Swallowing Neurorehabilitation: From the Research Laboratory to Routine Clinical Application

This manuscript version is made available under the CC-BY-NC-ND 4.0 license http://creativecommons.org/licenses/by-nc-nd/4.0/The recent application of neurostimulation techniques to enhance the understanding of swallowing neural plasticity has expanded the focus of rehabilitation research from manipulation of swallowing biomechanics to manipulation of underlying neural systems. Neuromodulatory strategies that promote the brain's ability to reorganize its neural connections have been shown to hold promising potential to aid the recovery of impaired swallowing function. These techniques include those applied to the brain through the intact skull, such as transcranial magnetic stimulation or transcranial direct current stimulation, or those applied to the sensorimotor system in the periphery, such as neuromuscular electrical stimulation. Recent research has demonstrated that each of these techniques, either by themselves or in combination with these and other treatments, can, under certain circumstances, modify the excitability of motor representations of muscles involved in swallowing. In some studies, experimentally induced plastic changes have been shown to have functional relevance for swallowing biomechanics. However, the transition of novel, neuromodulatory brain stimulation techniques from the research laboratory to routine clinical practice is accompanied by a number of ethical, organizational, and clinical implications that impact professions concerned with the treatment of swallowing rehabilitation. In this article, we provide a brief overview of the neuromodulatory strategies that may hold potential to aid the recovery of swallowing function, and raise a number of issues that we believe the clinical professions involved in the rehabilitation of swallowing disorders must confront as these novel brain stimulation techniques emerge into clinical practice

Intake of thickened liquids by hospitalized adults with dysphagia after stroke

Author manuscript made available in accordance with publisher copyright policy.There is widespread concern that individuals with dysphagia as a result of stroke do not drink enough fluids when they are prescribed thickened liquids. This paper details a retrospective audit of thickened liquid consumption of 69 individuals with dysphagia following stroke in acute and rehabilitation hospitals in Adelaide, South Australia. Hospitalized individuals with dysphagia following stroke drank a mean of 781 ml (SD = 507 ml) of prescribed thickened liquids per day, significantly less in the acute setting (M = 519 ml, SD = 305 ml) than in the rehabilitation setting (M = 1274 ml, SD = 442 ml) (t(67) = -8.34, p < .001). This daily intake of thickened liquids was lower than recommended standards of fluid intake for hospitalized adults. Fluid intake could be increased with definitive protocols for the provision and monitoring of consumption of thickened liquids, by offering more fluid via food or free water protocols or by routine use of non-oral supplementary routes. Future research into the effectiveness of such recommendations needs to evaluate not only the impact on fluid intake but also on health outcomes

Does a Water Protocol Improve the Hydration and Health Status of Individuals with Thin Liquid Aspiration Following Stroke? A Randomized Controlled Trial

Author accepted manuscript made available following 12 month embargo from date of publication (17 Feb 2016) in accordance with publisher copyright policy. “The final publication is available at Springer via http://dx.doi.org/10.1007/s00455-016-9694-x”.The benefit of water protocols for individuals with thin liquid aspiration remains controversial, with mixed findings from a small number of randomized controlled trials (RCTs). This study aimed to contribute to the evidence of the effectiveness of water protocols with a particular emphasis on health outcomes, especially hydration. An RCT was conducted with patients with known thin liquid aspiration post stroke randomized to receiving thickened liquids only or a water protocol. For the 14 participants in rehabilitation facilities whose data proceeded to analysis, there was no difference in the total amount of beverages consumed between the water protocol group (mean = 1103 ml per day, SD = 215 ml) and the thickened liquids only group (mean = 1103 ml, SD = 247 ml). Participants in the water protocol group drank on average 299 ml (SD 274) of water but offset this by drinking less of the thickened liquids. Their hydration improved over time compared with participants in the thickened liquids only group, but differences between groups were not significant. Twenty-one percent of the total sample was diagnosed with dehydration, and no participants in either group were diagnosed with pneumonia. There were significantly more diagnoses of urinary tract infection in the thickened liquids only group compared to the water protocol group (χ 2 = 5.091, p = 0.024), but no differences between groups with regard to diagnoses of dehydration (χ 2 = 0.884, p = 0.347) or constipation (χ 2 = 0.117, p = 0.733). The findings reinforce evidence about the relative safety of water protocols for patients in rehabilitation post stroke and provide impetus for future research into the potential benefits for hydration status and minimizing adverse health outcomes

Aphasia Rehabilitation Service Delivery in a Stroke Rehabilitation Unit in Australia: A Clinical Audit of Speech Pathology Practices

Purpose: To investigate service delivery of aphasia rehabilitation in a metropolitan rehabilitation hospital by speech pathologists and assess adherence to both the National Stroke Foundation (NSF) Clinical Guidelines and the Australasian Rehabilitation Outcomes Centre (AROC) database of benchmarks. Method: A retrospective audit of 34 discharged patients was conducted within a dedicated stroke rehabilitation unit from March 2012 to July 2013 in Australia. Discharge reports, Functional Independence Measure (FIM) scores and clinical time statistics derived from the organization’s electronic database were studied and compared with NSF’s Clinical Guidelines for best practice recommendations and AROC benchmarks. Results: Patients with aphasia were admitted to inpatient rehabilitation at an average of 21 days post stroke, 2 days beyond the AROC benchmark for inpatient rehabilitation. The mean length of stay of patients with aphasia was 60 days, significantly longer than the average AROC benchmark of 32.8 days. Patients received an average of 4.25 hours of speech pathology therapy per week, more than twice the minimum amount of therapy time recommended by the NSF Guidelines. Conclusion: The current clinical audit is the first known speech pathology audit investigating adherence to stroke and aphasia rehabilitation guidelines set forth by the NSF clinical guidelines and AROC benchmarks in Australia. By comparing current care with advocated best practice, strengths were identified in service delivery, as well as priority areas for quality improvement

A survey of thickened fluid prescribing and monitoring practices of Australian health professionals.

"This is the peer reviewed version of the following article: [Murray, J., Miller, M., Doeltgen, S. & Scholten, I. (2014). A survey of thickened fluid prescribing and monitoring practices of Australian health professionals. Journal of Evaluation in Clinical Practice, 20(5), 596-600.], which has been published in final form at [http://dx.doi.org/10.1111/jep.12154]. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Self-Archiving. http://olabout.wiley.com/WileyCDA/Section/id-820227.html#terms"RATIONALE, AIMS AND OBJECTIVES: This study aimed to describe (1) how thickened fluids are supplied to clients with dysphagia; (2) how clients' consumption of thickened fluids and hydration status is monitored; and (3) the impact of institutional factors on thickened fluid intake and hydration in Australian health care settings. METHODS: Speech pathologists, dietitians and nurses working in Australian health care settings were asked to voluntarily participate in an online survey that was advertised through their respective professional associations. The questions required a self-report of their practice with respect to thickened fluids. RESULTS: Few health care facilities (17%) monitored thickened fluid consumption routinely even though, in the opinion of 51% the respondents, clients on thickened fluids at their facility do not drink enough. Palatability of the thickened fluid products and patients' dependence on others for drinking were thought to have a major impact on fluid intake. Respondents also highlighted institutional factors such as inadequate assistance from staff and inconsistent systems for monitoring fluid intake and signs of dehydration. The most common way to address inadequate intake was for nurses to 'push fluids' (87%). Free water protocols were used only 14% of the time and setting small oral fluid targets throughout the day was the least common strategy (11%). CONCLUSIONS: There is a need for Australian health care facilities to educate all clinical staff about the risks of dehydration and develop clinical pathways for clients with dysphagia, which include routine monitoring of oral fluid consumption and dehydration and timely intervention

A Descriptive Study of the Fluid Intake, Hydration, and Health Status of Rehabilitation Inpatients without Dysphagia Following Stroke

Author manuscript made available here following 12 month embargo from the date of publication (12 August 2015) in accordance with publisher copyright policy.Adequate hydration is important for all people, particularly when hospitalized with illness. Individuals with dysphagia following stroke are considered to be at risk of inadequate fluid intake and, therefore, dehydration, but there is little information about the fluid intake or hydration of individuals without dysphagia poststroke. This cohort study measured the average beverage intake, calculated the urea/creatinine ratio as a measure of hydration, and documented specific health outcomes of 86 people without dysphagia poststroke who were inpatients in rehabilitation centers. Participants drank on average 1504 ml per day (SD 359 ml), which typically represented 67% of their estimated daily requirement. Approximately 44% of the participants in the sample were dehydrated based on a blood urea nitrogen/creatinine ratio >20:1. Sixteen percent of participants were diagnosed with one or more of the health outcomes of dehydration/hypernatremia, urinary tract infection, or constipation. A greater level of dependence was associated with poorer beverage intake and higher risk of an adverse health outcome. Those in the older/elderly age range (particularly older women) and those with poor mobility were most at risk of poor hydration. This study highlights that patients in rehabilitation facilities poststroke, even without dysphagia, may be at risk of suboptimal fluid intake and hydration

Physiological evidence consistent with reduced neuroplasticity in human adolescents born preterm

Preterm-born children commonly experience motor, cognitive, and learning difficulties that may be accompanied by altered brain microstructure, connectivity, and neurochemistry. However, the mechanisms linking the altered neurophysiology with the behavioral outcomes are unknown. Here we provide the first physiological evidence that human adolescents born preterm at or before 37 weeks of completed gestation have a significantly reduced capacity for cortical neuroplasticity, the key overall mechanism underlying learning and memory. We examined motor cortex neuroplasticity in three groups of adolescents who were born after gestations of ≤32 completed weeks (early preterm), 33–37 weeks (late preterm), and 38–41 weeks (term) using a noninvasive transcranial magnetic brain stimulation technique to induce long-term depression (LTD)-like neuroplasticity. Compared with term-born adolescents, both early and late preterm adolescents had reduced LTD-like neuroplasticity in response to brain stimulation that was also associated with low salivary cortisol levels. We also compared neuroplasticity in term-born adolescents with that in term-born young adults, finding that the motor cortex retains a relatively enhanced neuroplastic capacity in adolescence. These findings provide a possible mechanistic link between the altered brain physiology of preterm birth and the subsequent associated behavioral deficits, particularly in learning and memory. They also suggest that altered hypothalamic–pituitary–adrenal axis function due to preterm birth may be a significant modulator of this altered neuroplasticity. This latter finding may offer options in the development of possible therapeutic interventions

Correlating stroke lesion location with clinical outcomes – an example from deglutition research

This article may be used for non-commercial purposes in accordance With Wiley Terms and Conditions for self-archiving'.Copyright © 2016 John Wiley & Sons, Inc. All rights reserved. This author accepted manuscript is made available following 12 month embargo from date of publication (23 April 2016) in accordance with the publisher's copyright policy

Variables Impacting the Time Taken to Wean Children From Enteral Tube Feeding to Oral Intake

Made available per the LWW Author Permission Guidelines. Copyright © 2019 Espghan and Naspghan. This author accepted manuscript is made available following 12 month embargo from date of publication (June 2019) in accordance with the publisher’s archiving policyObjectives: This study investigated biological factors, which may influence the time taken for children to wean from enteral to oral intake. Methods: Retrospective case-note audit of 62 tube-fed children (nasogastric or percutaneous endoscopic gastrostomy) aged 6 months to 8 years, participating in an intensive tube weaning program. Program design included family-focused mealtimes, child autonomy, and appetite stimulation. A regression model was developed, which shows the combination of variables with the most predictive power for time taken to wean. Results: Data from 62 children who were highly dependent (minimum 93% of calories provided enterally) on tube feeding for an extended period of time (mean = 2.1 years) were analysed. Children's mean body mass index z score at time of weaning was -0.47 (standard deviation 1.03) (mean weight = 10.54 kg) and 54 (87%) presented with a range of medical conditions. Forty-four children (71%) remained completely tube free at 3 months postintervention and an additional 5 children (10%) were fully tube weaned within 10 months of program commencement. Type of feeding tube, medical complexity, age, and length of time tube fed all significantly correlated with time taken to wean. Logistic regression modelling indicated that the type of feeding tube in combination with the degree of medical complexity and time tube fed were the strongest predictors of time taken to wean. Conclusions: Biological factors usually considered to impact on successful weaning from tube feeding (volume of oral intake, oral skill, or mealtime behaviours) were not relevant; however, the type of feeding tube in combination with the degree of medical complexity and time tube fed were the strongest predictors. The impact of psychosocial factors should be investigated to identify if these mitigated the effects of the biological variables

Exploring clinical management of cognitive and behavioural deficits in MND. A scoping review

Objectives: Little is known about how cognitive and behavioural decline in MND is managed clinically. This review aimed to summarise clinical management approaches of cognitive and behavioural decline in MND reported in peer-reviewed and grey literature. Methods: A scoping review was conducted across Embase, Medline, Psychinfo and Emcare in October 2022. Grey literature was also searched across Google Scholar and Google in October 2022. Results: A total of N = 26 studies and 8 documents were included. Thematic analysis revealed six key areas of clinical management: i. Assessment, ii. Education, iii. Advance Care Planning, iv. Adaptation of Care Plan, v. Communication and vi. Carer Support. Conclusions: The literature on management of cognitive and behavioural decline in MND is sparse. Most peer-reviewed literature consists of expert commentary and there is a lack of primary data to guide practitioners and families on how to manage cognitive and behavioural change in MND. Practice Implications: Determining as early as practicable the presence of cognitive and behavioural changes in pwMND will enable practitioners to make adaptations to communication, provide education and supported decision-making for forward planning. This will enable individualised care, planned in partnership with families with MND, which incorporates personal needs and wishes