I. Case selection criteria
Patients with primary cerebral infarction or cerebral hemorrhage diagnosed by the diagnostic points of various types of cerebrovascular diseases adopted at the Fourth National Academic Conference on Cerebrovascular Diseases in 1995 [3] and confirmed by cranial CT or MRI. Patients were aged 39-78 years, within 1 week after stabilization of vital signs, with swallowing dysfunction able to understand the instructional language, with some retention of attention, and willing to sign an informed consent form. Those with the following conditions were excluded: motor neuron disease, severe dementia, severe mental retardation, severe behavioral problems after traumatic brain injury, or delirium [4].
II.General information
Sixty acute stroke patients who met the above selection criteria and were hospitalized in the Rehabilitation Center of Neurology Department of Shandong Jiaotong Hospital from May 2004 to July 2008 were selected. There were 36 male and 24 female patients aged 39-78 years, with an average age of 65±11 years. The enrolled patients were stratified according to cerebral infarction (ICA) and cerebral hemorrhage (HCA), and then the patients in each stratum were randomized to the rehabilitation treatment group and the control group by regional group randomization. There were 30 cases in each of the two groups. The rehabilitation group was given tertiary swallowing rehabilitation treatment, and the control group was given general swallowing rehabilitation treatment.
Treatment methods
(I) Three-stage swallowing rehabilitation
A collaborative treatment team was formed by a rehabilitation physician, an internist, a speech-speech therapist (ST), a physical therapist (PT), an occupational therapist (OT), a clinical dietician and nursing staff.
The first phase of treatment for patients in the rehabilitation group, from onset (V0) to the end of the 2nd week after onset (V1), was mainly carried out in the neurology ward, where patients were given early bedside rehabilitation after stabilization, i.e., immediately after the patient’s vital signs were stabilized within 1 week; the second phase of treatment, from the end of the 2nd week after onset to the end of the 1st month (V2), was carried out in the rehabilitation The second phase of treatment, from the end of the second week to the end of the first month (V2), takes place in the rehabilitation ward; and the third phase, from the end of the first month to the end of the second month (V3), takes place in the patient’s home under the supervision of a therapist or in a community health center. The “primary rehabilitation” refers to the regular treatment and early rehabilitation in the acute hospital or neurology department, the rehabilitation in the rehabilitation ward/center, and the “tertiary rehabilitation” refers to the continued rehabilitation in the community or at home [5,6 ].
(ii) Rehabilitation treatment methods
For primary swallowing rehabilitation, indirect therapy such as lip and tongue exercises, together with acupuncture treatment, and feeding training for patients with suitable conditions, are used twice a day for 20 minutes each time. In the second level of swallowing rehabilitation, indirect therapy, feeding training and compensatory methods are combined with cognitive training and biofeedback devices, t-type swallowing and speech diagnostic therapy devices, and acupuncture treatment. The practice of home rehabilitation exercises and various misopharyngeal prevention methods were the main focus during the tertiary swallowing rehabilitation, which was performed twice daily for about 30 minutes each time.
(C) Control group
Patients in the control group had the same routine medical treatment as the rehabilitation group and were not given systematic tertiary swallowing rehabilitation. Some patients performed self-activation under the verbal medical advice of the clinician, some patients were helped to move according to their own knowledge, and it was not excluded that the patients were discharged to other rehabilitation units for treatment, including swallowing function training. The patient’s family members were informed of this situation and had signed an informed consent form.
IV. Main observation indexes and assessment methods
After clinical observation, the swallowing function was graded according to the Japanese scholar Saedo grading method [7]; grade 7: normal range, grade 6: mild problems, grade 5: oral problems, grade 4: chance misopharyngeal, grade 3: water misopharyngeal, grade 2: food misopharyngeal, and grade 1: saliva misopharyngeal.
And the corresponding dysphagia score was given according to the above grading, which was divided into 1-7 points, with 7 points equivalent to grade 7, indicating normal swallowing, and 1 point equivalent to grade 1 of the Jaito grading, indicating the most severe degree of dysphagia.
All assessments were made by the same rehabilitation physician, and the assessor was not involved in the treatment and did not know whether the assessment was for the rehabilitation treatment group or the control group.
V. Statistical analysis
SAS 9.0 statistical software was used for statistical analysis. t-test was used for comparison of measurement data, and chi-square test was used for comparison of count data.
Results
I. Comparison of swallowing function between the 2 groups of patients at each stage of treatment
The swallowing function scores in the rehabilitation group were significantly higher than those in the control group at each stage (P<0.05 or P<0.01), with significant differences. Before treatment (V0), at the end of treatment 2 (V1), compared with 41.0%, 55.9%, 60.4% and 63% in the control group, respectively; the swallowing function of patients in the rehabilitation group was equivalent to that of the control group before treatment, at the end of treatment 2, at the end of January and at the end of February, respectively.
Comparison of training time and efficacy between the 2 groups
The effective rate of the rehabilitation group was 53.3% at 2 weeks of treatment and increased by 20.0% at 2 weeks of continued treatment, and only increased by 10.0% at more than 1 month of continued treatment. The effective rate of the rehabilitation group was 86.7% at 2 weeks of treatment, 6.6% increase at 2 weeks of continued treatment, and only 3.4% increase at more than 1 month of continued treatment. It is suggested that the effect of rehabilitation treatment is obvious within 2 weeks, and then enters a slow rise period. See Table 5.
Discussion
Swallowing disorders due to cerebrovascular disease are caused by dysfunction of the neural conduction bundle in the brain, resulting in motor dysfunction of the muscles governing the pharynx, larynx, and tongue that prevent food from being transported from the mouth to the stomach. In this study, we used the swallowing function grading scale to measure the change of swallowing function of patients, and found that after the rehabilitation treatment, the swallowing function score and score difference of patients at each stage were significantly higher than those of the control group; the swallowing function of patients in the rehabilitation group before treatment, at the end of treatment 2 weeks, at the end of January and at the end of February was equivalent to 102.1%, 126.6%, 134.8% and 140.8% of that of the control group, respectively. That is, the patients’ swallowing function improved significantly better than that of the control group after the rehabilitation treatment. These indicate that tertiary swallowing rehabilitation therapy can significantly improve the swallowing function of the patients.
The results of the study showed that there was a significant natural recovery process in the patients, as evidenced by the percentage change in the functional equivalent of normal in the control group patients at each stage.
The difference in swallowing function scores of patients in the rehabilitation group during the same period was higher than that of the control group by 0.98, 0.43 and 0.33 points, respectively. The recovery effect of swallowing function was faster in the first 2 weeks of onset and became slower in the later stages, and patients in the rehabilitation group still had a more significant recovery in the later stages compared with the control group. In terms of the relationship between treatment time and efficacy, the recovery was obvious within 2 weeks of treatment and entered a slow rise after 1 month.
The target of rehabilitation treatment for swallowing disorders is the process starting with the cognitive period until the food enters the esophagus. Indirect treatments such as lip and tongue exercises aim to improve the neural and muscular movements necessary for the swallowing process. Indirect therapy can work through the mechanism of neuroplasticity. The purpose of ingestion training is to improve the actual swallowing ability by using foods of different nature and allowing the patient to do swallowing exercises. The purpose of swallowing speech therapy device is to stimulate the paralyzed nerve fibers and muscles through pulses, so that the motor disorders of the swallowing muscles can be relieved and the brain cells of the motor and sensing system can be regenerated and reorganized, while maintaining the muscles to prevent atrophy due to long-term disuse. While strengthening local blood circulation, acupuncture can activate the upstream brainstem reticular system, forming a stimulating and promoting effect on the central nervous system and promoting the reconstruction and recovery of the swallowing reflex arc.
In conclusion, the rehabilitation group may have accelerated the establishment of cerebral collateral circulation, promoted the repair or reconstruction of the tissue around the lesion, and the compensation of the corresponding area of the contralateral brain tissue, and greatly exerted the plasticity of the brain due to the assessment and treatment in strict accordance with the tertiary swallowing rehabilitation [8-10]. Patients in the control group may learn and train certain functions spontaneously, but often not in a timely and correct manner, and with insufficient activity. These will seriously affect the process of neurological recovery in the control group of patients.