Meng QN, Zhu Y, Liu SW, Hu B, Chai DJ, Dong CX. Study on the treatment of dysphagia after stroke with electromyographic biofeedback intensive training. World J Clin Cases 2024; 12(19): 3725-3733 [DOI: 10.12998/wjcc.v12.i19.3725]
Corresponding Author of This Article
Chun-Xue Dong, Doctor, Doctor, Department of Rehabilitation Medicine, The Second Affiliated Hospital of Qiqihar Medical College, No. 37 Zhonghua West Road, Jianhua District, Qiqihar 161000, Heilongjiang Province, China. dongchunxue316@163.com
Research Domain of This Article
Clinical Neurology
Article-Type of This Article
Retrospective Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Qing-Nan Meng, Yue Zhu, Si-Wen Liu, Bin Hu, De-Jun Chai, Chun-Xue Dong, Department of Rehabilitation Medicine, The Second Affiliated Hospital of Qiqihar Medical College, Qiqihar 161000, Heilongjiang Province, China
Author contributions: Meng QN contributed primary to this manuscript; Zhu Y and Liu SW made substantial contributions to clinical data collection; Hu B and Chai DJ contributed to the disease analysis; Meng QN drafted the manuscript; Dong CX critically revised the manuscript for literature review and edited it for clarity.
Supported bythe Research Program of Basic Research Operating Expenses of Provincial Higher Education Institutions in Heilongjiang Province in 2021, No. 2021-KYYWF-0369.
Institutional review board statement: This study has been approved by Second Affiliated Hospital of Qiqihar Medical College, No. 20211141.
Informed consent statement: The data used in the study were not involved in the patients’ privacy information, and all patient data obtained, recorded, and managed only used for this study, without any harm to the patient. So the informed consent was waived by the ethics committee of Second Affiliated Hospital of Qiqihar Medical College.
Conflict-of-interest statement: Dr. Dong has nothing to disclose.
Data sharing statement: Data can be obtained by contacting the corresponding author.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Chun-Xue Dong, Doctor, Doctor, Department of Rehabilitation Medicine, The Second Affiliated Hospital of Qiqihar Medical College, No. 37 Zhonghua West Road, Jianhua District, Qiqihar 161000, Heilongjiang Province, China. dongchunxue316@163.com
Received: February 29, 2024 Revised: April 23, 2024 Accepted: May 10, 2024 Published online: July 6, 2024 Processing time: 121 Days and 1.7 Hours
Abstract
BACKGROUND
Dysphagia, or swallowing disorder, is a common complication following stroke, significantly impacting patients' quality of life. Electromyographic biofeedback (EMGBF) therapy has emerged as a potential rehabilitation technique to improve swallowing function, but its efficacy in comparison with conventional treatments remains to be further explored.
AIM
To investigate the effects of different treatment intensities of EMGBF on swallowing function and motor speed after stroke.
METHODS
The participants were divided into three groups, all of which received routine neurological drug therapy and motor function rehabilitation training. On the basis of routine swallowing disorder training, the EMGBF group received additional EMGBF training, while the enhanced EMGBF group received two additional training sessions. Four weeks before and after treatment, the degree of swallowing disorder was evaluated using the degree of swallowing disorder score (VGF) and the Rosenbek penetration-aspiration scale (PAS).
RESULTS
Initially, there was no significant difference in VGF and PAS scores among the groups (P > 0.05). After four weeks, all groups showed significant improvement in both VGF scores and PAS scores. Furthermore, the standardized swallowing assessment and videofluoroscopic dysphagia scale scores also improved significantly post-treatment, indicating enhanced swallowing function and motor function of the hyoid-bone laryngeal complex, particularly in the intensive EMGBF group.
CONCLUSION
EMGBF training is more effective than traditional swallowing training in improving swallowing function and the movement rate of the hyoid laryngeal complex in patients with post-stroke dysphagia.
Core Tip: This study evaluates the efficacy of electromyographic biofeedback (EMGBF) training in improving swallowing function in patients with post-stroke dysphagia. It differentiates between conventional rehabilitation, standard EMGBF, and intensive EMGBF protocols, focusing on their impact on swallowing mechanics and the hyoid-bone laryngeal complex movement. Results indicate that intensive EMGBF significantly enhances swallowing function, suggesting its superiority over conventional methods. This highlights EMGBF's potential as a beneficial clinical tool for post-stroke dysphagia rehabilitation, warranting its broader adoption and further investigation into its long-term effects and mechanisms.
Citation: Meng QN, Zhu Y, Liu SW, Hu B, Chai DJ, Dong CX. Study on the treatment of dysphagia after stroke with electromyographic biofeedback intensive training. World J Clin Cases 2024; 12(19): 3725-3733
Post-stroke dysphagia is a post-stroke complication that seriously affects the quality of life of stroke patients and endangers their lives[1]. We observed the effect of electromyographic biofeedback (EMGBF) on swallowing function and motor rate of the hyoid-laryngeal complex in patients with post-stroke dysphagia at different treatment times[2]. Dysphagia after stroke (DAS), a relatively common dysfunction after stroke, can lead to a variety of complications if not treated with timely rehabilitation, and the number and complexity of biofeedback devices have increased with the demand for them by clinicians[3]. Today these devices range from lightweight portable devices to desktop models with multiple microprocessor components[4]. The National Institute of Mental Health report on biofeedback contributed to the current use of EMGBF in the rehabilitation process noting that this training method is considered an adjunct to rehabilitative exercise for rehabilitated patients[5]. In the following more than 20 years of development and practice, the research on EMGBF techniques in the West has become more and more mature and the application areas have become more and more extensive, but in China it is still in its infancy[6]. As an effective aid for chronic DAS, EMGBF training establishes a feedback pathway outside the body, which on the one hand stimulates the excitation of pharyngeal muscles and prevents disuse atrophy[7]. On the other hand, active training through feedback signals promotes motor relearning, improves the regulation of cortical motor areas and corticolimbic swallowing functions, and facilitates the reorganization or remodeling of brain functions. In addition, low-frequency pulsed currents cause coordinated contraction and expansion of local muscles and increase the pressure in the mouth and pharynx to move food into the esophagus[8].
Although the application of myoelectric biofeedback technology has made very remarkable progress, its basic research in each therapeutic area is still in its infancy, which requires more effort to explore this area for better use in rehabilitation therapy. Second, EMGBF may promote rehabilitation and improve expected risk in the short term, but may not lead to significant long-term increases, and further research is needed to determine whether EMGBF is beneficial for long-term treatment of stroke patients[9]. We have explored the effects of different EMGBF on swallowing function and the rate of hyoid-laryngeal complex movement in patients with post-stroke dysphagia.
MATERIALS AND METHODS
Research object
Ninety stroke patients treated in our hospital from September 2021 to May 2022 were selected as the subjects of this retrospective study, and were divided into conventional rehabilitation training group (n = 30), EMGBF group (n = 30) and intensive EMGBF group (n = 30) according to the different treatment methods. Stroke diagnosis[10]: Clinically confirmed cerebral infarction or cerebral hemorrhage (hemispheric or brainstem) and confirmed by cranial computed tomography (CT) or magnetic resonance imaging (MRI), and disease diagnosis in accordance with the relevant criteria in the Chinese Expert Consensus on Assessment and Treatment of Swallowing Disorders; Diagnostic criteria for swallowing disorders[11]: Confirmed by CT or MRI, articulation and speech disorders, chewing and swallowing difficulties, and choking on drinking water. Dyskinesia of the soft palate, pharyngeal muscles, tongue muscles, bite muscles or facial muscles, but no tongue muscle atrophy or tremor, presence or diminished or absent pharyngeal reflex, diminished or absent soft palate reflex, hyperactive mandibular reflex, positive pathological brainstem reflex. Cone bundle sign (paralysis of one or both limbs) or affective disorder (indifferent expression, dementia or strong crying and laughing).
Inclusion and exclusion criteria
Inclusion criteria: (1) The patient has a first-time onset and has recovered from cerebral infarction or hemorrhage, with a onset time between 2 wk and 3 months; (2) The patient and their family members were informed to voluntarily participate in this study and sign a written consent form; (3) The patient's consciousness is clear and stable, and there are abnormal manifestations in the pharynx during the Puddlefield drinking water test and swallowing imaging evaluation; and (4) The patient has no severe cognitive impairment or aphasia, can maintain a correct sitting position for more than half an hour, and can cooperate with the doctor to complete various examinations and rehabilitation training.
Exclusion criteria: (1) The patient has a history of other serious physical or mental illnesses and cannot cooperate with the doctor to complete relevant examinations; (2) Malignant tumors of the skull caused by malignant tumors, metastases, etc.; (3) The patient has a history of throat and neck treatment or metal internal fixation; and (4) The patient may have severe cognitive impairment and aphasia on the production line, poor compliance, and cannot cooperate with the doctor to complete various examinations and related treatments.
Methods
Patients in all three groups received conventional neurological drug treatment and motor function rehabilitation training, and drugs to lower cranial pressure and improve cerebral circulation to activate nerve cells were selected according to their conditions. The motor function rehabilitation training included, health education: patients were given the "Stroke Swallowing Disorder Guidance and Education Manual", which introduced the causes of onset, common clinical manifestations and the management of some of their problems. Basic bedside rehabilitation training: instruct patients to perform motor training of the mouth and face, such as mouth opening, mouth closing, lip pouting and cheek puffing, to exercise the recovery of the lip muscles, 20 times for each movement, 3 times a day, and record the training of patients. Swallowing function training: use ice swabs to stimulate the root of the patient's tongue and soft palate, etc., once a day for 10 min. Food requirements: Use paste food in the early stage, gradually transition to solid food in the later stage, once a day, just complete 5 training sessions a week.
On this basis, the regular group was given regular swallowing function training for 30 min/d, 5 d/wk, and all swallowing function training was completed under the guidance of speech therapists, including the training of swallowing organs. (1) Cheek muscle and neck movement: The patient opened his mouth and inhaled, then puffed his cheeks, followed by exhalation and gentle exhalation of gas; the patient extended his head forward to stretch the submandibular muscle, then exerted an upward force under the jaw; the patient lowered his head and raised the back of his tongue (i.e., tongue up against the hard palate); (2) Tongue muscle movement: The patient extended his tongue forward, then swung it from side to side, then licked his upper and lower lips with the tip of his tongue and pressed against the hard palate; (3) Ice stimulation (Stim): A cotton swab with a ball-shaped head end was dipped in; (4) Ice Stim: Stimulate the tongue and palate arch with a ball-shaped cotton swab dipped in ice water, then ask the patient to do swallowing action; (5) Direct feeding training: The patient sits or semi-recumbent position, head is bent forward, the shoulder of the hemiplegic side is padded with a soft pillow, the feeder is located on the patient's healthy side, and try to feed the food into the back of the healthy side of the tongue or the healthy side of the cheek, according to the patient's individual situation to choose the food to eat, from easy to difficult, in the order of liquid - semi-liquid - semi-solid and solid. The amount of food intake per mouth was 5-20 mL, with an interval of about 30 s each time; the above training was performed once a day for 45 min each time; and (6) Ingestion training: Different strategies could be used according to the condition, including head rotation swallowing, lateral swallowing, low head swallowing, nodding swallowing, head back swallowing, empty swallowing and cross swallowing, supraglottic swallowing, supraglottic swallowing, forceful swallowing, etc.
EMGBF group added 1 session of myoelectric biofeedback therapy, 1 time/d, 5 times/wk, to the conventional swallowing disorder training, using a nerve and muscle Stim physiotherapy apparatus. Alcohol cotton balls were used to sterilize the patient's neck, and some patients with hair on the skin surface were prepared to reduce the resistance between the surface electrodes and the skin. Placement of electrode pads: Three electrode pads were placed, two of which were symmetrically placed on both sides of the median line of the supraglottis area, and the other reference electrode was placed at the muscle belly of the chin hyoid muscle. Setting parameters: Turn on the instrument, select s-electromyographic (sEMG) + Stim combined treatment mode, electrical Stim parameters in this mode: All clear mode: Rectangular symmetrical biphasic zero Dual Channel net, frequency 30-80 Hz adjustable, wave width 300 μs, pulse ratio 300 μs adjustable, current Stim intensity 0-20 mA. ask the patient to swallow 3 times, capture the average between each peak of the patient's muscle contraction during the period Expressed electromyography (EMG) value, according to the percentage set target value; myoelectric biofeedback therapy: The rehabilitation therapist explained the treatment method and purpose to the patient, so that the patient actively cooperate. The patient was then instructed to pay attention to the EMG values displayed on the screen and to train according to the voice prompts of the instrument, such as when the patient heard "contract and hold", he/she swallowed as hard as he/she could and held it, followed by "relax", and a swallowing action was the treatment was repeated. During the treatment period, water and a 10 mL disposable syringe were prepared, and when the patient could not complete the swallowing action because of dry mouth, a small amount of water could be given to moisten the mouth, and care was taken not to inject too much at one time to avoid choking and coughing, which would affect the treatment effect. The intensive EMGBF group added 2 sessions of myoelectric biofeedback therapy, 2 times/d, 10 times/wk to the conventional swallowing disorder training. All patients received 4 wk of swallowing function treatment.
Observation indicator
Patients in the three groups were assessed by the same rehabilitation physician and rehabilitation therapist before and after 4 wk of treatment for functional assessment, including the degree of swallowing disorder score (VGF)[12], and the Rosenbek penetration-aspiration scale (PAS)[13]. The efficacy was assessed for each group of patients. The degree of swallowing disorder was scored: oral phase: Unable to send food from the mouth into the throat, out of the mouth and lips, or only gravity into the throat was scored as 0; the score could not form a food block into the throat, but could only form food into the throat in the form of Ling group was scored as 1; unable to send food completely into the throat in one time, after one swallowing action, some food remained in the mouth was scored as 2; one swallow could finish sending food 3 points for being able to deliver food into the throat in one swallow. Pharyngeal phase: 0 points for failure to cause pharyngeal uplift, atresia of the epiglottis and closure of the soft palate arch, and inadequate gag reflex; 1 point for having a large amount of residual food in the pharyngeal recess and the pyriform fossa; 2 points for storing a small amount of residual food and swallowing all the residual food into the lower pharynx with several swallows; 3 points for sending food into the esophagus with a single swallow. The degree of swallowing by mistake: 0 points for most swallowing without choking and coughing; 1 point for most swallowing with choking and coughing; 2 points for a small amount of swallowing without choking and coughing; 3 points for a small amount of swallowing with choking and coughing; 4 points for no swallowing. The standardized swallowing assessment (SSA)[14] assessed patients' swallowing function with a total score of 18-46, with higher scores indicating poorer swallowing function. The videofluoroscopic dysphagia scale (VDS)[15] was used to assess the degree of swallowing impairment in patients. The VDS includes a total of 14 entries, among which are lip closure, glottis formation, mastication, swallowing disuse, tongue contact with the hard palate, posterior glottis leakage, oral passage time, pharyngeal phase swallow initiation, epidural valley residual, laryngeal elevation, pear-shaped crypt residual, posterior pharyngeal wall residual, and misaspiration, with scores ranging from 0 to 100, with higher scores demonstrating a higher degree of dysphagia in patients.
Statistical analysis
All statistical data in this study were entered into excel software by the first author and the corresponding author respectively, and the statistical processing software was SPSS 25.0 for calculation. Repeated measures analysis of variance between groups was used to measure the measurement expressed as mean ± SD. One-way ANOVA was used for intra-group and inter-group comparisons of measurement data. Count data expressed as a percentage (%) were tested by χ2. the risk factors with significant differences were screened. Included data that did not conform to a normal distribution were described by M(QR), using the Mann-Whitney test. The statistical significance was P < 0.05.
RESULTS
Comparison general data
There was no statistically significant difference between the two groups by t-test and chi-square test (P > 0.05) in the comparison of general data such as gender, mean age, disease duration, and lesion site (Table 1).
Table 1 Comparison of general information between two groups of patients [n/mean ± SD)].
General information
Group
χ2/F
P value
Regular group (30)
EMGBF group (30)
Intensive EMGBF group (30)
Gender (Male/Female)
16/14
14/16
17/13
0.623
0.732
Average age (yr)
66.63 ± 1.32
65.62 ± 1.31
66.27 ± 2.14
2.935
0.058
Duration of disease(yr)
4.31 ± 0.67
4.33 ± 0.25
4.34 ± 0.25
0.036
0.964
Lesion site
Hemispheres
14
17
18
1.165
0.559
Brainstem
16
13
12
Comparison of VGF scores and PAS scores
There was no statistically significant difference in VGF score and PAS score between the 3 groups before treatment (P > 0.05); after 4 wk of treatment, it was found that the VGF score increased and PAS score improved significantly in all 3 groups, and the difference in VGF score and PAS score between the 3 groups was found to be statistically significant (P < 0.05). The efficiency of the intensive EMGBF group was improved compared with the conventional group (P < 0.05). Compared with the EMGBF group, the practice group was significantly improved, and the PAS score was improved in the intensive EMGBF group compared with the EMGBF group, and the difference was statistically significant (P < 0.05). The VGF scores in the intensive EMGBF group improved in efficiency, but the difference was not statistically significant (P > 0.05; Figure 1).
Figure 1 Comparison of the swallowing disorder score and penetration-aspiration scale score.
All statistical data in this study were entered into excel software by the first author and corresponding author respectively, and the statistical processing software was SPSS 25.0 for calculation, expressed as the measurement value of the mean ± SD, does not meet the the data with normal distribution was described by M (QR), and the Mann-Whitney test was used. The data in line with the normal distribution used repeated measures analysis of variance. It was found that there was no significant difference in the swallowing disorder score (VGF) score and Rosenbek penetration-aspiration scale (PAS) score between the three groups before treatment (P > 0.05); after 4 wk of treatment, it was found that the VGF scores of the three groups of patients were all increased compared with before, and the PAS scores were significantly improved (P < 0.05). Among them, the effective rate of the intensive electromyographic biofeedback (EMGBF) group was higher than that of the conventional group (P < 0.05). Compared with the EMGBF group, the training group was significantly improved, and the intensive EMGBF group improved the PAS score compared with the EMGBF group, and the difference was statistically significant (P < 0.05). The VGF score of the enhanced EMGBF group was improved, but the difference was not statistically significant (P > 0.05). A: The swallowing disorder score; B: Rosenbek penetration-aspiration scale score. EMGBF: Electromyographic biofeedback; VGF: The swallowing disorder score; PAS: Rosenbek penetration-aspiration scale.
Comparison of forward and upward movement speed of hyoid bone
There was no significant difference in the forward and upward movement speed of the hyoid bone between the three groups before treatment (P > 0.05). After 4 wk of treatment, it was found that the results of the forward and upward movement speed of the hyoid bone in the three groups were significantly improved compared with the previous ones, and the comparison between the three groups showed that there was a statistically significant difference in the forward and upward movement speed of the hyoid bone between the three groups (P < 0.05), the forward and upward movement rates of the hyoid bone in the EMGBF group and the enhanced EMGBF group were significantly higher than those in the conventional group (P < 0.05; Figure 2).
Figure 2 Comparison of the forward and upward movement speed of the hyoid bone.
All statistical data in this study were entered into excel software by the first author and the corresponding author respectively, and the statistical processing software was SPSS 25.0 for calculation, expressed as the measurement of mean ± SD. The data that did not conform to the normal distribution were described by M (QR), and the Mann-Whitney test was used. The data that conformed to the normal distribution were found using repeated measures analysis of variance. There was no significant difference between the two groups (P > 0.05). After 4 wk of treatment, it was found that the forward and upward movement speed of the hyoid bone in the three groups was significantly improved compared with the previous one. The difference in movement speed between groups was statistically significant (P < 0.05), among which the forward and upward movement rates of the hyoid bone in the electromyographic biofeedback (EMGBF) group and the enhanced EMGBF group were significantly higher than those in the conventional group, and the forward and upward movement of the hyoid bone in the enhanced EMGBF group was higher than that in the EMGBF group. The rate improved significantly, and the statistics showed that the difference was statistically significant (P < 0.05). A: Forward movement speed of hyoid bone; B: Upward movement speed of hyoid bone. EMGBF: Electromyographic biofeedback.
Comparison of SSA and VDS scores
Before treatment, there was no significant difference in the SSA and VDS scores of the three groups before and after treatment (P > 0.05). The differences among the three groups were statistically significant (P < 0.05; Figure 3).
Figure 3 Comparison of standardized swallowing assessment and videofluoroscopic dysphagia scale scores.
All statistical data in this study were entered into excel software by the first author and the corresponding author respectively, and the statistical processing software was SPSS 25.0 for calculation, and expressed as the measurement value of the mean ± SD, which did not meet the positive. The data of the normal distribution were described by M (QR), and the Mann-Whitney test was used. The data conforming to the normal distribution was analyzed by repeated measures analysis of variance. It was found that there was no significant difference in the standardized swallowing assessment (SSA) and videofluoroscopic dysphagia scale (VDS) scores between the three groups before and after treatment (P > 0.05), after 4 wk of treatment, it was found that the SSA and VDS scores of the three groups were significantly improved compared with the previous ones, and the difference between the three groups was found to be statistically significant (P < 0.05). A: SSA score; B: VDS score. EMGBF: Electromyographic biofeedback; SSA: Standardized swallowing assessment; VDS: Videofluoroscopic dysphagia scale.
DISCUSSION
DAS, a relatively common post-stroke dysfunction, can lead to a variety of complications, and in fact patients diagnosed with swallowing aspiration by television fluoroscopy are up to eight times more likely to develop pneumonia[16]. EMGBF therapy or training is also known as a psychological strategy through which we can control the responses within our body at will[17]. EMGBF consists of two components, the first one is the awareness or understanding of internal responses and the second one is learning to control these responses. These two are in principle based on operant conditioning. EMGBF uses the surface EMG technique, which is based on the recording of electrical signals generated by depolarization of the myocyte membrane during muscle contraction, and the EMGBF instrument detects and amplifies the signals from the body and feeds back information[18]. In this way, the rehabilitation therapist teaches the patient to contract and relax the muscle in an appropriate functional manner, and the patient consciously uses this information in an effort to modify or alter specific physiological processes. It has been shown that myoelectric biofeedback training for swallowing disorders primarily promotes displacement of the hyoid-laryngeal complex[19].
Functional recovery in stroke patients results from the patient's pre-onset function, the neurological changes triggered by the stroke itself, and the environmental and behavioral influences on brain function and organization[20]. Thus, the ultimate goal of rehabilitation is to control an individual's environmental and behavioral experiences after a stroke in order to direct neurological reorganization in a manner that promotes recovery, and the body usually requires coherent activation of multiple muscles to achieve activities of daily living[21]. Neuromotor control can be modified by EMGBF techniques to ensure that target swallowing movements are trained during rehabilitation rather than maladaptive movements[22]. Intensive training is a rehabilitation approach designed to modify clinical symptoms by incorporating task-specific focused associations, a measure that emphasizes extensive hands-on, repetitive, targeted task-specific training[23]. Supporting evidence for the ability of reinforcement training to induce neuroplasticity comes from basic neuroscience and clinical research in stroke rehabilitation, with animal studies showing that intensive and repetitive behavioral training leads to significant neurological and functional changes[24]. Although the therapeutic dose required to initiate these central changes remains unknown, intensive training interventions are provided in many animal studies and such intensive training appears to be necessary to achieve rehabilitation benefits[25]. The finding that intensive repetitive training leads to significant changes in somatosensory cortical Stim areas and that intensive training causes neural reorganization has also been repeated in several animal studies[26]. In order to induce cortical reorganization and behavioral changes, a certain intensity of rehabilitation must be met, and the current neuroscience and cognitive psychology literature each has a view on rehabilitation, with neuroscience research suggesting that intensive training is a key factor in rehabilitation and is necessary to achieve functional and neurological changes after the onset of stroke[27].
The EMG feedback electrical Stim used in our study included sEMG and electrical Stim, which is a combined mode of active and passive movement. Patients actively mobilized muscle activity to complete swallowing movements at the target threshold through audiovisual information fed by the instrument, and once the set target threshold was reached or exceeded, a single electrical Stim was given to stimulate muscle contraction and movement of the hyoid laryngeal complex[28]. After 4 wk of treatment, VGF scores, PAS scores and hyoid bone movement rates were significantly improved in the three groups of patients compared between groups, and VGF scores, PAS scores and hyoid bone movement rates were significantly improved in the EMGBF and intensive EMGBF groups compared with the conventional group, suggesting that EMGBF training can better improve swallowing function, and the possible reason for this is that EMGBF training makes weak myoelectric signals that cannot be perceived by the naked eye. The possible reason for this is that EMGBF training allows weak EMG signals that cannot be perceived by the naked eye to be displayed through visualized audiovisual signals, so that patients have a more intuitive experience and can actively participate in the treatment process, which increases the degree of cooperation and confidence of patients and enhances the treatment effect[29]. Secondly, patients can indirectly observe muscle strength and various muscle contractions through visualized EMG waveforms, voice feedback and other information, which helps to improve the rhythmical and sequential nature of swallowing[30]. The central nervous system is highly plastic, and EMGBF training uses the principle of motor relearning to enable patients to relearn complex swallowing motions, promote regeneration of nerve collateral buds and reconnection of axon synapses through extensive repetitive training, promote recovery of swallowing feedback loops, and establish correct swallowing patterns[31].
In our study, we added the comparison of intensive training, and the improvement of PAS score and hyoid bone movement rate after treatment in the intensive EMGBF group was better than that in the EMGBF group, which indicated that high-intensity EMGBF training was beneficial for improving the swallowing function of patients. The Chinese stroke rehabilitation treatment guidelines level 2 recommendation, level B evidence suggests that the intensity of rehabilitation training for stroke patients should be increased appropriately when conditions permit to help functional recovery[32]. Some outcome studies suggest that intensive therapy can have a positive impact on the biomechanics of swallowing, however we need to pay attention to more randomized controlled trials to validate the role of treatment techniques, the amount of treatment and the intensity of treatment[33]. Reinforcement training provides patients with high-intensity, reproducible training with repeated functional reinforcement, repeatedly transmitting information about the practice pattern to the central nervous system numerous times, promoting synaptic connections and inducing functional reorganization of the cerebral cortex[34]. It has been shown that normal swallowing patterns can be established in patients during intensive training and are maintained over time by intensive training[35]. In our study, after 4 wk of treatment all three groups of patients had improved VGF scores compared to the previous ones, but the difference between the intensive EMGBF group and the EMGBF group was not statistically significant. The reasons for this analysis may be: The VGF score is a subjective evaluation of the patients and there is some error in the assessment; the small volume of the study and the short experimental time. There are still many shortcomings in our study, for example, the number of observed cases is small; the short duration of the experiment does not allow for long-term follow-up of patients; Video fluoroscopic Swallowing Stud (VFSS) requires dynamic observation under X-rays, and patients are exposed to X-rays for a long time, and the experiment does not target the long-term effects of X-rays on patients for follow-up. Finally, the experimental subjects were not strictly distinguished between true and false bulbar palsy, and it could not be ruled out whether the improvement of swallowing function had some correlation with their own recovery.
We found that after 4 wk of treatment it was found that the SSA and VDS score results of patients in the three groups were significantly improved compared to the previous ones, and the differences between the three groups were found to be statistically significant by comparison between the groups for the following reasons: although traditional swallowing training can also help patients to improve swallowing function, it is ineffective and cannot effectively correct abnormalities in the synergistic contraction of the pharyngeal muscles, resulting in a low efficiency of rehabilitation treatment[36]. In contrast, EMGBF is used to provide feedback signals through visual or auditory pathways by collecting EMG signals during voluntary muscle contraction activity so that patients can understand the changes in muscle function[37]. Visual or auditory combines physiological treatment and psychological interventions to facilitate feedback training of the patient's laryngeal muscles, stimulating damaged nerves and restoring normal muscle contraction function[38]. In addition, EMG feedback is a repetitive stimulus based on the cerebral cortex during voluntary muscle contraction activity, and after repetitive drive, the stimulus forms a conditioned reflex that contributes to the reorganization of brain function to form an effective swallowing reflex pathway[39]. In addition to this, the EMG response can fully mobilize the patient's initiative and increase the patient's confidence in recovery[40].
There are still many shortcomings in our study, for example, the number of observed cases is small; the short duration of the experiment does not allow for long-term follow-up of patients; VFSS requires dynamic observation under X-rays, and patients are exposed to X-rays for a long time, and the experiment did not follow up on the long-term effects of X-rays on patients. Finally, the experimental subjects were not strictly distinguished between true and false bulbar palsy, and it could not be ruled out whether the improvement of swallowing function had some correlation with their own recovery. In conclusion, myoelectric biofeedback reinforcement training is superior to conventional swallowing training and myoelectric biofeedback training in improving swallowing function and increasing the motor rate of the hyoid-bone laryngeal complex in patients with swallowing disorders, and its therapeutic effect is significant and worthy of clinical adoption and promotion.
CONCLUSION
EMGBF training is more effective than traditional swallowing training in improving swallowing function and the movement rate of the hyoid laryngeal complex in patients with post-stroke dysphagia.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Clinical neurology
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade C
Novelty: Grade B
Creativity or Innovation: Grade B
Scientific Significance: Grade B
P-Reviewer: Patrice N, France S-Editor: Lin C L-Editor: A P-Editor: Zhang XD
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