer can provide clinicians information about short-term and long-term functional outcomes, like quality of life (QoL) and voice outcome. This information is important when counseling patients or choosing a primary treatment modality. The present study assessed long-term (2 years) QoL and voice outcome in patients with extended T1 and limited T2 glottic carcinoma treated with transoral CO2 laser microsurgery (TLM) (unilateral type III or bilateral type II resections). METHODS: Three questionnaires were administered: the Voice Handicap Index (VHI), the European Organization for Research and Treatment of Cancer (EORTC) QoL questionnaire (QLQ)-C30, the EORTC QLQ-HN35. A perceptual voice evaluation at six different time points was conducted: preoperatively, and postoperatively at 6 weeks, 3 months, 6 months, 1 year, and 2 years. Fluctuations over time were investigated. RESULTS: Sixty-one patients were included in the analysis. Patients reported high-level functioning and low symptom scores 2 years postoperatively. Gender significantly affected the VHI scores at 2 years (mean VHI scores: female 8.7 vs. male, 23.9; p = 0.023). The major improvement in VHI scores was observed within the first 6 months. The tumor stage (T1a, T1b, and T2) significantly impacted the grade (mean scores at 2 years: 1.0, 1.9, and 1.7; p = 0.001). These scores stabilized at 6 months. CONCLUSIONS: Patients show good long-term QoL with low symptom scores, a low voice handicap, and mild to moderate dysphonia, 2 years postoperatively. Scores stabilize at 6 months and provide a clear indication of status at 1 and 2 years.

Bilateral vocal fold injection with autologous fat in patients with vocal fold atrophy with or without sulcus.

PURPOSE: To evaluate voice outcome after bilateral vocal fold injection with autologous fat in patients with non-paralytic glottic insufficiency due to vocal fold atrophy with or without sulcus. METHODS: This is a retrospective cohort study from September 2012 to December 2017 including 23 patients undergoing bilateral vocal fold injection with autologous fat (24 procedures) for vocal fold atrophy (15 procedures) or atrophy with sulcus (Ford type II or III) (9 procedures). Voice data were collected and analyzed for the preoperative and the 3- and 12-month postoperative time points according to a standardized protocol, including Voice Handicap Index (VHI)-30 and perceptive, acoustic and aerodynamic parameters. Failure rate was defined as non-relevant improvement (< 10 points) in VHI-30 at 12 months and number of revisions within 12 months. RESULTS: There was a clinically relevant (≥ 15 points) and statistically significant improvement in the VHI-30 (preoperative: 49.1 points; postoperative at 12 months: 29.7 points). Change in dynamic range was also statistically significant over time (p = 0.028). There were no differences in voice parameters between patients with atrophy only and atrophy with sulcus, although grade tended to be lower in patients with atrophy only over all time points. CONCLUSION: This study shows that bilateral vocal fold injection with autologous fat is a beneficial treatment not only for patients with atrophy but also for patients with sulcus. A comparison of the results with those reported from other forms of sulcus surgery confirmed this finding. However, there is a need for further prospective studies comparing the short- and long-term effects of different techniques.

Using Rasch Analysis to Evaluate the Reliability and Validity of the Swallowing Quality of Life Questionnaire: An Item Response Theory Approach.

The Swallowing Quality of Life questionnaire (SWAL-QOL) is widely used clinically and in research to evaluate quality of life related to swallowing difficulties. It has been described as a valid and reliable tool, but was developed and tested using classic test theory. This study describes the reliability and validity of the SWAL-QOL using item response theory (IRT; Rasch analysis). SWAL-QOL data were gathered from 507 participants at risk of oropharyngeal dysphagia (OD) across four European countries. OD was confirmed in 75.7% of participants via videofluoroscopy and/or fiberoptic endoscopic evaluation, or a clinical diagnosis based on meeting selected criteria. Patients with esophageal dysphagia were excluded. Data were analysed using Rasch analysis. Item and person reliability was good for all the items combined. However, person reliability was poor for 8 subscales and item reliability was poor for one subscale. Eight subscales exhibited poor person separation and two exhibited poor item separation. Overall item and person fit statistics were acceptable. However, at an individual item fit level results indicated unpredictable item responses for 28 items, and item redundancy for 10 items. The item-person dimensionality map confirmed these findings. Results from the overall Rasch model fit and Principal Component Analysis were suggestive of a second dimension. For all the items combined, none of the item categories were 'category', 'threshold' or 'step' disordered; however, all subscales demonstrated category disordered functioning. Findings suggest an urgent need to further investigate the underlying structure of the SWAL-QOL and its psychometric characteristics using IRT.

'What About Swallowing?' Diagnostic Performance of Daily Clinical Practice Compared with the Eating Assessment Tool-10.

In daily clinical practice, patients are frequently asked about their swallowing as part of the patient-clinician interview. This study compares the diagnostic performance of a single open question 'What about swallowing?' (usual care) with the Eating Assessment Tool (EAT-10) as reference test in screening for oropharyngeal dysphagia (OD). 303 outpatients at risk of OD were recruited at three university hospitals: 162 men and 141 women with a mean age of 70 years. All data were retrieved by phone. To identify patients at risk of dysphagia, two different cut-off scores for the EAT-10 total score were retrieved from the literature. The diagnostic performance of the single question was determined by comparing dichotomized answers to the single question (no problems versus difficulties in swallowing) with the EAT-10 as reference test. Sensitivity, specificity, positive and negative predictive values ranged between 0.75-0.76, 0.75-0.84, 0.93-0.97 and 0.38-0.43, respectively. Mostly, the results of this exploratory study indicate a sufficient diagnostic performance of the single question in identifying patients who are at risk of dysphagia when using the EAT-10 questionnaire as a reference test. Further research, is, however, necessary to provide additional psychometric data on Functional Health Status (FHS) questionnaires including the single question using either FEES or VFS as gold standard or reference test.

Living with oropharyngeal dysphagia: effects of bolus modification on health-related quality of life--a systematic review.

PURPOSE: Difficulty swallowing, oropharyngeal dysphagia, is widespread among many patient populations (such as stroke and cancer groups) and aged community-dwelling individuals. It is commonly managed with bolus modification: altering food (usually cutting, mashing or puréeing) or fluids (typically thickening) to make them easier or safer to swallow. Although this treatment is ubiquitous, anecdotal evidence suggests patients dislike this management, and this may affect compliance and well-being. This review aimed to examine the impact of bolus modification on health-related quality of life. METHODS: A systematic review of the literature was conducted by speech pathologists with experience in oropharyngeal dysphagia. The literature search was completed with electronic databases, PubMed and Embase, and all available exclusion dates up to September 2012 were used. The search was limited to English-language publications which were full text and appeared in peer-reviewed journals. RESULTS: Eight studies met the inclusion criteria. Generally, bolus modification was typically associated with worse quality of life. Modifications to foods appeared to be more detrimental than modifications to fluids, but this may be due to the increased severity of dysfunction that is implied by the necessity for significant alterations to foods. The number of studies retrieved was quite small. The diverse nature of methodologies, terminologies and assessment procedures found in the studies makes the results difficult to generalise. CONCLUSION: Overall, even though the severity of dysphagia may have been a confounding factor, the impact of bolus modification on health-related quality of life in patients with oropharyngeal dysphagia appears to be negative, with increased modification of food and fluids often correlating to a decreased quality of life. Further, associated disease factors, such as decreased life expectancy, may also have affected health-related quality of life. More research is needed.

The Huntington's Disease Dysphagia Scale.

BACKGROUND: Little is known about the swallowing disturbances of patients with Huntington's disease; therefore, we developed the Huntington's Disease Dysphagia Scale. METHODS: The scale was developed in four stages: (1) item generation, (2) comprehension testing, (3) evaluation of reliability, (4) item reduction and validity testing. The questionnaire was presented twice to 50 Huntington's disease patients and their caregivers. The Kruskal-Wallis test was used to evaluate whether the severity of swallowing difficulties increased with advancing disease. Pearson's correlation coefficient was used to examine the construct validity with the Swallowing Disturbance Questionnaire. RESULTS: The final version contained 11 items with five response options and exhibited a Cronbach's alpha coefficient of 0.728. The severity of swallowing difficulties was significantly higher in more advanced Huntington's disease. The correlation with the Swallowing Disturbance Questionnaire was 0.734. CONCLUSION: We developed a valid and reliable 11-item scale to measure the severity of dysphagia in Huntington's disease.

Psychometric characteristics of health-related quality-of-life questionnaires in oropharyngeal dysphagia.

Dysphagia can have severe consequences for the patient's health, influencing health-related quality of life (HRQoL). Sound psychometric properties of HRQoL questionnaires are a precondition for assessing the impact of dysphagia, the focus of this study, resulting in recommendations for the appropriate use of these questionnaires in both clinical practice and research contexts. We performed a systematic review starting with a search for and retrieval of all full-text articles on the development of HRQoL questionnaires related to oropharyngeal dysphagia and/or their psychometric validation from the electronic databases PubMed and Embase published up to June 2011. Psychometric properties were judged according to quality criteria proposed for health status questionnaires. Eight questionnaires were included in this study. Four are aimed solely at HRQoL in oropharyngeal dysphagia: the deglutition handicap index (DHI), dysphagia handicap index (DHI'), M.D. Anderson Dysphagia Inventory (MDADI), and SWAL-QOL, while the EDGQ, EORTC QLQ-STO 22, EORTC QLQ-OG 25 and EORTC QLQ-H&N35 focus on other primary diseases resulting in dysphagia. The psychometric properties of the DHI, DHI', MDADI, and SWAL-QOL were evaluated. For appropriate applicability of HRQoL questionnaires, strong scores on the psychometric criteria face validity, criterion validity, and interpretability are prerequisites. The SWAL-QOL has the strongest ratings for these criteria, while the DHI' is the most easy to apply given its 25 items and the use of a uniform scoring format. For optimal use of HRQoL questionnaires in diverse settings, it is necessary to combine psychometric and utility approaches.

A Psychometric Evaluation of the Dysphagia Handicap Index Using Rasch Analysis.

Background/Objectives: The Dysphagia Handicap Index (DHI) is commonly used in oropharyngeal dysphagia (OD) research as a self-report measure of functional health status and health-related quality of life. The DHI was developed and validated using classic test theory. The aim of this study was to use item response theory (Rasch analysis) to evaluate the psychometric properties of the DHI. Methods: Prospective, consecutive patient data were collected at dysphagia or otorhinolaryngology clinics. The sample included 256 adults (53.1% male; mean age 65.2) at risk of OD. The measure's response scale, person and item fit characteristics, differential item functioning, and dimensionality were evaluated. Results: The rating scale was ordered but showed a potential gap in the rating category labels for the overall measure. The overall person (0.91) and item (0.97) reliability was excellent. The overall measure reliably separated persons into at least three distinct groups (person separation index = 3.23) based on swallowing abilities, but the subscales showed inadequate separation. All infit mean squares were in the acceptable range except for the underfitting for item 22 (F). More misfitting was evident in the Z-Standard statistics. Differential item functioning results indicated good performance at an item level for the overall measure; however, contrary to expectation, an OD diagnosis presented only with marginal DIF. The dimensionality of the DHI showed two dimensions in contrast to the three dimensions suggested by the original authors. Conclusions: The DHI failed to reproduce the original three subscales. Caution is needed using the DHI subscales; only the DHI total score should be used. A redevelopment of the DHI is needed; however, given the complexities involved in addressing these issues, the development of a new measure that ensures good content validity may be preferred.

Long-term outcomes of bilateral medialisation thyroplasty in patients with vocal fold atrophy with or without sulcus.

OBJECTIVE: Evaluate long-term voice outcome after bilateral medialisation thyroplasty in glottic insufficiency due to vocal fold atrophy with or without sulcus. METHODS: Patients after medialisation thyroplasty for vocal fold atrophy with or without sulcus were identified. Long-term post-operative subjective voice outcomes (> 1 year) using Voice Handicap Index-30, subjective ratings on voice aspects and study-specific questionnaire were compared to pre-operative and shorter-term (1 year) values. RESULTS: Thirty-six patients were identified, of which 26 were included (16 atrophy, 10 sulcus) with median follow up of 6.7 years. Mean Voice Handicap Index score at > 1 year (40.0) showed clinically relevant (≥ 15 for groups) and statistically significant improvement compared to pre-operative score (58.1) and remained stable compared to post-operative score (35.7) at one year. Ten patients (56 per cent) reported clinically relevant improvement (≥ 10) after more than five years. CONCLUSION: Long-term improvement in subjective voice outcomes is attainable in a significant proportion of patients undergoing bilateral medialisation thyroplasty for atrophy with or without sulcus.

Effects of Oral Health Interventions in People with Oropharyngeal Dysphagia: A Systematic Review.

People with oropharyngeal dysphagia (OD) are at risk of developing aspiration pneumonia. However, there is no "best practice" for oral health interventions to improve swallowing-related outcomes, the incidence of aspiration pneumonia, and oral health in people with OD. Systematic literature searches were conducted for oral health interventions in OD in PubMed, Embase, CINAHL, and PsycINFO until July 2021. Original articles published in English and reporting pre- and post-intervention measurements were included. The methodology and reporting were guided by the PRISMA checklist. The methodological quality of the eight included studies was rated using the QualSyst critical appraisal tool. The oral health interventions in people with OD were diverse. This study shows little evidence that regular oral care and the free water protocol or oral disinfection reduced the incidence of aspiration pneumonia in people with OD. Oral cleaning, twice a day with an antibacterial toothpaste in combination with intraoral cleaning or the free water protocol, proved to be the most promising intervention to improve oral health. The effect of improved oral health status on swallowing-related outcomes could not be established. Increasing awareness of the importance of oral health and implementing practical oral care guidelines for people involved in the daily care of people with OD are recommended.

Development of Two Patient Self-Reported Measures on Functional Health Status (FOD) and Health-Related Quality of Life (QOD) in Adults with Oropharyngeal Dysphagia Using the Delphi Technique.

Introduction. Patient self-evaluation is an important aspect in the assessment of dysphagia and comprises both Functional Health Status (FHS) and Health-Related Quality of Life (HR-QoL). As many measures combine both FHS and HR-QoL, disease-related functioning cannot be distinguished from disease-related quality of life as experienced by the patient. Moreover, current patient self-reported measures are limited by poor and incomplete data on psychometric properties. Objective. This study aimed to establish content validity for the development of two new self-reported measures on FHS and HR-QoL in adults with oropharyngeal dysphagia (OD), in line with the psychometric taxonomy and guidelines from the COSMIN group (COnsensus-based Standards for the selection of health Measurement INstruments). Methods. Using the Delphi technique, international expert consensus was achieved; participants and patients with dysphagia evaluated relevance, comprehensiveness, and comprehensibility of definitions of relevant constructs (i.e., dysphagia, FHS and HR-QoL) and potential items. Results. A total of 66 Delphi participants from 45 countries achieved consensus across two rounds. The Delphi study resulted in two prototype measures, the Functional health status measure of Oropharyngeal Dysphagia (FOD) and the health-related Quality of life measure of Oropharyngeal Dysphagia (QOD), consisting of 37 and 25 items, respectively. Minimal revisions were required based on feedback by patients. Conclusions. This study provides evidence of good content validity for both newly developed prototype measures FOD and QOD. Future studies will continue the process of refining the measures, and evaluate the remaining psychometric properties using both Classic Test Theory (CTT) and Item Response Theory (IRT) models.

Reply to Dziewas, R.; Bath, P.M. Endpoints in Dysphagia Trials. Comment on "Speyer et al. Neurostimulation in People with Oropharyngeal Dysphagia: A Systematic Review and Meta-Analyses of Randomised Controlled Trials-Part I: Pharyngeal and Neuromuscular Electrical Stimulation. J. Clin. Med. 2022, 11, 776".

Our systematic review and meta-analysis of pharyngeal electrical stimulation (PES) and neuromuscular electrical stimulation (NMES) in patients with oropharyngeal dysphagia (OD) is the first paper (Part I) [...].

Behavioural Interventions in People with Oropharyngeal Dysphagia: A Systematic Review and Meta-Analysis of Randomised Clinical Trials.

OBJECTIVE: To determine the effects of behavioural interventions in people with oropharyngeal dysphagia. METHODS: Systematic literature searches were conducted to retrieve randomized controlled trials in four different databases (CINAHL, Embase, PsycINFO, and PubMed). The methodological quality of eligible articles was assessed using the Revised Cochrane risk-of-bias tool for randomised trials (RoB 2), after which meta-analyses were performed using a random-effects model. RESULTS: A total of 37 studies were included. Overall, a significant, large pre-post interventions effect size was found. To compare different types of interventions, all behavioural interventions and conventional dysphagia treatment comparison groups were categorised into compensatory, rehabilitative, and combined compensatory and rehabilitative interventions. Overall, significant treatment effects were identified favouring behavioural interventions. In particular, large effect sizes were found when comparing rehabilitative interventions with no dysphagia treatment, and combined interventions with compensatory conventional dysphagia treatment. When comparing selected interventions versus conventional dysphagia treatment, significant, large effect sizes were found in favour of Shaker exercise, chin tuck against resistance exercise, and expiratory muscle strength training. CONCLUSIONS: Behavioural interventions show promising effects in people with oropharyngeal dysphagia. However, due to high heterogeneity between studies, generalisations of meta-analyses need to be interpreted with care.

Neurostimulation in People with Oropharyngeal Dysphagia: A Systematic Review and Meta-Analyses of Randomised Controlled Trials-Part I: Pharyngeal and Neuromuscular Electrical Stimulation.

Objective. To assess the effects of neurostimulation (i.e., neuromuscular electrical stimulation (NMES) and pharyngeal electrical stimulation (PES)) in people with oropharyngeal dysphagia (OD). Methods. Systematic literature searches were conducted to retrieve randomised controlled trials in four electronic databases (CINAHL, Embase, PsycINFO, and PubMed). The methodological quality of included studies was assessed using the Revised Cochrane risk-of-bias tool for randomised trials (RoB 2). Results. In total, 42 studies reporting on peripheral neurostimulation were included: 30 studies on NMES, eight studies on PES, and four studies on combined neurostimulation interventions. When conducting meta analyses, significant, large and significant, moderate pre-post treatment effects were found for NMES (11 studies) and PES (five studies), respectively. Between-group analyses showed small effect sizes in favour of NMES, but no significant effects for PES. Conclusions. NMES may have more promising effects compared to PES. However, NMES studies showed high heterogeneity in protocols and experimental variables, the presence of potential moderators, and inconsistent reporting of methodology. Therefore, only conservative generalisations and interpretation of meta-analyses could be made. To facilitate comparisons of studies and determine intervention effects, there is a need for more randomised controlled trials with larger population sizes, and greater standardisation of protocols and guidelines for reporting.