Long COVID and rehabilitation.

Coronavirus disease 2019 (COVID-19) has caused tremendous morbidity and mortality worldwide. The large number of post-COVID survivors has drawn attention to the management of post-COVID condition, known as long COVID. This review examines current knowledge of long COVID, regarding its epidemiology, mechanism, and clinical presentations in both adults and children. We also review the rehabilitation principles, modules, and effects, and share Taiwan's efforts to provide a top-down, nationwide care framework for long COVID patients. Dyspnea, chronic cough, and fatigue are the most commonly reported symptoms in the first 6 months after infection, but cognitive impairment and psychological symptoms may persist beyond this time. Several possible mechanisms behind these symptoms were proposed, but remained unconfirmed. These symptoms negatively impact individuals' function, activities, participation and quality of life. Rehabilitation is a key element of management to achieve functional improvement. Early management should start with comprehensive evaluation and identification of red flags. Exercise-based therapy, an essential part of management of long COVID, can be conducted with different modules, including telerehabilitation. Post-exertional symptom exacerbation and orthostatic hypotension should be carefully monitored during exercise. Randomized control trials with a large sample size are needed to determine the optimal timing, dosage, and modules.

The Cortical and Subcortical Neural Control of Swallowing: A Narrative Review.

Swallowing is a sophisticated process involving the precise and timely coordination of the central and peripheral nervous systems, along with the musculatures of the oral cavity, pharynx, and airway. The role of the infratentorial neural structure, including the swallowing central pattern generator and cranial nerve nuclei, has been described in greater detail compared with both the cortical and subcortical neural structures. Nonetheless, accumulated data from analysis of swallowing performance in patients with different neurological diseases and conditions, along with results from neurophysiological studies of normal swallowing have gradually enhanced understanding of the role of cortical and subcortical neural structures in swallowing, potentially leading to the development of treatment modalities for patients suffering from dysphagia. This review article summarizes findings about the role of both cortical and subcortical neural structures in swallowing based on results from neurophysiological studies and studies of various neurological diseases. In sum, cortical regions are mainly in charge of initiation and coordination of swallowing after receiving afferent information, while subcortical structures including basal ganglia and thalamus are responsible for movement control and regulation during swallowing through the cortico-basal ganglia-thalamo-cortical loop. This article also presents how cortical and subcortical neural structures interact with each other to generate the swallowing response. In addition, we provided the updated evidence about the clinical applications and efficacy of neuromodulation techniques, including both non-invasive brain stimulation and deep brain stimulation on dysphagia.

Effects of a swallowing and oral-care program on resuming oral feeding and reducing pneumonia in patients following endotracheal extubation: a randomized, open-label, controlled trial.

BACKGROUND: The resumption of oral feeding and free from pneumonia are important therapeutic goals for critically ill patients who have been successfully extubated after prolonged (≥ 48 h) endotracheal intubation. We aimed to examine whether a swallowing and oral-care (SOC) program provided to critically ill patients extubated from prolonged mechanical ventilation improves their oral-feeding resumption and reduces 30-day pneumonia incidence. METHODS: In this randomized, open-label, controlled trial, participants were consecutively enrolled and randomized to receive the SOC program or usual care. The interventions comprised three protocols: oral-motor exercise, sensory stimulation and lubrication, and safe-swallowing education. Beginning on the day following patient extubation, an SOC nurse provided the three-protocol care for seven consecutive days or until death or hospital discharge. With independent outcome assessors, oral-feeding resumption (yes, no) corresponded to level 6 or level 7 on the Functional Oral Intake Scale (censored seven days postextubation) along with radiographically documented pneumonia (yes, no; censored 30 days postextubation), abstracted from participants' electronic medical records were coded. RESULTS: We analyzed 145 randomized participants (SOC group = 72, control group = 73). The SOC group received, on average, 6.2 days of intervention (14.8 min daily) with no reported adverse events. By day 7, 37/72 (51.4%) of the SOC participants had resumed oral feeding vs. 24/73 (32.9%) of the control participants. Pneumonia occurred in 11/72 (15.3%) of the SOC participants and in 26/73 (35.6%) of the control participants. Independent of age and intubation longer than 6 days, SOC participants were likelier than their control counterparts to resume oral feeding (adjusted hazard ratio, 2.35; 95% CI 1.38-4.01) and had lower odds of developing pneumonia (adjusted odds ratio, 0.28; 95% CI 0.12-0.65). CONCLUSIONS: The SOC program effectively improved patients' odds that oral feeding would resume and the 30-day pneumonia incidence would decline. The program might advance dysphagia care provided to critically ill patients extubated from prolonged mechanical ventilation. TRIAL REGISTRATION: NCT03284892, registered on September 15, 2017.

The Influence of Hemoglobin and Swallowing Ability on Daily Living Activities After Hospital Discharge in Taiwanese Stroke Patients: A Longitudinal Study.

OBJECTIVE: This study aimed to examine the mediating effect of swallowing ability on hemoglobin levels and activities of daily living (ADL). DESIGN: Prospective longitudinal study. SETTING: Two rehabilitation wards in a national referral center for Northern Taiwan, followed by discharge. PARTICIPANTS: 101 participants were admitted for first or recurrent infarction or hemorrhagic stroke and transferred to the rehabilitation ward of a medical center (N=101). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Hemoglobin data were collected from medical records. Swallowing ability and ADL were measured using the Functional Oral Intake Scale and Barthel Index, respectively, with higher scores indicating better functioning. RESULTS: Mediation analysis performed using path analysis illustrated that hemoglobin at the time of transfer to the rehabilitation ward had a direct and positive effect on swallowing ability at 1-3 days before discharge (path coefficient=0.21, 95% confidence interval [CI]: 0.04-0.35, P=.018), and swallowing ability at 1-3 days before discharge had a direct and positive effect on ADL at 1 month after discharge (path coefficient=0.36, 95% CI: 0.13-0.57, P=.002). Hemoglobin level at the time of transfer to the rehabilitation ward did not directly influence ADL 1 month after discharge (path coefficient=0.12, 95% CI: -0.05-0.28, P=.166). These results indicate that swallowing ability substantially mediates the relation between previous hemoglobin levels and subsequent ADL. CONCLUSION: Low hemoglobin levels and poor swallowing ability should be concurrently addressed to improve ADL performance.

The Hyoid Bone Kinematics in Dysphagic Stroke Patients: Instantaneous Velocity, Acceleration and Temporal Sequence Matters.

Hyoid bone excursion (HBE) is one of the most critical events in the pharyngeal phase of swallowing. Most previous studies focused on the total displacement and average velocity of HBE. However, HBE during swallowing is not one-dimensional, and the change of velocity and acceleration is not linear. This study aims to elucidate the relationship between the instantaneous kinematics parameters of HBE and the severity of penetration/aspiration and pharyngeal residue in patients with stroke. A total of 132 sets of video-fluoroscopic swallowing study images collected from 72 dysphagic stroke patients were analyzed. The maximal instantaneous velocity, acceleration, displacement, and the time required to reach these values in the horizontal and vertical axes were measured. Patients were grouped according to the severity of the Penetration-Aspiration Scale and the Modified Barium Swallow Impairment Profile- Pharyngeal Residue. The outcome was then stratified according to the consistencies of swallowing materials. Stroke patients with aspiration were associated with a lower maximal horizontal instantaneous velocity and acceleration of HBE, a shorter horizontal displacement, and prolonged time to maximal vertical instantaneous velocity compared to the non-aspirators. In patients with pharyngeal residue, the maximal horizontal displacement of HBE was decreased. After stratification according to bolus consistencies, the temporal parameters of HBE were more significantly associated with aspiration severity when swallowing thin bolus. Meanwhile spatial parameters such as displacement had a bigger influence on aspiration severity when swallowing viscous bolus. These novel kinematic parameters of HBE could provide important reference for estimating swallowing function and outcomes in dysphagic stroke patients.

Case report: Dysphagia after COVID-19 infection in a stroke patient-Is neurostimulation a potential management?

A 90-year-old man with stroke was weaned from tube feeding 4 months after stroke onset. However, he had a coronavirus disease 2019 (COVID-19) infection after 2 months and suffered from drastically worsened oropharyngeal dysphagia that required a reinsertion of the nasogastric tube. A videofluoroscopic swallowing study revealed poor bolus oral transit, significantly delayed swallowing reflex, reduced pharyngeal movements, and insufficient cough response. Repetitive transcranial magnetic stimulation and neuromuscular electrical stimulation were applied, in addition to conventional swallowing training. The feeding tube was removed after 20 treatment sessions. Clinicians should be aware of the risk of dysphagia after COVID-19 infection in patients with underlying neurological diseases. The management of post-COVID-19 dysphagia has not yet been fully established. Repetitive transcranial electrical stimulation combined with neuromuscular electrical stimulation may be used as an auxiliary intervention in specific cases.

Alteration in coracohumeral ligament and distance in people with symptoms of subcoracoid impingement.

BACKGROUND: Differentiation between subacromial impingement versus subcoracoid impingement are important for the treatment target. We evaluated the correlations between coracohumeral ligament (CHL) thickness and distance (CHD) and characterized the CHL and subscapularis (SSC) in subcoracoid impingement subjects. METHODS: An observational, cross-sectional study was carried out. Twenty subcoracoid impingement subjects and age/gender matched controls were assessed in 4 different shoulder positions by ultrasonography. RESULTS: Moderate correlations between CHL thickness with CHD (r = 0.455 in neutral rotation, p = 0.044; r = 0.483 in interior rotation, p = 0.031) were found in subacromial subjects. Subcoracoid impingement subjects had greater CHL thickness (difference = 0.3 mm, effect size = 0.85, p = 0.006), SSC tendon thickness (difference = 0.7 mm, effect size = 0.92, p = 0.01) and SSC/CHD occupation ratio (difference = 8%, effect size = 0.95, p = 0.005) compared with the control. CONCLUSIONS: Coracohumeral distance is related to ligament thickness, especially in subacromial impingement subjects. Increased coracohumeral ligament and subscapularis thickness as well as decreased subscapularis/coracohumeral distance occupation ratio are characterized in subcoracoid impingement subjects. These quantitative measurements can be useful in identifying patients at risk of subcoracoid impingement from subacromial impingement.

Deep Learning for Automatic Hyoid Tracking in Videofluoroscopic Swallow Studies.

The hyoid bone excursion is one of the most important gauges of larynx elevation in swallowing, contributing to airway protection and bolus passage into the esophagus. However, the implications of various parameters of hyoid bone excursion, such as the horizontal or vertical displacement and velocity, remain elusive and raise the need for a tool providing automatic kinematics analysis. Several conventional and deep learning-based models have been applied automatically to track the hyoid bone, but previous methods either require partial manual localization or do not transform the trajectory by anatomic axis. This work describes a convolutional neural network-based algorithm featuring fully automatic hyoid bone localization and tracking and spine axis determination. The algorithm automatically estimates the hyoid bone trajectory and calculates several physical quantities, including the average velocity and displacement in horizontal or vertical anatomic axis. The model was trained in a dataset of 365 videos of videofluoroscopic swallowing from 189 patients in a tertiary medical center and tested using 44 videos from 44 patients with different dysphagia etiologies. The algorithm showed high detection rates for the hyoid bone. The results showed excellent inter-rater reliability for hyoid bone detection, good-to-excellent inter-rater reliability for calculating the maximal displacement and the average velocity of the hyoid bone in horizontal or vertical directions, and moderate-to-good reliability in calculating the average velocity in horizontal direction. The proposed algorithm allows for complete automatic kinematic analysis of hyoid bone excursion, providing a versatile tool with high potential for clinical applications.

The Application of Ultrasound Guidance in Electrodiagnostic Studies - A Narrative Review.

Electrodiagnostic studies, including nerve conduction study and electromyography, were conducted based on surface anatomy in a conventional manner. However, the anatomical variations and difficulty in the identification of target nerves or muscles render the accuracy of electrodiagnostic studies questionable. In recent years, high-resolution ultrasound (US) has been used to scan both the peripheral nerves and musculoskeletal system. Furthermore, an increasing number of clinicians have incorporated US into electrodiagnostic studies to achieve accurate sampling and prevent potential unwanted tissue injuries. In this review article, we present summarized information about the utility of US in assisting electrodiagnostic studies.

A multicenter study to compare the effectiveness of the inpatient post acute care program versus traditional rehabilitation for stroke survivors.

There is insufficient evidence to prove the effect of the Post-acute Care (PAC) program on post-stroke recovery. This study aimed to determine the effectiveness of the PAC versus traditional inpatient rehabilitation (non-PAC) for middle- and old-aged stroke survivors. This multicenter cohort study enrolled 334 stroke patients admitted for post-stroke rehabilitation. The outcome variables included the Barthel Index (BI), Functional Oral Intake Scale (FOIS), Mini Nutritional Assessment-Short Form (MNA-SF), EuroQoL-5D (EQ-5D), Lawton-Brody Instrumental Activities of Daily Living (ADL) Scale, and Mini-Mental State Examination (MMSE). The inverse-probability-of-treatment-weighting method was used to analyze the differences in outcomes between the PAC and non-PAC groups. The PAC group showed better improvements in BI, MNA-SF, EQ-5D, Instrumental ADL, and MMSE compared to the non-PAC group, with differences in effect sizes of 0.54 (95% confidence interval [CI] 0.38-0.71), 0.26 (95% CI 0.10-0.42), 0.50 (95% CI 0.33-0.66), 0.44 (95% CI 0.28-0.60) and 0.34 (95% CI 0.17-0.50), respectively. The PAC project showed more improvement in basic and instrumental ADL and status of swallowing, nutrition, and cognition than those of non-PAC, which had less length of stay restricted by the National Health Insurance. More studies are warranted to investigate the influence of hospital stay and duration from stroke onset on the PAC's effectiveness.

Differences in the gut microbiome and reduced fecal butyrate in elders with low skeletal muscle mass.

BACKGROUND AND AIMS: Despite animal studies revealing a causal link between the gut microbiota and skeletal muscle mass, the role of the gut microbiome and its metabolites in humans having low muscle mass remains unclear. METHODS: Eighty-eight subjects older than 65 years were measured for sarcopenia-related parameters, including body composition, grip strength, gait speed and flexibility. Participants were divided into normal muscle mass group (NM, n = 52) and low muscle mass group (LM, n = 36) and fresh fecal samples were collected for metagenome and short chain fatty acids (SCFAs) analysis. RESULTS: The richness and evenness of gut microbiota diversity were significantly decreased in the subjects with low muscle mass, including observed ASVs, Shannon and Chao 1 index. A significant difference of gut microbiota profile was noted between NM group and LM group. The Firmicutes/Bacteroidetes ratio was significantly reduced in the LM group. A significant decrease in the abundance of a SCFA-producer, Marvinbryantia spp., whereas a remarkable enrichment of a flavonoid degrader, Flavonifractor spp., was observed in the LM elders. Comparing with the NM group, the fecal butyrate significantly diminished in the LM group and correlated with skeletal muscle mass index. CONCLUSIONS: This is the first study that demonstrates the reduced fecal butyrate in elders with low muscle mass and highlights the associated gut microbiome changes. The identified gut microbial features and fecal butyrate level may serve as potential biomarkers for early detection of sarcopenic patients.

The kinematic features of hyoid bone movement during swallowing in different disease populations: A narrative review.

The anterior-superior movement of the hyoid bone plays a significant role in securing the airway and smooth passage of food through the cricopharyngeal muscle. The hyoid bone can be detected easily with instruments such as the videofluoroscopic swallow study (VFSS) and ultrasonography (US), which have made quantitative kinematic analysis possible. Dysphagia is a critical issue in different diseases, including stroke, Parkinson's disease (PD), head and neck cancer, and amyotrophic lateral sclerosis (ALS), and the data obtained on these diseases from swallowing kinematic analysis has been accumulating. In this review article, we aimed to present the distinct features of kinematic analysis of hyoid movement in stroke, PD, head and neck cancer, and ALS. We also present the possible relationship between altered hyoid kinematics and dysphagia.

A multi-disciplinary rehabilitation approach for people surviving severe COVID-19-a case series and literature review.

BACKGROUND/PURPOSE: COronaVIrus Disease 2019 (COVID-19) has caused tremendous casualties and morbidities worldwide. Multisystem manifestations, including muscle weakness, dyspnea, cognitive decline, dysphagia, and dysarthria are frequently reported among critically ill patients. The resultant activity limitations and participation restrictions call for an organized and multidisciplinary approach to rehabilitation. Taiwan had a rapid surge in community infection cases from May to July 2021, and our team established a team-based approach in response to the rehabilitation needs for the in-patients, especially the critically-ill group. METHODS: We built a core treatment team and established a referral pathway for critically ill patients with COVID-19 based on a multidisciplinary approach. The care process and outcomes of a case series of patients who received in-patient rehabilitation after medical stabilization were presented. RESULTS: Our clinical care module was established according to interim World Health Organization guidance and current research and demonstrated a high degree of feasibility. Five patients with multiple impairments received in-patient rehabilitation and experienced significant functional improvement. We documented improvements in motor function, swallowing function, and activities of daily living after the rehabilitation. CONCLUSION: Our clinical experience suggests considerable benefits can be obtained from a well-organized and multidisciplinary rehabilitation approach for severe COVID-19 patients.

Swallowing kinematic analysis might be helpful in predicting aspiration and pyriform sinus stasis.

Aspiration due to dysphagia can lead to aspiration, which negatively impacts a patient's overall prognosis. Clinically, videofluoroscopic swallow study (VFSS) is considered the gold-standard instrument to determine physiological impairments of swallowing. According to previously published literature, kinematic analyses of VFSS might provide further information regarding aspiration detection. In this study, 449 files of VFSS studies from 232 patients were divided into three groups: normal, aspiration, and pyriform sinus stasis. Kinematic analyses and between-group comparison were conducted. Significant between-group differences were noted among parameters of anterior hyoid displacement, maximal hyoid displacement, and average velocity of hyoid movement. No significant difference was detected in superior hyoid displacement. Furthermore, receiver-operating characteristic (ROC) analyses of anterior hyoid displacement, velocity of anterior hyoid displacement, and average velocity of maximal hyoid displacement showed acceptable predictability for detecting aspiration. Using 33.0 mm/s as a cutoff value of average velocity of maximal hyoid displacement, the sensitivity of detecting the presence of aspiration was near 90%. The investigators therefore propose that the average velocity of maximal hyoid displacement may serve as a potential screening tool to detect aspiration.

Prognostic factors of functional outcome in post-acute stroke in the rehabilitation unit.

BACKGROUND/PURPOSE: This retrospective study aimed to determine which factors, such as cognition, motor recovery, swallowing function, and bladder and bowel functions, significantly predicted independence in the activities of daily living (ADL) at hospital discharge in a domestic population of patients experiencing post-acute stroke who received in-hospital rehabilitation. METHODS: We reviewed medical records that were retrieved from the Integrated Medical Database, National Taiwan University Hospital (NTUH-iMD) of 3000 patients who suffered from stroke and were admitted to NTUH from 2014 to 2017. The main outcome measure was independence in the basic ADL (modified Barthel index [mBI]) at discharge. Regression analyses were used to identify prognostic factors for the basic ADL (mBI). RESULTS: The total mBI improved from 40.7 ± 33.0 to 63.1 ± 34.1 in eligible 2538 patients during their hospital stay. The baseline daily activity function (R2 change = 0.042) was the most important prognostic factor associated with independence at discharge, followed by dependence in sitting up (R2 change = 0.014), impaired sitting balance (R2 change = 0.010), the Brunnstrom stage of hemiplegic lower limb (R2 change = 0.006), and the presence of bladder incontinence (R2 change = 0.006) assessed by physician upon rehabilitation admission (R2 = 0.53, p < 0.05). Dependency in sitting up, impaired sitting balance, and the presence of urinary incontinence were negative prognostic factors of ADL independence at discharge (p < 0.05). By contrast, the Brunnstrom stage of hemiplegic lower limb and baseline mBI scores at rehabilitation admission were positive prognostic factors of ADL independence at discharge (p < 0.05). CONCLUSION: Baseline ADL function was the most important prognostic factor of functional independence in post-acute stroke. Moreover, the activity limitation of dependency on sitting up and motor function impairment of hemiplegic lower limb prognosticated functional independence.