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Does Therapy With Biofeedback Improve Swallowing in Adults With Dysphagia? A Systematic Review and Meta-Analysis

      Abstract

      Objective

      To describe and systematically review the current evidence on the effects of swallow therapy augmented by biofeedback in adults with dysphagia (PROSPERO 2016:CRD42016052942).

      Data Sources

      Two independent reviewers conducted searches that included MEDLINE, EMBASE, trial registries, and gray literature up to December 2016.

      Study Selection

      Randomized controlled trials (RCTs) and non-RCTs were assessed, including for risk of bias and quality.

      Data Extraction

      Data were extracted by 1 reviewer and verified by another on biofeedback type, measures of swallow function, physiology and clinical outcome, and analysed using Cochrane Review Manager (random effects models). Results are expressed as weighted mean difference (WMD) and odds ratio (OR).

      Data Synthesis

      Of 675 articles, we included 23 studies (N=448 participants). Three main types of biofeedback were used: accelerometry, surface electromyography (sEMG), and tongue manometry. Exercises included saliva swallows, maneuvers, and strength exercises. Dose varied between 6 and 72 sessions for 20-60 minutes. Five controlled studies (stroke n=95; head and neck cancer n=33; mixed etiology n=10) were included in meta-analyses. Compared to control, biofeedback augmented dysphagia therapy significantly enhanced hyoid displacement (3 studies, WMD=0.22cm; 95% confidence interval [CI] [0.04, 0.40], P=.02) but there was no significant difference in functional oral intake (WMD=1.10; 95% CI [-1.69, 3.89], P=.44) or dependency on tube feeding (OR =3.19; 95% CI [0.16, 62.72], P=.45). Risk of bias was high and there was significant statistical heterogeneity between trials in measures of swallow function and number tube fed (I2 70%-94%). Several nonvalidated outcome measures were used. Subgroup analyses were not possible due to a paucity of studies.

      Conclusions

      Dysphagia therapy augmented by biofeedback using sEMG and accelerometry enhances hyoid displacement but functional improvements in swallowing are not evident. However, data are extremely limited and further larger well-designed RCTs are warranted.

      Keywords

      List of abbreviations:

      CI (confidence interval), FOIS (Functional Oral Intake Scale), MD (mean difference), NIHR (National Institute for Health Research), OR (odds ratio), PD (Parkinson disease), RCT (randomized controlled trial), sEMG (surface electromyography), WMD (weighted mean difference)
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      References

        • Rofes L.
        • Arreola V.
        • Almirall J.
        • et al.
        Diagnosis and management of oropharyngeal dysphagia and its nutritional and respiratory complications in the elderly.
        Gastroenterol Res Pract. 2011; 2011
        • Martino R.
        • Foley N.
        • Bhogal S.
        • Diamant N.
        • Speechley M.
        • Teasell R.
        Dysphagia after stroke: incidence, diagnosis, and pulmonary complications.
        Stroke. 2005; 36: 2756-2763
        • Takizawa C.
        • Gemmell E.
        • Kenworthy J.
        • Speyer R.
        A systematic review of the prevalence of oropharyngeal dysphagia in stroke, Parkinson's disease, Alzheimer's disease, head injury, and pneumonia.
        Dysphagia. 2016; 31: 434-441
        • Denaro N.
        • Merlano M.C.
        • Russi E.G.
        Dysphagia in head and neck cancer patients: pretreatment evaluation, predictive factors, and assessment during radio-chemotherapy, recommendations.
        Clin Exp Otorhinolaryngol. 2013; 6: 117-126
        • RCSLT
        Resource manual for commissioning and planning services for dysphagia.
        (Available at:) (Accessed July 14, 2014)
        • Altman K.W.
        • Yu G.P.
        • Schaefer S.D.
        Consequence of dysphagia in the hospitalized patient: impact on prognosis and hospital resources.
        Arch Otolaryngol Head Neck Surg. 2010; 136: 784-789
        • Guyomard V.
        • Fulcher R.A.
        • Redmayne O.
        • Metcalf A.K.
        • Potter J.F.
        • Myint P.K.
        Effect of dysphasia and dysphagia on inpatient mortality and hospital length of stay: a database study.
        J Am Geriatr Soc. 2009; 57: 2101-2106
        • Cohen D.
        • Roffe C.
        • Beavan J.
        • et al.
        Poststroke dysphagia: a review and design considerations for future trials.
        Int J Stroke. 2016; 11: 399-411
        • Newman R.
        • Vilardell N.
        • Clave P.
        • Speyer R.
        Effect of bolus viscosity on the safety and efficacy of swallowing and the kinematics of the swallow response in patients with oropharyngeal dysphagia: white paper by the European Society for Swallowing Disorders (ESSD).
        Dysphagia. 2016; 31: 232-249
        • Yeh S.J.
        • Huang K.Y.
        • Wang T.G.
        • et al.
        Dysphagia screening decreases pneumonia in acute stroke patients admitted to the stroke intensive care unit.
        J Neurol Sci. 2011; 306: 38-41
        • Bath P.M.W.
        • Lee H.
        Cochrane systematic review of interventions for dysphagia in acute stroke.
        Int J Stroke. 2014; 9: 22
        • Cichero J.
        Thickening agents used for dysphagia management: effect on bioavailability of water, medication, and feelings of satiety.
        Nutr J. 2013; 12: 54
        • Speyer R.
        • Baijens L.
        • Heijnen M.
        • Zwijnenberg I.
        Effects of therapy in oropharyngeal dysphagia by speech and language therapists: a systematic review.
        Dysphagia. 2010; 25: 40-65
        • Winstein C.J.
        • Stewart J.C.
        Conditions of task practice for individuals with neurologic impairments.
        in: Textbook of Neural Repair and Rehabilitation. Vol. 2. Cambridge University Press, Cambridge2006: 89-102
        • Humbert I.A.
        • Christopherson H.
        • Lokhande A.
        • German R.
        • Gonzalez-Fernandez M.
        • Celnik P.
        Human hyolaryngeal movements show adaptive motor learning during swallowing.
        Dysphagia. 2013; 28: 139-145
        • Subramanian S.K.
        • Massie C.L.
        • Malcolm M.P.
        • Levin M.F.
        Does provision of extrinsic feedback result in improved motor learning in the upper limb poststroke? A systematic review of the evidence.
        Neurorehabil Neural Repair. 2010; 24: 113-124
        • Tate J.J.
        • Milner C.E.
        Real-time kinematic, temporospatial, and kinetic biofeedback during gait retraining in patients: a systematic review.
        Phys Ther. 2010; 90: 1123-1134
        • Giggins O.M.
        • Persson U.M.
        • Caulfield B.
        Biofeedback in rehabilitation.
        J Neuroeng Rehabil. 2013; 10: 60
        • Sapir S.
        • Ramig L.O.
        • Hoyt P.
        • Countryman S.
        • O’Brien C.
        • Hoehn M.
        Speech loudness and quality 12 months after intensive voice treatment (LSVT) for Parkinson’s disease: a comparison with an alternative speech treatment.
        Folia Phoniatr Logop. 2002; 54: 296-303
        • Aviv J.E.
        • Martin J.H.
        • Jones M.E.
        • et al.
        Age-related changes in pharyngeal and supraglottic sensation.
        Ann Otology Rhinol Laryngol. 1994; 103: 749-752
        • Aviv J.E.
        • Martin J.H.
        • Sacco R.L.
        • et al.
        Supraglottic and pharyngeal sensory abnormalities in stroke patients with dysphagia.
        Ann Otol Rhinol Laryngol. 1996; 105: 92-97
        • Clayton N.A.
        • Carnaby G.D.
        • Peters M.J.
        • Ing A.J.
        Impaired laryngopharyngeal sensitivity in patients with COPD: the association with swallow function.
        Int J Speech Lang Pathol. 2014; 16: 615-623
        • Groher M.E.
        • Crary M.
        Dysphagia: Clinical management in adults and children.
        2nd ed. Mosby, St. Louis2016
        • Ishibashi A.
        • Fujishima I.
        Lesion of the nucleus solitarius leads to impaired laryngeal sensation in bulbar palsy patients.
        J Stroke Cerebrovasc Dis. 2012; 21: 174-180
        • Ramsey D.J.
        • Smithard D.G.
        • Kalra L.
        Early assessments of dysphagia and aspiration risk in acute stroke patients.
        Stroke. 2003; 34: 1252-1257
        • Archer S.K.
        • Wellwood I.
        • Smith C.H.
        • Newham D.J.
        Dysphagia therapy in stroke: a survey of speech and language therapists.
        Int J Lang Commun Disord. 2013; 48: 283-296
        • Higgins J.P.
        • Altman D.G.
        • Gotzsche P.C.
        • et al.
        The Cochrane Collaboration's tool for assessing risk of bias in randomised trials.
        BMJ (Clinical research ed). 2011; 343: d5928
        • Chambless D.L.
        • Hollon S.D.
        Defining empirically supported therapies.
        J Consult Clin Psychol. 1998; 66: 7-18
        • Tate R.L.
        • McDonald S.
        • Perdices M.
        • Togher L.
        • Schultz R.
        • Savage S.
        Rating the methodological quality of single-subject designs and n-of-1 trials: introducing the Single-Case Experimental Design (SCED) Scale.
        Neuropsychol Rehabil. 2008; 18: 385-401
        • Graham J.E.
        • Karmarkar A.M.
        • Ottenbacher K.J.
        Small sample research designs for evidence-based rehabilitation: issues and methods.
        Arch Phys Med Rehabil. 2012; 93: S111-S116
        • Hozo S.P.
        • Djulbegovic B.
        • Hozo I.
        Estimating the mean and variance from the median, range, and the size of a sample.
        BMC Med Res Methodol. 2005; 5: 13
        • Huimin Z.
        • Yongchao Y.
        • Jiang R.
        • et al.
        Effect of surface electromyographic biofeedback on the pharyngeal phase activities in patients with dysphagia after stroke.
        Chinese Journal of Cerebrovascular Diseases. 2015; 12 ([Chinese]): 572-576
        • Robbins J.
        • Kays S.A.
        • Gangnon R.E.
        • et al.
        The effects of lingual exercise in stroke patients with dysphagia.
        Arch Phys Med Rehabil. 2007; 88: 150-158
        • McCullough G.H.
        • Kamarunas E.
        • Mann G.C.
        • Schmidley J.W.
        • Robbins J.A.
        • Crary M.A.
        Effects of Mendelsohn maneuver on measures of swallowing duration post stroke.
        Top Stroke Rehabil. 2012; 19: 234-243
        • Martin-Harris B.
        • McFarland D.
        • Hill E.G.
        • et al.
        Respiratory-swallow training in patients with head and neck cancer.
        Arch Phys Med Rehabil. 2015; 96: 885-893
        • Bogaardt H.C.
        • Grolman W.
        • Fokkens W.J.
        The use of biofeedback in the treatment of chronic dysphagia in stroke patients.
        Folia Phoniatr Logop. 2009; 61: 200-205
        • Zoratto D.C.B.
        • Chau T.
        • Steele C.M.
        Hyolaryngeal excursion as the physiological source of swallowing accelerometry signals.
        Physiol Meas. 2010; 31: 843-855
        • Reddy N.P.
        • Simcox D.L.
        • Gupta V.
        • et al.
        Biofeedback therapy using accelerometry for treating dysphagic patients with poor laryngeal elevation: case studies.
        J Rehabil Res Dev. 2000; 37: 361-372
        • Krishnan G.
        • N S
        • Prasad T.
        Compensatory strategies and feedback of hyolaryngeal excursion for swallow in treatment of swallowing difficulties in Parkinson’s disease: a case report.
        Journal of the All India Institute of Speech & Hearing. 2013; 32: 90-100
        • Hageman C.
        Application of thin film piezoelectric accelerometry technology to treat chronic dysphagia patients.
        (Available at:) (23/7/2018). Accessed July 24, 2018
        • Li C.M.
        • Wang T.G.
        • Lee H.Y.
        • et al.
        Swallowing training combined with game-based biofeedback in poststroke dysphagia.
        PM R. 2016; 8: 773-779
        • Li C.M.
        • Lee H.Y.
        • Hsieh S.H.
        • Wang T.G.
        • Wang H.P.
        • Chen J.
        Development of innovative feedback device for swallowing therapy.
        Journal of Medical and Biological Engineering. 2016; 36: 357-368
        • Steele C.M.
        • Bailey G.L.
        • Polacco R.E.
        • et al.
        Outcomes of tongue-pressure strength and accuracy training for dysphagia following acquired brain injury.
        Int J Speech Lang Pathol. 2013; 15: 492-502
        • Aoki Y.K.S.
        • Ozeki Y.
        • Tanaka T.
        • Ota K.
        The effect of tongue pressure strengthening exercise for dysphagic patients.
        Japanese Journal of Comprehensive Rehabilitation Science. 2015; 6
        • Steele C.M.
        • Bayley M.T.
        • Peladeau-Pigeon M.
        • et al.
        A randomized trial comparing 2 tongue-pressure resistance training protocols for poststroke dysphagia.
        Dysphagia. 2016; 31: 452-461
        • Yeates E.M.
        • Molfenter S.M.
        • Steele C.M.
        Improvements in tongue strength and pressure-generation precision following a tongue-pressure training protocol in older individuals with dysphagia: three case reports.
        Clin Interv Aging. 2008; 3: 735-747
        • Felix V.N.
        • Correa S.M.
        • Soares R.J.
        A therapeutic maneuver for oropharyngeal dysphagia in patients with Parkinson's disease.
        Clinics (Sao Paulo). 2008; 63: 661-666
        • De Luca C.J.
        • Contessa P.
        Hierarchical control of motor units in voluntary contractions.
        J Neurophysiol. 2012; 107: 178-195
        • Haynes S.N.
        Electromyographic biofeedback treatment of a woman with chronic dysphagia.
        Biofeedback Self Regul. 1976; 1: 121-126
        • Steele C.M.
        • Bennett J.W.
        • Chapman-Jay S.
        • Polacco R.C.
        • Molfenter S.
        • Oshalla M.
        Electromyography as a biofeedback tool for rehabilitating swallowing muscle function in dysphagia.
        in: Steele C.M. Applications of EMG in clinical and sports medicine. InTech Publishing, 2012: 311-328
        • Athukorala R.P.
        • Jones R.D.
        • Sella O.
        • Huckabee M.L.
        Skill training for swallowing rehabilitation in patients with Parkinson's disease.
        Arch Phys Med Rehabil. 2014; 95: 1374-1382
        • Crary M.A.
        • Carnaby Mann G.D.
        • Groher M.E.
        • Helseth E.
        Functional benefits of dysphagia therapy using adjunctive sEMG biofeedback.
        Dysphagia. 2004; 19: 160-164
        • Bryant M.
        Biofeedback in the treatment of a selected dysphagic patient.
        Dysphagia. 1991; 6: 140-144
        • Huckabee M.L.
        • Cannito M.P.
        Outcomes of swallowing rehabilitation in chronic brainstem dysphagia: a retrospective evaluation.
        Dysphagia. 1999; 14: 93-109
        • Carnaby-Mann G.D.
        • Crary M.A.
        McNeill dysphagia therapy program: a case-control study.
        Arch Phys Med Rehabil. 2010; 91: 743-749
        • Carnaby-Mann G.
        • Crary M.
        A case-control evaluation of the McNeill dysphagia therapy program (MDTP).
        Dysphagia. 2009; 24: 451
        • McCullough G.H.
        • Kim Y.
        Effects of the Mendelsohn maneuver on extent of hyoid movement and UES opening post-stroke.
        Dysphagia. 2013; 28: 511-519
        • Denk D.M.
        • Kaider A.
        Videoendoscopic biofeedback: a simple method to improve the efficacy of swallowing rehabilitation of patients after head and neck surgery.
        ORL J Otorhinolaryngol Relat Spec. 1997; 59: 100-105
        • Crary M.A.
        • Carnaby-Mann G.D.
        • Groher M.E.
        Biomechanical correlates of surface electromyography signals obtained during swallowing by healthy adults.
        J Speech Lang Hear Res. 2006; 49: 186-193
        • Schultz J.L.
        • Perlman A.L.
        • VanDaele D.J.
        Laryngeal movement, oropharyngeal pressure, and submental muscle contraction during swallowing.
        Arch Phys Med Rehabil. 1994; 75: 183-188
        • Palmer P.M.
        • Luschei E.S.
        • Jaffe D.
        • McCulloch T.M.
        Contributions of individual muscles to the submental surface electromyogram during swallowing.
        J Speech Lang Hear Res. 1999; 42: 1378-1391
        • Huckabee M.L.
        • Butler S.G.
        • Barclay M.
        • Jit S.
        Submental surface electromyographic measurement and pharyngeal pressures during normal and effortful swallowing.
        Arch Phys Med Rehabil. 2005; 86: 2144-2149
        • Reddy N.P.
        • Katakam A.
        • Gupta V.
        • Unnikrishnan R.
        • Narayanan J.
        • Canilang E.P.
        Measurements of acceleration during videofluorographic evaluation of dysphagic patients.
        Med Eng Phys. 2000; 22: 405-412
        • van de Port I.G.
        • Wood-Dauphinee S.
        • Lindeman E.
        • Kwakkel G.
        Effects of exercise training programs on walking competency after stroke: a systematic review.
        Am J Phys Med Rehabil. 2007; 86: 935-951