Evaluating oral stimulation as a treatment for dysphagia after stroke.

Deglutitive aspiration is common after stroke and can have devastating consequences. While the application of oral sensory stimulation as a treatment for dysphagia remains controversial, data from our laboratory have suggested that it may increase corticobulbar excitability, which in previous work was correlated with swallowing recovery after stroke. Our study assessed the effects of oral stimulation at the faucial pillar on measures of swallowing and aspiration in patients with dysphagic stroke. Swallowing was assessed before and 60 min after 0.2-Hz electrical or sham stimulation in 16 stroke patients (12 male, mean age = 73 +/- 12 years). Swallowing measures included laryngeal closure (initiation and duration) and pharyngeal transit time, taken from digitally acquired videofluoroscopy. Aspiration severity was assessed using a validated penetration-aspiration scale. Preintervention, the initiation of laryngeal closure, was delayed in both groups, occurring 0.66 +/- 0.17 s after the bolus arrived at the hypopharynx. The larynx was closed for 0.79 +/- 0.07 s and pharyngeal transit time was 0.94 +/- 0.06 s. Baseline swallowing measures and aspiration severity were similar between groups (stimulation: 24.9 +/- 3.01; sham: 24.9 +/- 3.3, p = 0.2). Compared with baseline, no change was observed in the speed of laryngeal elevation, pharyngeal transit time, or aspiration severity within subjects or between groups for either active or sham stimulation. Our study found no evidence for functional change in swallow physiology after faucial pillar stimulation in dysphagic stroke. Therefore, with the parameters used in this study, oral stimulation does not offer an effective treatment for poststroke patients.

Psychiatric aspects of thalamic stimulation for neuropathic pain.

Twenty-four patients with neuropathic pain underwent thalamic stimulation after conventional surgical and medical treatments had failed. Psychiatric interviews and psychometric testing were carried out before and after surgery to screen candidates and to assess therapeutic response. Eighteen patients obtained either complete or partial pain relief by regular stimulation. Because of technical problems surgery was unsuccessful in 6 patients. Predictions of outcome by the psychiatrist based on the patient's premorbid personality traits, alcohol and narcotic abuse, psychopathology at interview, and psychosocial stressors showed no correlation with these surgical results. When surgery failed, therapeutic intervention was needed for severe disappointment and suicidal behaviour. In follow-up studies 2 of the 6 patients with continuing pain have died by suicide. When surgery succeeded, patients returned to a near normal and satisfactory way of life. Thalamic stimulation offers a promising alternative treatment for intractable neuropathic pain.