1. Introduction
Swallowing disorders, or oropharyngeal dysphagia (OD), can be the result of many underlying conditions such as stroke, progressive neurological diseases, and acquired brain injury. They may also be the consequence of treatment side effects; for example, radiation or surgical interventions in patients with head and neck oncological disorders. Prevalence of OD in the general population ranges from 2.3 to 16% [1]. However, depending on underlying disease severity and outcome measures used (e.g., instrumental assessment, screening or patient self-report) [2], prevalence estimates can be as high as 80% in stroke and Parkinson’s disease patients, up to 30% in traumatic brain injury patients, and over 90% in patients with community-acquired pneumonia [3]. Also, pooled prevalence estimates for swallowing problems in people with cerebral palsy determined by meta-analyses are as high as 50.4% [4].
OD may have severe effects on a person’s health as dysphagia can lead to dehydration, malnutrition, and aspiration pneumonia. OD also has a high disease burden and poses a major societal challenge, which is associated with significant psychological and social burden, resulting in reduced quality-of-life for both patients and caregivers [5].
The treatment of OD may include surgical, pharmacological and behavioural interventions. Behavioural interventions include: bolus modification and management (e.g., adjusting the viscosity, volume, temperature and/or acidity of food and drinks), motor behavioural techniques or oromotor exercises, general body and head postural adjustments, swallowing manoeuvres (e.g., manoeuvres to improve food propulsion into the pharynx and airway protection), and sensory and neurophysiologic stimulation (e.g., neuromuscular electrical stimulation [NMES]) [6].
An increasing number of reviews have been published over the last two decades on the treatment effects of behavioural interventions in people with OD. However, only one systematic review [7] summarised the effects of swallowing therapy as applied by speech and language therapists without restrictions on subject populations or study designs. Furthermore, while most reviews have focussed on selected types of interventions and patient populations, very few reviews use criteria related to study designs (e.g., [8,9] solely including randomised controlled trials [RCTs], ranked as the highest level of evidence [10]).
This systematic review aimed to determine the effects of behavioural interventions in people with OD based on the highest level of evidence (RCTs) only. Behavioural interventions comprised any intervention by a dysphagia expert, excluding surgical and pharmacological interventions. Clinicians being referred to as dysphagia experts include speech therapists, occupational therapists, or physiotherapists, but may incorporate other disciplines depending on national healthcare and education systems. Finally, neurostimulation techniques were considered out of scope of this current review.
2. Methods
The methodology and reporting of this systematic review were based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and checklist. The PRISMA 2020 statement and checklist (Supplementary Tables S1 and S2) aim to enhance the essential and transparent reporting of systematic reviews [11,12]. The protocol for this review was registered at PROSPERO, the international prospective register of systematic reviews (registration number: CRD42020179842).
2.1. Information Sources
To identify studies, literature searches were conducted on 6 March 2021, across these four databases: CINAHL, Embase, PsycINFO, and PubMed. Publications dates ranged from 1937–2021, 1902–2021, 1887–2021, and late 1700s–2021, respectively. Additional searches included checking the reference lists of eligible articles.
2.2. Search Strategies
Electronic search strategies were performed in all four databases using subheadings (e.g., MeSH and Thesaurus terms) and free text terms. Two strings of terms were combined: (1) dysphagia and (2) randomised controlled trial. The full electronic search strategies are reported in Table 1.
2.3. Inclusion and Exclusion Criteria
The following criteria for inclusion were applied: (1) participants had a diagnosis of OD; (2) behavioural interventions were aimed at reducing swallowing or feeding problems; (3) studies included a comparison group; (4) participants were randomly assigned to one of the study arms or groups; (5) studies were published in English.
Studies focussing on drooling, self-feeding, gastro-oesophageal reflux or oesophageal dysphagia (e.g., dysphagia resulting from oesophageal carcinoma or esophagitis) were excluded. Further excluded studies were those describing drug-induced swallowing problems, temporary swallowing problems caused by oedema post-surgery (e.g., anterior cervical discectomy), or swallowing problems associated with adverse effects of interventions such as inflammation and oedema resulting from recent radiotherapy (≤three months after intervention) or thyroidectomy. Studies reporting solely on feeding tube removal after intervention that did not provide data on swallowing or feeding problems, were also excluded. Studies on behavioural eating problems including bulimia, anorexia, and picky eaters, were out of scope of this review. Finally, only original research was included, thus excluding, for example, conference abstracts, doctoral theses and reviews.
2.4. Systematic Review
Methodological Quality and Risk of Bias. The Revised Cochrane risk-of-bias tool for randomised trials (RoB 2) [13] was used to assess the methodological quality of the included studies. The RoB 2 tool provides a framework for evaluating the risk of bias in the findings of any type of randomised trial. The tool is structured along five domains through which bias might be introduced into the study results: (1) the randomisation process; (2) deviations from intended interventions; (3) missing outcome data; (4) measurement of the outcome; (5) selection of the reported result.
Data Collection Process. A data extraction form was created to extract data from the included studies under the following categories: methodological quality, participant diagnosis, inclusion criteria, sample size, age, gender, intervention goal, intervention agent/delivery/dosage, intervention condition, outcome measures and treatment outcome.
Data, Items and Synthesis of Results. Two independent raters reviewed all titles and abstracts, then original articles, for eligibility. Inclusion of studies was based on consensus between raters. To ensure rating accuracy, two group sessions were held to discuss ratings of one hundred randomly selected records to achieve consensus before rating the remaining abstracts. Where consensus could not be reached between the first two raters, a third party was consulted for resolution. Methodological quality assessment was also rated by two independent researchers, after which consensus was reached with involvement of a third reviewer, when necessary. No evident bias in article selection or methodological study quality rating was present as none of the reviewers had formal or informal affiliations with any of the authors of the included studies. At this stage reviewers did not exclude studies based on type of intervention (e.g., behavioural intervention, neurostimulation).
During data collection, data points across all studies were extracted using comprehensive data extraction forms. Risk of bias was assessed per individual study using RoB 2 [13]. The main summary measures for assessing treatment outcome were effect sizes and significance of findings.
2.5. Meta-Analysis
Data was extracted from relevant studies to compare the effect sizes for the following: (1) pre-post outcome measures of OD and (2) mean difference in outcome measures from pre to post between different types of behavioural interventions. All interventions were categorised into compensatory (e.g., body and postural adjustments, or bolus modification), rehabilitative (e.g., oromotor exercises or Shaker exercise), combined compensatory and rehabilitative interventions, and no dysphagia intervention. Only studies using instrumental assessment (videofluoroscopic swallow study [VFSS] or fiberoptic endoscopic evaluation of swallowing [FEES]) to confirm OD were included. Outcome measures based on visuoperceptual evaluation of instrumental assessment and clinical non-instrumental assessments, were eligible for inclusion in meta-analyses. However, if both types of data were available, instrumental assessment was preferred over non-instrumental assessment outcome data. Oral intake measures, screening tools and patient self-report measures were excluded from meta-analyses. Measures other than the authors’ primary outcomes may have been selected if these measures helped to reduce heterogeneity between studies.
To compare effect sizes, group means, standard deviations, and sample sizes for pre- and post-measurements were entered into Comprehensive Meta-Analysis Version 3.3.070 [14]. If only non-parametric data were available (i.e., medians, interquartile ranges), then data were converted into parametric data for meta-analyses. Participants in studies of multiple intervention groups were analysed separately. Where studies used the same participants, only one study was included in the meta-analysis. If studies provided insufficient data for meta-analyses, authors were contacted by e-mail for additional data.
Effect sizes were calculated in Comprehensive Meta-Analysis using a random-effects model. Due to variations in participant characteristics, intervention approaches, and outcome measurements, studies were unlikely to have similar true effects. Heterogeneity was estimated using the Q statistic to determine the spread of effect sizes about the mean and I2 was used to estimate the ratio of true variance to total variance. I2-values of less than 50%, 50% to 74%, and higher than 75% indicate low, moderate, and high heterogeneity, respectively [15]. Using the Hedges g formula for standardized mean difference with a confidence interval of 95%, effect sizes were calculated and interpreted using Cohen’s d convention: g ≤ 0.2 as no or negligible effect; 0.2 < g ≤ 0.5 as minor effect; 0.5 < g ≤ 0.8 as moderate effect; and g > 0.8 as large effect [16].
Forest plots of effect sizes for OD outcome scores were generated for pre-post behavioural interventions. Due to blended configurations of intervention groupings across studies it was not possible to compare a homogenous behavioural intervention group against a comparison group that did not have a behavioural component. For this reason, only a subgroup between group analysis was conducted (and not an overall between group analysis) to explore effect sizes as a function of various moderators. Behavioural interventions (compensatory, rehabilitative, or combined compensatory and rehabilitative interventions) were compared with conventional dysphagia treatment (CDT), or no dysphagia therapy groups. Other subgroup analyses were conducted to compare effect sizes between selected interventions (i.e., Shaker exercise, Chin Tuck Against Resistance exercise [CTAR], and Expiratory Muscle Strength Training [EMST]), medical diagnoses, and outcome measures. Only between-subgroup meta-analyses were conducted using post-intervention data, to account for possible spontaneous recovery during the period of intervention.
Using Comprehensive Data Analysis software, publication bias was assessed following the Begg and Muzumdar’s rank correlation test and the fail-safe N test. The Begg and Muzumdar’s rank correlation test reports the rank correlation between the standardised effect size and the variances of these effects [17]. This statistical procedure produces tau as well as a two tailed p value; values of zero indicate no relationship, whereas deviations away from zero indicate a relationship. High standard error would be associated with larger effect sizes if asymmetry is caused by publication bias. Tau would be positive if larger effects are presented by low values, while tau would be negative if larger effects are represented by high values.
The fail-safe N test calculates how many studies with effect size zero could be added to the meta-analysis before the result lost statistical significance. That is, the number of missing studies that would be required to nullify the effect [18]. If this number is relatively small, then there is cause for concern. However, if this number is large, it can be stated with confidence that the treatment effect, while possibly inflated by the exclusion of some studies, is not nil.
3. Results
3.1. Study Selection
A total of 8059 studies were retrieved across four databases: CINAHL (n = 239), Embase (n = 4550), PsycINFO (n = 231), and PubMed (n = 3039). After removal of duplicate titles and abstracts (n = 1113), a total of 6946 records remained. After assessing titles and abstracts, 261 original articles were identified. Full-text records were accessed to verify all inclusion criteria. During full-text assessment, articles were divided into different types of interventions, as this systematic review reports on behavioural interventions only. Based on the inclusion criteria, 36 articles were included, after which one study was identified through reference checking of the included articles. Figure 1 presents the flow diagram of the article selection process according to PRISMA.
3.2. Description of Studies
All 37 included studies are described in detail in Table 2 and Table 3. Table 2 reports on study characteristics, definitions and methods of diagnosing oropharyngeal dysphagia, and details on participant groups. Information such as medical diagnosis, sample size, age and gender, is provided on all study groups. Table 3 presents intervention goals, intervention components, outcome measures and treatment outcome of each included study.
Participants (Table 2). The 37 studies included a total of 2656 participants (mean = 72; SD = 124.5), with the sample sizes across studies ranging from 10 [30] to 742 participants [38]. All but two studies reported the mean age of participants [38,49], which was 65.6 years (SD = 8.8). Participant age range was only reported in five studies, ranging between 55 [36] and 95 [38] years. The mean percentage of male participants across all studies was 55.8% (SD = 13.7).
Most studies included stroke patients (n = 24). Other diagnoses included: patients with Parkinson’s disease [19,39,52], acquired brain injury [30], multiple sclerosis [51] and nasopharyngeal cancer [50]. Two studies included a mixed patient population with Parkinson’s disease or dementia [38], and stroke or head and neck cancer patients after chemoradiation [40]. Five studies did not provide further details on diagnoses [28,38,49,54,55]. The most frequent method for confirming OD was VFSS (n = 17), with only four studies using FEES (n = 4) [20,31,38,40]. Seven studies used non-instrumental clinical assessments, five studies used a screening tool [28,29,39,48,56], and four studies used patient self-reported dysphagia [49,52,54,55]. The included studies were conducted across fifteen countries, with studies most frequently conducted in Korea (n = 13), USA (n = 6), China (n = 3) and Japan (n = 3).
Outcome measures (Table 3). Many different outcome measures were used across the included studies targeting different domains within the area of OD. The most frequently used measures were the Penetration Aspiration Scale (PAS; 15 studies), the Functional Oral Intake Scale (FOIS; 8 studies), various water swallow tests (4 studies), and the Mann Assessment of Swallowing Ability (MASA; 3 studies). All other outcome measures were used in one or two studies only, confirming the substantial heterogeneity in outcome measures.
Interventions (Table 3). The included 37 studies comprised a range of behavioural interventions, delivered by various health professionals. The interventions were most frequently implemented by single allied health disciplines: occupational therapists in ten studies, speech pathologists in eight studies, physical therapists in two studies [36,48], and nursing staff in one study [55]. In five studies, more than one discipline was involved [23,27,28,33,48], and two studies reported caregivers as the intervention agent either as a single agent [24] or in addition to occupational therapists [22]. Nine studies did not specify disciplines involved in providing the interventions. The intervention dosage varied greatly, ranging from one training session [54] to exercise 3 times daily, 7 days per week for 42 days [25].
Behavioural intervention groups (Table 3). Of the 37 included studies, seven studies comprised three participant groups [19,20,21,23,25,26,38], whereas all other studies included two groups. Based on authors’ description of therapy contents, all intervention groups were categorised into compensatory, rehabilitative, and combined compensatory and rehabilitative interventions. Ten studies included different types of intervention groups (i.e., compensatory, rehabilitative and/or combined compensatory and rehabilitative intervention groups). Five studies included only compensatory groups [20,24,38,39,55], ten studies included only rehabilitative groups, and thirteen studies included only groups combining compensatory and rehabilitative interventions.
Most studies (n = 23) included a comparison group that received a type of dysphagia treatment often referred to as traditional therapy, standard swallow therapy, or conventional dysphagia treatment (CDT). Some studies also used the term usual care for CDT groups. CDT treatment could include counselling and the provision of information about swallowing and dysphagia, compensatory strategies (e.g., bolus modification and adjusted head positioning), rehabilitation, oromotor exercises and/or thermal stimulation. Three studies included a comparison group receiving medical standard care without dysphagia treatment [20,51,56]. In three studies, patients underwent sham dysphagia training [36,43,53]. Several studies compared two or three behavioural interventions without having a CDT or medical standard care group included [33,34,46,49,50,55].
3.3. Risk of Bias Assessment
The Begg and Mazumdar rank correlation procedure produced a tau of 0.305 (two-tailed p = 0.113), indicating there is no evidence of publication bias. This meta-analysis incorporates data from 15 studies, which yield a z-value of 7.528 (two-tailed p < 0.001). The fail-safe N is 207. This means that 207 ‘null’ studies need to be located and included for the combined two-tailed p-value to exceed 0.050. That is, there would need to be 13.8 missing studies for every observed study for the effect to be nullified. Both of these procedures (i.e., Begg and Mazumdar rank correlation and fail-safe N) indicate the absence of publication bias.
3.4. Methodological Quality
Risk of bias of the included RCTs was assessed using the RoB 2 tool. Figure 2 and Figure 3 present the risk of bias summary per domain for individual studies and for all included studies. Most studies showed low risk of bias per domain, but more than half of the included studies (19/37) scored overall as having some concerns, with three studies identified as being at high risk.
3.5. Meta—Analysis: Effect of Interventions
Twenty-one studies were included in the meta-analyses [21,22,24,25,28,29,30,31,34,35,40,41,42,43,44,45,46,49,51,52,54]. All study groups were categorised into compensatory interventions, rehabilitative interventions, combined compensatory and rehabilitative interventions, and no dysphagia intervention. Seventeen studies were excluded from meta-analyses: one study included patients with self-reported swallowing difficulties without confirmed OD diagnosis by instrumental assessment (VFSS or FEES) [48], four studies did not report on instrumental or clinical non-instrumental outcome data [20,28,37,40], ten studies provided insufficient data for meta-analysis [21,24,27,34,38,39,48,51,56,57], and two studies were excluded to reduce heterogeneity between studies [32,53].
Overall, within group analysis. (Figure 4). A significant, large pre-post intervention effect size was calculated using a random-effects model (z(35) = 8.047, p < 0.001, Hedges’ g = 1.139, and 95% CI = 0.862–1.416). Pre-post intervention effects varied greatly between studies, ranging from 0.058 to 5.732. Of the 36 intervention groups included in the meta-analysis, 19 groups showed large effect sizes (Hedges’ g > 0.8), six groups showed moderate effects sizes (0.5 < Hedges’ g ≤ 0.8), seven groups showed minor effect sizes (0.2 < Hedges’ g ≤ 0.5), and four groups showed negligible effect sizes (Hedges’ g ≤ 0.2). Between-study heterogeneity was significant (Q(35) = 152.938, and p < 0.001), with I2 showing heterogeneity accounted for 77.115% of variation in effect sizes across studies.
Between subgroup analyses. Subgroup analyses (Table 4) were conducted comparing different types of interventions: behavioural interventions were compared with conventional dysphagia treatment (CDT), or no dysphagia therapy groups (Figure 5). Both behavioural interventions and CDT were categorised into mainly 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 CDT, and combined interventions with compensatory CDT. When comparing selected interventions based on commonalities across studies against CDT, significant, large effect sizes were found in favour of Shaker exercise, chin tuck against resistance exercise (CTAR), and expiratory muscle strength training (EMST). Most studies were conducted in stroke populations and showed significant, moderate effect sizes. Comparisons between outcome measures indicated at significant effects for PAS only.
4. Discussion
This systematic review aimed to determine the effects of behavioural interventions in people with OD based on the highest level of evidence (RCTs) only. Findings from the literature were reported using PRISMA and meta-analysis procedures.
4.1. Systematic Review Findings
In total, 37 behavioural RCTs in OD were identified. Considering the high prevalence [3] and severe impact of OD on health [57], quality of life [5,58], and health-economics [59], the limited number of high-level evidence studies is concerning. RCTs are costly and usually require extensive funding [60]. Possibly, the general lack of awareness of OD [61] might place funding applications in this research area at a disadvantage when competing with well-known, life-threatening diseases such as cancer or stroke. Although OD is a symptom of these diseases, and many other underlying conditions, limited public knowledge persists, resulting in reduced understanding and recognition of the devastating consequences of OD, in both health-care and non-health-care practitioners [61].
Further, although RCTs are characterised by random allocation and allocation concealment, few of the included studies included sufficient reporting on the processes of randomization and blinding. These finding are in line with current literature on quality assessments of RCTs [62,63], confirming that the risk of selection bias [63] and the success of blinding methods in RCTs [62] can often not be ascertained due to frequent poor reporting.
When comparing behavioural RCTs in OD, several methodological challenges arise. Authors may use different definitions for OD or fail to provide sufficient details when reporting on the swallowing problems of the included patient populations. Also, several studies used non-instrumental assessments (i.e., patient self-report or a screening tool) to identify or confirm OD, making the comparison between studies precarious. The use of a screening tool is especially problematic in identifying OD and cannot act as confirmation of OD. A screening tool’s purpose is merely to identify patients at risk of OD, after which further assessment may confirm or refute the diagnosis [2]. Additionally, although instrumental assessment is considered the optimal tool for confirming OD diagnosis, VFSS and FEES protocols may differ (e.g., using different numbers of swallow trials, viscosities, and volumes).
Studies used a wide range of outcome measures to evaluate treatment effects. Since OD is a multidimensional phenomenon [64], different dimensions of OD may result in different therapy outcomes. For example, changes in dysphagia-related quality of life or oral intake do not necessarily correlate with findings from instrumental assessment. As such, to reduce heterogeneity in meta-analyses, patient self-report and oral intake measures were excluded. Also, some studies included outcome measures with poor or unknown psychometric properties, which in turn undermines the interpretation of treatment effects as data may not be valid or reliable. In addition, measures with weak responsiveness characteristics are not sensitive to treatment changes and should therefore be avoided as outcome measures aiming to determine intervention effects [2].
Most studies included a combined rehabilitative and compensatory intervention group or a rehabilitative intervention group, with only a few studies including exclusively compensatory groups. As the interventions classified as CDT comparison groups showed large variation as well, CDT comparison groups were categorised into similar group types (compensatory and/or rehabilitative CDT). Overall, terminology in the literature referring to CDT comparison groups was varied and complex. This was especially pertinent when interventions were not described in sufficient detail and descriptive terms such as “usual care” or “traditional therapy” did not provide further clarity on the type or content of CDT provided. Despite using categories to group different types of interventions, some degree of heterogeneity was inevitable. Interventions used different types of exercises or care, in distinct dosages, and were applied by different health care professionals. Therefore, it is challenging to identify the “active” ingredients of individual interventions, especially as most studies combined the use of different treatment strategies.
4.2. Meta-Analysis Findings
When considering meta-analyses for behavioural interventions, overall significant treatment effects were identified as favouring behavioural interventions over CDT and withholding dysphagia therapy. Most promising intervention approaches were rehabilitative interventions, which were associated with large effect sizes. Additionally, rehabilitative interventions such as Shaker exercise, CTAR exercise, and EMST showed significant, large effect sizes. However, since most studies included in the meta-analysis provided data on stroke patients only, future research still needs to confirm these findings in other diagnostic populations such as Parkinson’s disease, acquired brain injury or patients with head and neck oncology. As stated above, patient self-report and oral intake measures were excluded from meta-analyses to increase homogeneity between studies. Though self-report and oral intake data might be interesting for future meta-analyses, this would require additional RCTs to be published, as currently there is limited data available in the literature. Finally, future studies should report on treatment dosage and duration in more detail. Due to high heterogeneity between studies and incomplete reporting, no subgroup meta-analyses could be conducted for these variables.
4.3. Limitations
Although reporting of this review followed the PRISMA guidelines to reduce bias, some limitations are inherent to this study. As only RCTs published in English were included, some RCTs may have been excluded based on language criteria. In addition, meta-analyses were restricted because of heterogeneity of the included studies. As such, comparisons across studies are challenging and, generalisations and meta-analyses results should be interpreted with caution.
5. Conclusions
Meta-analyses for behavioural studies in oropharyngeal dysphagia identified an overall, significant, large pre-post interventions effect size. Significant treatment effects were identified favouring behavioural interventions over conventional dysphagia treatment. Notably, large effect sizes were found when comparing rehabilitative interventions with no dysphagia treatment and combined interventions with compensatory conventional dysphagia treatment. Selected interventions compared with conventional dysphagia treatment showed significant, large effect sizes in favour of Shaker exercise, CTAR, and EMST.
Behavioural interventions show promising effects in people with oropharyngeal dysphagia. Still, generalisations from this meta-analysis need to be interpreted with care due to high heterogeneity across studies.
Conceptualization: R.S., R.C., A.-L.S., L.B. Formal analysis: R.S., R.C. Methodology: R.S., R.C. Project administration: R.S., R.C. Validation: R.S., R.C. Writing–review & editing: R.S., R.C., A.-L.S., L.R., B.J.H., M.B., T.P., M.M., L.B. All authors have read and agreed to the published version of the manuscript.
This research received no external funding.
The authors declare no conflict of interest.
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Enlarge this image.Figure 2. Risk of bias summary for all included studies (n = 37) in accordance with RoB2.
![View Image - Figure 3. Risk of bias summary for individual studies (n = 37) in accordance with RoB2 [19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55]. Note. If one or more yellow or red circles (domains) have been identified for a particular study, the Overall score (last column) shows an exclamation mark, indicating that either the study shows some concerns (yellow circle with exclamation mark) or is at high risk (red circle with exclamation mark).](https://media.proquest.com/media/hms/THUM/6/fZJAM?_a=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&_s=TWczEEXzhXm6djUgfk113pL%2F0T8%3D "View Image - Figure 3. Risk of bias summary for individual studies (n = 37) in accordance with RoB2 [19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55]. Note. If one or more yellow or red circles (domains) have been identified for a particular study, the Overall score (last column) shows an exclamation mark, indicating that either the study shows some concerns (yellow circle with exclamation mark) or is at high risk (red circle with exclamation mark).")
Enlarge this image.Figure 3. Risk of bias summary for individual studies (n = 37) in accordance with RoB2 [19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55]. Note. If one or more yellow or red circles (domains) have been identified for a particular study, the Overall score (last column) shows an exclamation mark, indicating that either the study shows some concerns (yellow circle with exclamation mark) or is at high risk (red circle with exclamation mark).
![View Image - Figure 4. Within intervention group pre-post meta-analysis [21,22,24,25,28,29,30,31,40,41,42,43,44,45,46,49,51,52,54,56]. Note. Refer to Table 2 for explanation of the subgroups.](https://media.proquest.com/media/hms/THUM/8/fZJAM?_a=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&_s=24M28rPWnXhMSXB99hMEKrCM0aU%3D "View Image - Figure 4. Within intervention group pre-post meta-analysis [21,22,24,25,28,29,30,31,40,41,42,43,44,45,46,49,51,52,54,56]. Note. Refer to Table 2 for explanation of the subgroups.")
Enlarge this image.Figure 4. Within intervention group pre-post meta-analysis [21,22,24,25,28,29,30,31,40,41,42,43,44,45,46,49,51,52,54,56]. Note. Refer to Table 2 for explanation of the subgroups.
![View Image - Figure 5. Between subgroup meta-analysis for different types of interventions: behavioural interventions compared with conventional dysphagia treatment (CDT) or no dysphagia therapy [21,22,25,29,30,31,34,35,41,42,43,44,46,52]. Note. Refer to Table 2 for explanation of the subgroups.](https://media.proquest.com/media/hms/THUM/10/fZJAM?_a=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&_s=iTe8RXrti%2FcuWif2D5IsKpQhfts%3D "View Image - Figure 5. Between subgroup meta-analysis for different types of interventions: behavioural interventions compared with conventional dysphagia treatment (CDT) or no dysphagia therapy [21,22,25,29,30,31,34,35,41,42,43,44,46,52]. Note. Refer to Table 2 for explanation of the subgroups.")
Enlarge this image.Figure 5. Between subgroup meta-analysis for different types of interventions: behavioural interventions compared with conventional dysphagia treatment (CDT) or no dysphagia therapy [21,22,25,29,30,31,34,35,41,42,43,44,46,52]. Note. Refer to Table 2 for explanation of the subgroups.
Search strategies.
| Database and Search Terms | Number of Records |
|---|---|
| Cinahl: ((MH “Deglutition”) OR (MH “Deglutition Disorders”)) AND (MH “Randomized Controlled Trials”) | 239 |
| Embase: (swallowing/OR dysphagia/) AND (randomization/or randomized controlled trial/OR “randomized controlled trial (topic)”/OR controlled clinical trial/) | 4550 |
| PsycINFO: (swallowing/OR dysphagia/) AND (RCT OR (Randomised AND Controlled AND Trial) OR (Randomized AND Clinical AND Trial) OR (Randomised AND Clinical AND Trial) OR (Controlled AND Clinical AND Trial)).af. | 231 |
| PubMed: (“Deglutition” [Mesh] OR “Deglutition Disorders” [Mesh]) AND (“Randomized Controlled Trial” [Publication Type] OR “Randomized Controlled Trials as Topic” [Mesh] OR “Controlled Clinical Trial” [Publication Type] OR “Pragmatic Clinical Trials as Topic” [Mesh]) | 3039 |
Study characteristics of studies on behavioural interventions for people with oropharyngeal dysphagia.
Study
|
|
Sample (N)
|
Group Descriptive (Mean ± SD) |
|---|---|---|---|
Ayres, et al. [
|
OD: Oropharyngeal dysphagia determined by FEES |
n = 32:
|
Experimental group/Orientation group/control group |
Carnaby, et al. [
|
OD: Diagnosis of swallowing difficulty by speech pathologist, <85 on Hospital’s dysphagia assessment |
n = 306:
|
High intensity/low intensity/UC: mean (SD) |
Carnaby, et al. [
|
OD: Dysphagia on admission- score < 178 on MASA, no history of swallowing disability, head/neck surgery. |
n = 53:
|
NMES/MDTP/UC: mean (SD) |
Choi, et al. [
|
OD: Dysphagia after stroke confirmed by VFSS |
n = 32:
|
Experimental SE + CDT/control (CDT): mean (SD) |
DePippo, et al. [
|
OD: MBS, BDST, VFSS, speech pathologists determined dysphagia |
n = 115, allocated to graded therapist treatment levels:
|
Group A/Group B/Group C |
Eom, et al. [
|
OD: Dysphagia caused by a stroke, confirmed by VFSS |
n = 30:
|
Experimental/Placebo |
Gao and Zhang [
|
OD: VFSS evaluation |
n = 90:
|
Control/Shaker/CTAR |
Guillén-Solà, et al. [
|
OD: Dysphagia confirmed by VFSS score ⩾3 in 8-point PAS |
n = 62:
|
Control/IEMT/NMES |
Hägglund, et al. [
|
OD: Swallowing function assessed with timed water swallow test; diagnosed dysfunction when swallowing rate did not exceed 10 mL/s. |
n = 116:
|
Control/Intervention |
Hägglund, et al. [
|
OD: Swallowing dysfunction (pathological TWST test 4-weeks post-stroke) |
n= 40:
|
Control/Intervention |
Hwang, et al. [
|
OD: OD confirmed by VFSS |
n = 25:
|
Experimental/Control |
Jakobsen, et al. [
|
OD: Clinical signs of dysphagia; score ≥3 on PAS, FEES. |
n = 10:
|
Control/Intervention |
Jang, et al. [
|
OD: Swallowing difficulty VFSS-patients who showed velopharyngeal incompetence (VPI) on VFSS were enrolled |
n = 36:
|
Study/Control |
Jeon, et al. [
|
OD: Swallowing dysfunction/dysphagia as determined by VDS and PAS scores on VFSS |
n= 34:
|
Experimental/Control |
Kim, et al. [
|
OD: Dysphagia defined as a disorder that causes difficulty with chewing and swallowing food |
n= 26:
|
Experimental/Control |
Kim and Park [
|
OD: Dysphagia confirmed by VFSS |
n = 30:
|
Experimental/Control |
Koyama, et al. [
|
OD: Stroke related dysphagia, hypopharyngeal residue found by VFSS |
n = 12:
|
Intervention/control |
Krajczy, et al. [
|
OD: Level 1–3 or 5–7 on SRS |
n = 60:
|
Study/Control |
Kyodo, et al. [
|
OD: Dysphagia determined by endoscopic swallowing evaluation |
n= 62 (randomized crossover trial):
|
Total sample
|
Logemann, et al. [
|
OD: Speech pathologist referral after swallow screening, patient aspirating thin liquids. |
n = 742
|
Age range: 50–79, 41% |
Manor, et al. [
|
OD: Referred to speech pathologist for evaluation of swallowing disturbances, confirmed via FEES. |
n = 42:
|
Vast/Conventional therapy |
Mepani, et al. [
|
OD: Post deglutitive dysphagia, pharyngeal phase dysphagia, VFSS to confirm |
n = 11:
|
Traditional/Shaker
|
Moon, et al. [
|
OD: Aspiration or penetration, oropharyngeal residue, confirmed VFSS. |
n = 16:
|
TPSAT/Control |
Park, et al. [
|
OD: Dysphagia confirmed by VFSS |
n = 27:
|
Experimental/Placebo |
Park, et al. [
|
OD: Dysphagia following stroke was confirmed by VFSS |
n = 22:
|
Experimental/Control |
Park, et al. [
|
OD: OD after stroke by VFSS |
n = 24:
|
Experimental/Control |
Park, et al. [
|
OD: pharyngeal dysphagia confirmed through VFSS |
n = 37 patients:
|
Experimental/Control |
Park, et al. [
|
OD: Dysphagia after stroke, by VFSS |
n = 40:
|
Experimental/Placebo |
Ploumis, et al. [
|
OD: Dysphagia screening-at least one severe symptom, validated in Greek Ohkuma questionnaire |
n = 70:
|
Experimental/Control |
Sayaca, et al. [
|
OD: ‘Swallowing difficulties’ determined with Turkish version of the eating assessment tool (T-EAT-10) |
n = 50:
|
Shaker/PNF |
Steele, et al. [
|
OD: Dysphagia post stroke (VFSS) |
n = 14:
|
TPPT/TPSAT |
Tang, et al. [
|
OD: Radiation-induced dysphagia and trismus by non-instrumental clinical assessment |
n = 43:
|
Rehabilitation group/Control group |
Tarameshlu, et al. [
|
OD: Dysphagia based on DYMUS questionnaire (patient self-report) |
n = 20:
|
TDT/UC |
Troche, et al. [
|
OD: Swallowing disturbance (screening followed by VFSS) |
n = 60:
|
EMST/Sham |
Wakabayashi, et al. [
|
OD: Dysphagia, Eating Assessment Tool (EAT-10) score ≥3 points |
n = 91:
|
Intervention/Control |
Woisard, et al. [
|
OD: Dysphagia- by Deglutition Handicap Index (DHI) |
n = 56:
|
D-/D+ |
Zhang and Ju [
|
OD: Swallowing dysfunction (water swallow test upon inclusion) |
n = 120:
|
Control/intervention |
a Terminology as used by author(s). Notes. ABI = Acquired brain injury; BDI = Beck Depression Inventory; BDST = Burke Dysphagia Screening Test; CVA = cerebrovascular accident; DOSS = Dysphagia Outcome and Severity scale; FEES = Fiberoptic Endoscopic Evaluation of Swallowing; FOIS = Functional Oral Intake Scale; GCS = Glasgow Coma Scale; H&Y disability score = Hoehn and Yahr disability score; K-MMSE or MMSE-K = Mini-mental examination Korean version; K- NIHSS = Korean version of National Institute of Health Stroke Scale; MASA = Mann Assessment of Swallowing Ability; MBS = Modified Barium Swallow; MIE = Minimally Invasive Oesophagectomy; MDTP = McNeill Dysphagia Therapy Program; MMSE = Mini-Mental State Examination; MOCA = Montreal Cognitive Assessment; NIHSS = National Institute of Health Stroke Scale; NMES = Neuromuscular Electrical stimulation; NR = Not reported; OD = Oropharyngeal dysphagia; PAS = Penetration-Aspiration Scale; PD = Parkinson’s disease; P-DHI = Persian Dysphagia Handicap Index; PDQ-39: Parkinson’s Disease Questionnaire-39; PNF = proprioceptive neuromuscular facilitation; RCT = Randomised Controlled Trial; SLP: Speech-Language Pathology; SRS = Swallowing Rating Scale; SSA = Standardized Swallowing Assessment; SIS-6 = Swallowing Impairment Score; SWAL-QOL = Swallow Quality-of-Life Questionnaire; tDCS = transcranial Direct Current Stimulation; UC = Usual Care; VDS = Video-fluoroscopic Dysphagia Scale; VFSS = Video-Fluoroscopic Swallowing Study; WHO = World Health Organisation; WST = Water Swallow Test; TWST = Timed Water-Swallow Test.
Outcome of behavioural interventions for people with oropharyngeal dysphagia.
| Study | Intervention Goal | Intervention Agent, Delivery and Dosage a | Materials and Procedures a | Outcome Measures | Treatment Outcome a |
|---|---|---|---|---|---|
| Ayres et al. [ |
To verify the effectiveness of a manoeuvre application in swallowing therapy in patients with PD. | Intervention agent: NR |
Three groups: |
Primary outcomes: |
Experimental group showed significant improvement in clinical evaluation of dysphagia compared to two other groups regarding solid (p = < 0.001) and liquid (p = 0.022). Analysis of FEES did not show differences between groups. Experimental group presented with significant improvement in scores of domains frequency of symptoms (p = 0.029) and mental health (p = 0.004) on the SWAL-QOL when compared with the groups that did not receive intervention. |
| Carnaby et al. [ |
Compare standard low-intensity and high-intensity behavioural interventions with usual care (UC) for dysphagia | Intervention agent: Speech pathologist (Low/high intensity); physician and speech pathologist when referred (UC) |
UC (control): Physician management. Patient referred to hospital speech pathology if needed. Treatment- feeding supervision, safe swallowing. If prescribed–VFSS. |
Primary outcomes: return to pre stroke diet < 6 months |
Compared with usual care and low-intensity therapy, high-intensity therapy was associated with an increased proportion of patients who returned to a normal diet (p = 0.04) and recovered swallowing (p = 0.02) by 6 months. |
| Carnaby et al. [ |
Effectiveness and safety of exercise based |
Intervention agent: NMES & MDTP-Speech pathologists, >5 years dysphagia experience. |
McNeill Dysphagia Therapy Program (MDTP): Exercise-based swallowing-criteria for initial oral bolus materials for therapy and advancement on 11-step “food hierarchy”. Simple swallowing. Clinicians monitor each swallow. |
Primary outcomes: Ability to swallow (MASA), oral intake (FOIS). |
Post treatment dysphagia severity significant between groups (p ≤ 0.01). MDTP greater change vs. NMES or UC for increased oral intake (p ≤ 0.02), functional outcomes at 3-mnths (RR = 1.7, 1.0–2.8), earlier time for “return to pre-stroke diet” (p < 03). |
| Choi et al. [ |
Effects of Shaker exercise on aspiration and oral diet | Intervention agent: Caregiver (SE), occupational therapist (CDT) |
Shaker Exercise (SE): Isometric and isokinetic movements. 3 head lifts held for 60 s in supine; 60 s rest. 30 reps head lifts observe toes without raising shoulders-without hold. |
Primary outcomes: PAS from VFSS. |
Experimental group greater improvement on PAS (p < 0.05) and FOIS (p < 0.05) vs. control group. |
| DePippo et al. [ |
Effect of graded intervention on occurrence of dysphagia related complications | Intervention agent: Dysphagia therapist (SLP?) |
Group A–Patient-managed diet. One session-therapist recommended diet based on MBS results and compensatory swallowing techniques. Patient chose diet (regular vs. graded). |
Primary outcomes: Dysphagia related complications: Pneumonia, dehydration, calorie-nitrogen deficit, recurrent upper airway obstruction, and death. | No significance between groups for time until end inpatient stay or to 1-year post. Only significance was patients in group B developed pneumonia sooner than group A. |
| Eom et al. [ |
Effect of resistance Expiratory Muscle Strength Training (EMST) on swallowing function | Intervention agent: NR |
Experimental group (EMST + Conventional treatment): Portal Expiratory Muscle Strength Trainer (EMST150). Patients opened mouth after inhalation, EMST mouthpiece between lips. Blew strongly and rapidly until pressure release valve within EMST device opens. Pressure release set to open if pressure target exceeded. < 1-min break after each session, for muscle fatigue and dizziness. |
Primary outcomes: VDS and PAS based on a VFSS to analyse oropharyngeal |
Experimental significant in VDS pharyngeal phase (p = 0.02 and 0.01) and PAS vs. placebo (p = 0.01). Both significant VDS all phases (all p < 0.05). Experimental only significant in PAS (p = 0.01 vs. 0.102). |
| Gao and Zhang [ |
Effects of rehabilitation training on dysphagia and psychological state | Intervention agent: NR |
All patients received routine treatment including internal medicine, traditional rehabilitation and routine nursing. |
Primary outcomes: |
Degrees of dysphagia improvement, between 2–4 wks in CTAR and Shaker. Significantly higher in CTAR (87%) and Shaker (77%) vs. control (43%) (all p < 0.05). Significantly lower SDS in CTAR vs. Shaker/control 6 wks post (all p < 0.05). |
| Guillén-Solà et al. [ |
Effectiveness of inspiratory/expiratory muscle training (IEMT) and |
Intervention agent: Occupational, speech, physical therapist |
Control/SST: Multidisciplinary inpatient rehabilitation for mobility, activities of daily living, swallowing and communication. Education self-management of dysphagia, oral exercises and compensatory techniques based on VFSS. |
Primary outcomes: |
Maximal respiratory pressures most improved Group 2: treatment effect 12.9 (CI 4.5–21.2) and 19.3 (CI 8.5–30.3) for maximal inspiratory and expiratory pressures. Swallowing security improved in Groups 2 and 3. PAS and complications -no between group difference 3-months. |
| Hägglund et al. [ |
Effect of oral neuromuscular training among older people in intermediate care with impaired swallowing | Intervention agent: Dental hygienists |
Intervention (IQoro® + Usual care): The device IQoro® was used for oral neuromuscular training. The device is designed to stimulate sensory input and strengthen the facial, oral, and pharyngeal muscles. Professionals provided training instructions. If participants had difficulties performing training, staff or family members were instructed on how to assist. |
Primary outcomes: |
Swallowing rate significant improvement, intervention vs. controls post (p = 0.01), 6 months following (p = 0.03). Aspiration significantly reduced in intervention vs. controls (p = 0.01). QoL no between-group differences |
| Hägglund et al. [ |
To determine the effects of neuromuscular training on swallowing function in patients with stroke and dysphagia. | Intervention agent: |
Group A-Orofacial sensory-vibration stimulation: Patients received 5 weeks of continued oro-facial sensory vibration stimulation using an Oral B® electric toothbrush. Instructions given on how to stimulate the buccinator mechanism, lips, external floor, tongue. |
Primary outcome: |
Swallowing rate: After intervention, both groups had improved significantly (Group B, p< 0.001; Group A, p = 0.0001) in TWST, but no significant between-group difference in swallowing rate. At 12 month follow-up, Group2 had improved significantly in swallowing rate compared to Group A (p = < 0.032) |
| Hwang et al. [ |
Effect of tongue stretching exercises (TSE) on tongue motility and oromotor |
Intervention agent: |
Control group: Traditional Dysphagia Treatment (TDT)- oral facial massage, thermal-tactile stimulation, compensatory skill straining. Both groups received TDT. |
Primary outcomes: Oromotor function-Oral phase events of VDS, VFSS |
Experimental significant differences in tongue motility, bolus formation, tongue to palate, bolus loss, oral transit time-oral VDS phase (p < 0.05 for all). Control significant for lip closure only (p < 0.05). |
| Jakobsen et al. [ |
Effect of the intensification of the nonverbal facilitation of swallowing on dysphagia. | Intervention agent: Occupational therapist |
Experimental treatment: Facial Oral Tract Therapy (F.O.T.T.) concept-rehabilitation intervention using structured tactile input and nonverbal facilitation techniques (to allow for effective function in meaningful daily life activities). |
Primary outcomes: FOIS, PAS, and electrophysiological swallowing specific parameters (EMBI). | Intervention feasible. PAS and FOIS improved in both groups, no group differences. Swallowing specific parameters reflected clinically observed changes. |
| Jang et al. [ |
Effects of Mechanical Inspiration and Expiration (MIE) exercise using mechanical cough assist on velopharyngeal incompetence | Intervention agent: NR |
Study group MIE exercise: CNS-100 Cough Assist® and conventional swallowing rehabilitation. Inspiration- positive pressure 15–20 cm H2O, increased to 40 cm H2O for 2 s. Expiration–similar pressure 10–20 cm H2O above positive pressure; held 3–6 s, simulating airflow during cough. Patient coordinated respiratory rhythm to cough assist machine. |
Primary outcomes: Swallowing function American Speech-Language-Hearing association scale, functional dysphagia score, and PAS, VFSS. Coughing function-peak cough flow. | Study group significant improvement in functional dysphagia score- nasal |
| Jeon et al. [ |
To investigate the effects of NMES plus upper spine cervical mobilisation on forward head posture, and swallowing in stroke patients with dysphagia. | Intervention agent: Joint mobilisation was performed by a physical therapist (with over 160 h of manual therapy education. |
All interventions were performed in sitting position. |
Primary outcome: |
The intervention group showed significantly better scores in CCFT (p = 0.05) and in CVA (p = 0.05) than in control group. PAS scores were significantly better in the intervention group compared to control group (p = <0.05). Significant increase in VFS total score and PAS than in the control group (p = <0.05) |
| Kim et al. [ |
The effects of Proprioceptive Neuromuscular Facilitation (PNF) on swallowing function of stroke pts with dysphagia | Intervention agent: NR |
Experimental group: PNF
|
Primary outcome: |
Statistically significant improvements in: premature bolus loss, residue in the valleculae, laryngeal evaluation, epiglottic closure, residue in pyriform sinuses, coating of pharyngeal wall after swallowing, pharyngeal transit time and aspiration on both new VFSS scale and ASHA NOMS scale (p < 0.05). Control group also demonstrated statistically significant improvements in premature bolus loss, residue in the valleculae, laryngeal evaluation, epiglottic closure, residue in pyriform sinuses, pharyngeal transit time and aspiration (p < 0.05). No statistically significant differences between the groups were found in new VFSS scale and ASHA NOMS scale. |
| Kim and Park [ |
Effect of modified chin tuck against |
Intervention agent: Occupational therapist |
Experimental group mCTAR exercise: PhagiaFLEX-HF device. Subject seated, fixed part of device to desk, firmly attach chin surface under chin. Exercise performed in isotonic/isometric. Isometric- holding chin down for 10 s against resistance (10 s, 3 times). Isotonic-30 × reps chin-down against resistance. |
Primary outcomes: Aspiration and oral diet -PAS and FOIS. |
Experimental statistically |
| Koyama et al. [ |
Feasibility and effectiveness newly developed Modified Jaw Opening Exercise (MJOE) in poststroke patients with pharyngeal residue. | Intervention agent: Speech pathologist/physician |
Intervention MJOE: Surface electrodes mandibular midline. Participants closed mouth, sitting position, pressed tongue against hard palate. Trainer hand under participant’s chin and applied upward vertical resistance. Visual feedback given. Maintained 80% Maximum Voluntary Contraction (MVC). |
Primary outcomes: VFSS was performed before and after exercise. The distance between the mental spine and the hyoid bone (DMH) and hyoid displacement (HD) were measured. | No temporomandibular joint or neck pain. Intervention group, DMH decrease where anterior HD ended and an increase in anterior HD were seen. Control, no changes. |
| Krajczy et al. [ |
Effects of dysphagia therapy in patients in the early post-stroke period. | Intervention agent: Physiotherapist |
Control/both groups: Safe food education and neurological physiotherapy depending on patient dysfunction. Therapy included passive, assisted, supported and respiration exercises, erect posture, walking re-education, and training on NDT Bobath and PNF methods. |
Primary outcomes: |
Swallowing reflux, Cough and voice quality and swallowing time, number of swallows and SpO2 |
| Kyodo et al. [ |
To evaluate the effectiveness of puree diets containing a gelling agent for the prevention of aspiration pneumonia in elderly patients with moderate to severe dysphagia. | Intervention agent: |
Patients underwent endoscopic swallowing evaluation while sitting in a chair/sitting up in bed. Images of oropharynx and larynx were displayed on a monitor and recorded on digital video recorder. |
Primary outcome: |
Residuals in throat were significantly less likely with pureed rice with than without the gelling agent (median cyclic ingestion score (range); 1 (0–4) vs. 2 (0–4); p = 0.001. |
| Logemann et al. [ |
3 treatments for aspiration on thin liquids—chin-down posture, nectar-thickened liquids, or honey-thickened |
Intervention agent: Speech pathologist |
Chin-down intervention: chin to the front of the neck, three swallows of 3 mL of thin liquid from a spoon and three swallows of the same liquid from an 8-oz cup filled with 6 oz of liquid. |
Primary outcomes: |
49% aspirated all interventions, 25% not any. More on thin liquids despite chin-down posturing vs. using nectar-(p < 0.01) or honey-thickened (p < 0.01). More on nectar- vs. honey thickened (p < 0.01). |
| Manor et al. [ |
Effectiveness of visual information while treating swallowing disturbances in patients with PD. | Intervention agent: Speech and swallowing therapist |
Control–conventional therapy: Both interventions |
Primary outcomes: |
Significant improvement in swallowing functions both groups. FEES significantly greater reduction in food residues in pharynx in VAST vs. conventional treatment group. SWAL-QOL scores significant between groups favour of VAST: burden, eating desire, social functioning, mental health, symptom frequency (p < 0.01). |
| Mepani et al. [ |
Effect of the Shaker exercise on thyrohyoid muscle |
Intervention agent: Speech pathologist |
Traditional therapy: 5 times daily. Laryngeal and tongue ROM exercises and swallowing manoeuvres (Super-Supraglottic Swallow, Mendelsohn Manoeuvre, Effortful Swallow). |
Primary outcomes: |
After therapy, the percent change in thyrohyoid distance in the Shaker Exercise group was significantly greater vs. traditional therapy (p = 0.034). |
| Moon et al. [ |
Effects of Tongue pressure strength and accuracy training (TPSAT) on tongue pressure strength, swallowing function, and quality of life in stroke patients with dysphagia. | Intervention agent: Occupational therapist |
Both groups received standardized physical/occupational therapies. |
Primary outcomes: |
TPSAT with traditional dysphagia significantly improved MASA, SWAL-QOL, and MIPs. Traditional dysphagia significantly increased MASA, SWAL-QOL, and MIPs anteriorly (p < 0.05). TPSAT significant in anterior, posterior MIPs, tongue movement MASA, vs. controls (p < 0.05). |
| Park et al. [ |
Effects of EMST on the activity of suprahyoid muscles, aspiration and dietary stages in stroke patients with dysphagia. | Intervention agent: |
Experimental group: resistance set at 70% range of MEP (Maximal Expiratory Pressure). Subjects open mouth following maximum inhalation, EMST mouthpiece between lips, close mouth. Blow strong and fast until pressure release valve in EMST device opens- expiratory pressure exceeded set target. |
Primary outcomes: |
Experimental significantly more in suprahyoid muscle activity (p = 0.01), liquid PAS (p = 0.03) and FOIS (p = 0.06), but not semisolid type PAS (p = 0.32), vs. placebo. |
| Park et al. [ |
Effect of chin tuck against resistance exercise (CTAR) on the swallowing function in patients with dysphagia following subacute stroke. | Intervention agent: Occupational therapist |
CTAR: Isometric CTAR, patients chin tuck against device 3 × 60 s no repetition. Isotonic CTAR, patient 30 reps by strongly pressing against resistance of the device and releasing it. Therapist demonstrated exercise methods. |
Primary outcomes: |
Experimental more improvement in oral cavity, laryngeal elevation/epiglottic closure, residue in valleculae, and residue in pyriform sinuses of FDS and PAS compared vs. controls (p < 0.05, all). |
| Park et al. [ |
Effects of Effortful Swallowing Training (EST) on tongue strength and swallowing function in patients with stroke. | Intervention agent: Occupational therapist |
Experimental EST: Patients pushed tongue onto palate, squeezing neck muscles, swallow forcefully. Performed 10 times p/session, 3 sessions p/day. Effortful swallowing confirmed by therapist through visual observation and palpation. |
Primary outcomes: |
Experimental group greater improvements in anterior |
| Park et al. [ |
Effects of game-based Chin Tuck against resistance exercise (gbCTAR) and head-lift exercise on swallowing function and compliance in dysphagia post-stroke | Intervention agent: |
Experimental group: performed gbCTAR exercise LES 100 device. Before gbCTAR exercise, 1-RM measured for resistance values. 1-RM, resistance bar placed directly beneath jaw, and chin tuck directed against resistance. gbCTAR exercise at threshold of 70% 1-RM, divided into isometric and isotonic exercises, combined with the game. |
Primary outcomes: |
No significant between group difference in VDS, PAS, FOIS. Compliance, motivation and interest |
| Park et al. [ |
Effect of Resistive Jaw Opening Exercise (RJOE) on hyoid bone movement, aspiration, and oral intake level in stroke patients. | Intervention agent: Occupational therapist |
Experimental group: RJOE device to provide resistance to suprahyoid muscles. Isometric exercise, 30 s with device resistors pressed downward (3 times, 30–60 s of rest). Isotonic exercise repeatedly depressed by RJOE by holding device resistance down for 2–3 s then returned to original state (10 reps, 3 sets) with 30 s rest. |
Primary outcomes: |
Both groups significant differences in hyoid movement, PAS, FOIS (p< 0.05). No significant difference between groups except for liquid type, PAS. |
| Ploumis et al. [ |
Evaluate cervical isometric exercises in dysphagic patients with cervical spine alignment disorders due to hemiparesis after stroke. | Intervention agent: Allied health |
All patients -inpatient program including physiotherapy, occupational and speech therapy. Speech included deglutition muscle strengthening, compensatory techniques. |
Primary outcomes: |
Experimental group- more pronounced correction (p < 0.01) of cervical alignment in both planes and greater improvement (p < 0.05) of deglutition too, than control group. |
| Sayaca et al. [ |
Whether combined isotonic technique of Proprioceptive Neuromuscular |
Intervention agent: Shaker ‘CS’ (?). PNF physiotherapist |
Shaker exercises: isometric (3 reps) and isotonic contractions (30 reps) neck flexor muscles. Patients raised head to observe toes without raising shoulders. Isometric- lifted head, held for 1-min 3 times, 1-min rest. Isotonic- lifted head 30 reps, no holding. |
Primary outcomes: |
T-EAT-10 decreased both groups (p < 0.001). Water swallowing capacity and volume improved both groups (p < 0.001). No change in swallowing speed both groups (p > 0.05). Maximal voluntary contraction of suprahyoid muscles higher in PNF vs. Shaker (p < 0.05). |
| Steele et al. [ |
Compare outcomes of two tongue resistance training protocols | Intervention agent: |
Tongue-pressure profile training (TPPT): emphasized pressure-timing patterns that are typically seen in healthy swallows by focusing on gradual pressure release and saliva swallowing tasks. |
Primary outcomes: |
Both groups significant tongue strength and post-swallow vallecular residue with thin liquids. Stage transition duration (bolus control), PAS no significant differences. |
| Tang et al. [ |
Effect of rehabilitation therapy on radiation-induced dysphagia and trismus in nasopharyngeal carcinoma (NPC) patients after radiotherapy. | Intervention agent: Therapists, assistants |
Both groups routine treatment. |
Primary outcomes: |
Rehabilitation group only significant improvement in swallowing function. Percentage of patients with effective results in rehabilitation higher than control (p = 0.02). Control IID significantly decreased at Post (p = 0.001), both groups decreased at 3 months, rehabilitation group less than controls (p = 0.004). Trismus in rehabilitation higher vs. control (p = 0.02). |
| Tarameshlu et al. [ |
Effects of Traditional |
Intervention agent: Therapist |
Traditional Dysphagia Therapy (TDT): Includes oral motor control, range of motion exercises, swallowing manoeuvres, strategies to heighten sensory input. |
Primary outcomes: |
Groups improved MASA, PAS and PRRS (p < 0.001). All significantly greater in TDT vs. UC group. Large effect size MASA in TDT (d = 3.9) and UC (d = 1.1). |
| Troche et al. [ |
Treatment outcome of device-driven EMST on swallow safety, physiologic mechanisms through measures of swallow timing and hyoid displacement. | Intervention agent: Clinician |
Expiratory muscle strength training (EMST): device set to 75% of participant’s average MEP. Visited weekly by clinician-instructed to wear nose clips, deep breath, hold cheeks lightly, blow hard into device, identify air was flowing freely through device (once reached threshold pressure). |
Primary outcomes: Swallow function-judgments of swallow safety, PAS scores, swallow timing, and hyoid movement from VFS images. |
EMST improved swallow safety, PA scores vs. sham. EMST improvement of hyolaryngeal function during swallowing, findings not evident for sham group. |
| Wakabayashi et al. [ |
Effects of resistance training of swallowing muscles in community dwelling older individuals with dysphagia. | Intervention agent: Research co-workers |
Control/both groups: dysphagia brochure (about oral hygiene, tongue resistance exercise, head flexion exercise against manual resistance, nutrition, and food modifications). |
Primary outcomes: |
Percentage of participants with EAT-10 scores <3 not statistically significantly different between groups p = 0.6). Post intervention EAT-10 (p = 0.7) and mean tongue pressure (p = 0.4). |
| Woisard et al. [ |
Effect of a personalised transportable folding device for seating on |
Intervention agent: Occupational therapy |
D-/All groups: All patients training session: evaluation of needs, impact of head positioning on swallowing, adapted position of head through body positioning, practice using occupational therapy cushions or personalised transportable folding device for seating (DATP) according to randomisation. |
Primary outcomes:quality of swallowing |
Significantly better posture both groups (p < 0.001), more hyoid bone motion in D+ group. Significant mean difference for D+ group vs. D− group, for horizontal and vertical movement. Other swallowing markers not significant. |
| Zhang and Ju [ |
Clinical improvement of nursing intervention in swallowing dysfunction of elderly stroke patients. | Intervention agent: Nursing staff |
Control group: conventional nursing service that strictly conforms to the doctor’s advice. |
Primary outcomes: Swallowing dysfunction–30 mL water drink test |
Improved swallowing dysfunction higher in intervention vs. control (p < 0.05). Scores of physical, psychological and social functions, and material life and nursing satisfaction higher in intervention vs. control (p < 0.05). Pulmonary infection lower in intervention vs. control p < 0.05). |
a Terminology as by authors. Notes. CVA = cerebrovascular accident; EMST = Expiratory Muscle Strength Training; FEES = Fiberoptic Endoscopic Evaluation of Swallowing; FOIS = Functional Oral Intake Scale; MASA = Mann Assessment of Swallowing Ability; MBS = Modified Barium Swallow; MIE= Minimally Invasive Oesophagectomy; MDTP = McNeill Dysphagia Therapy Program; MEP = Maximum Expiratory Pressure; NMES = Neuromuscular Electrical stimulation; NR = Not reported; OD = Oropharyngeal dysphagia; PAS = Penetration-Aspiration Scale; PD = Parkinson’s disease; P-DHI = Persian Dysphagia Handicap Index; PNF= Proprioceptive Neuromuscular Facilitation; PRRS = Pharyngeal Residue Rating Scale; QoL = Quality of life; RCT = Randomised Controlled Trial; SIS-6 = Swallowing Impairment Score; SWAL-QOL= Swallow Quality-of-Life Questionnaire; VDS= Video-fluoroscopic dysphagia scale; VFSS = Video-Fluoroscopic Swallowing Study; TWST= Timed Water-Swallow Test; VDS = Videofluoroscopic Dysphagia Scale; VFSE = Videofluoroscopic Examination.
Between subgroup meta-analyses comparing intervention groups of included studies.
| Subgroup | Hedge’s g | Lower Limit CI | Upper Limit CI | Z-Value | p-Value |
|---|---|---|---|---|---|
| Intervention type | |||||
| Combined vs. CDT (Combined) (n = 5) | 0.610 | 0.263 | 0.957 | 3.446 | 0.001 * |
| Combined vs. CDT (Compensation) (n = 3) | 1.180 | 0.362 | 1.998 | 2.828 | 0.005 * |
| Rehabilitation vs. CDT (Combined) (n = 1) | 0.019 | −0.656 | 0.659 | 0.057 | 0.955 |
| Rehabilitation vs. CDT (Rehabilitation) (n = 3) | 0.178 | 0.304 | 1.133 | 3.395 | 0.001 * |
| Rehabilitation vs. No CDT (n = 3) | 0.842 | 0.440 | 1.244 | 4.110 | <0.001 * |
| Selected interventions | |||||
| Shaker vs. CDT (n = 2) | 1.038 | 0.300 | 1.776 | 2.756 | 0.006 * |
| CTAR vs. CDT (n = 3) | 1.045 | 0.427 | 1.663 | 3.316 | 0.001 * |
| EMST vs. no CDT (n = 2) | 0.819 | 0.389 | 1.250 | 3.733 | <0.001 * |
| Diagnostic groups | |||||
| Acquired Brain Injury (n = 1) | 0.947 | −0.247 | 2.141 | 1.554 | 0.120 |
| Parkinson’s disease (n = 1) | 0.792 | 0.273 | 1.311 | 2.898 | 0.003 * |
| Stroke (n = 13) | 0.731 | 0.474 | 0.988 | 5.573 | <0.001 * |
| Outcome measures | |||||
| Superior hyoid displacement (n = 1) | 0.994 | −0.124 | 2.112 | 1.743 | 0.081 |
| MASA (n = 2) | 0.512 | −0.574 | 1.599 | 0.925 | 0.355 |
| PAS (n = 11) | 0.804 | 0.572 | 1.036 | 6.789 | <0.001 * |
| Tongue motility oromotor function (n = 1) | 0.359 | −0.470 | 1.189 | 0.849 | 0.396 |
Notes. * Significant.
Supplementary Materials
The following supporting information can be downloaded at:
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; Cordier, Reinie 2
; Sutt, Anna-Liisa 3
; Remijn, Lianne 4
; Bas Joris Heijnen 5
; Balaguer, Mathieu 6
; Pommée, Timothy 6
; McInerney, Michelle 7
; Bergström, Liza 8
1 Department Special Needs Education, Faculty of Educational Sciences, University of Oslo, 0318 Oslo, Norway; Curtin School of Allied Health, Faculty of Health Sciences, Curtin University, Perth, WA 6102, Australia;
2 Curtin School of Allied Health, Faculty of Health Sciences, Curtin University, Perth, WA 6102, Australia;
3 Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD 4032, Australia;
4 School of Allied Health, HAN University of Applied Sciences, 6525 EN Nijmegen, The Netherlands;
5 Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands;
6 IRIT, CNRS, Université Paul Sabatier, 31400 Toulouse, France;
7 School of Allied Health (SoAH), Australian Catholic University (ACU), Sydney, NSW 2060, Australia;
8 Remeo Stockholm, 128 64 Stockholm, Sweden;