Swallowing and dysphagia rehabilitation: translating principles of neural plasticity into clinically oriented evidence.

PURPOSE: This review presents the state of swallowing rehabilitation science as it relates to evidence for neural plastic changes in the brain. The case is made for essential collaboration between clinical and basic scientists to expand the positive influences of dysphagia rehabilitation in synergy with growth in technology and knowledge. The intent is to stimulate thought and propose potential research directions. METHOD: A working group of experts in swallowing and dysphagia reviews 10 principles of neural plasticity and integrates these advancing neural plastic concepts with swallowing and clinical dysphagia literature for translation into treatment paradigms. In this context, dysphagia refers to disordered swallowing associated with central and peripheral sensorimotor deficits associated with stroke, neurodegenerative disease, tumors of the head and neck, infection, or trauma. RESULTS AND CONCLUSIONS: The optimal treatment parameters emerging from increased understanding of neural plastic principles and concepts will contribute to evidence-based practice. Integrating these principles will improve dysphagia rehabilitation directions, strategies, and outcomes. A strategic plan is discussed, including several experimental paradigms for the translation of these principles and concepts of neural plasticity into the clinical science of rehabilitation for oropharyngeal swallowing disorders, ultimately providing the evidence to substantiate their translation into clinical practice.     

Evidence-based systematic review: effects of intensity of treatment and constraint-induced language therapy for individuals with stroke-induced aphasia

PURPOSE: This systematic review summarizes evidence for intensity of treatment and constraint-induced language therapy (CILT) on measures of language impairment and communication activity/participation in individuals with stroke-induced aphasia. METHOD: A systematic search of the aphasia literature using 15 electronic databases (e.g., PubMed, CINAHL) identified 10 studies meeting inclusion/exclusion criteria. A review panel evaluated studies for methodological quality. Studies were characterized by research stage (i.e., discovery, efficacy, effectiveness, cost-benefit/public policy research), and effect sizes (ESs) were calculated wherever possible. RESULTS: In chronic aphasia, studies provided modest evidence for more intensive treatment and the positive effects of CILT. In acute aphasia, 1 study evaluated high-intensity treatment positively; no studies examined CILT. Four studies reported discovery research, with quality scores ranging from 3 to 6 of 8 possible markers. Five treatment efficacy studies had quality scores ranging from 5 to 7 of 9 possible markers. One study of treatment effectiveness received a score of 4 of 8 possible markers. CONCLUSION: Although modest evidence exists for more intensive treatment and CILT for individuals with stroke-induced aphasia, the results of this review should be considered preliminary and, when making treatment decisions, should be used in conjunction with clinical expertise and the client's individual values.     

Measuring and inducing brain plasticity in chronic aphasia

Brain plasticity associated with anomia recovery in aphasia is poorly understood. Here, I review four recent studies from my lab that focused on brain modulation associated with long-term anomia outcome, its behavioral treatment, and the use of transcranial brain stimulation to enhance anomia treatment success in individuals with chronic aphasia caused by left hemisphere stroke. In a study that included 15 participants with aphasia who were compared to a group of 10 normal control subjects, we found that improved naming ability was associated with increased left hemisphere activity. A separate study (N = 26) revealed similar results in that improved anomia treatment outcome was associated with increased left hemisphere recruitment. Taken together, these two studies suggest that improved naming in chronic aphasia relies on the damaged left hemisphere. Based on these findings, we conducted two studies to appreciate the effect of using low current transcranial electrical stimulation as an adjuvant to behavioral anomia treatment. Both studies yielded positive findings in that anomia treatment outcome was improved when it was coupled with real brain stimulation as compared with a placebo (sham) condition. Overall, these four studies support the notion that the intact cortex in the lesioned left hemisphere supports anomia recovery in aphasia. LEARNING OUTCOMES: Readers will (a) be able to appreciate the possible influence of animal research upon the understanding of brain plasticity induced by aphasia treatment, (b) understand where functional changes associated with anomia treatment occur in the brain, (c) understand the basic principles of transcranial direct current stimulation, and (d) understand how brain stimulation coupled with aphasia treatment may potentially improve treatment outcome.     

Traumatic aphasia in children: A case study

Traumatic aphasia in children has been recognized as a distinct clinical pathology, differing from adult aphasia in symptomatology and course of recovery. The upper limit for complete recovery has been identified as age 10. However, there is a paucity of literature documenting recovery of children with traumatic aphasia. It is apparent that definitive statements of the upper age limit for complete recovery from traumatic aphasia in children cannot be made at this time. This article reviews the literature concerning traumatic aphasia and presents case information of a 10-year-old traumatic aphasic girl seen at the North Texas State University Speech and Hearing Center. The design, execution, and assessment of therapeutic interaction and the observed language abilities of the client are reported.     

Evidence-based recommendations for antimicrobial nasal washes in chronic rhinosinusitis

BACKGROUND: Chronic rhinosinusitis (CRS) refractory to medical and surgical therapy is a difficult problem for patients and physicians. Topical antimicrobial nasal irrigations are commonly used for treatment with great variation in methodology and without clear scientific support for current treatment formulations. The purpose of this study was to develop a scientific rationale for creating standardized recommendations for clinical practice in the use of topical antimicrobial washes for CRS. METHODS: An extensive review of basic science and clinical literature on the treatment of CRS with topical antimicrobial washes was completed. Pharmacokinetics of and organism susceptibility to appropriate topically applied antimicrobial agents were reviewed. RESULTS: The most common organisms associated with CRS were identified. The relevant pharmacokinetics of drugs targeted at these organisms are presented. Susceptibility breakpoints set by the National Committee for Clinical Laboratory Standards are identified to help establish the most effective concentration of the identified drugs. Recommendations for agent selection, agent concentration, length of treatment, dosing schedule, and methods of irrigation are presented. CONCLUSION: Antimicrobial nasal washes provide a potentially effective treatment for the growing population of patients who remain symptomatic after appropriate medical and surgical intervention. This study establishes the basic principles supporting this treatment option and offers rational, evidence-based treatment guidelines. The study has identified additional areas that need to be investigated before prospective clinical trials can be effectively undertaken.     

Current concepts in the diagnosis and treatment of sudden sensorineural hearing loss

Sudden hearing loss (SHL) has been a controversial topic in the literature for the past several decades. Although much theoretical work has been done regarding its diagnosis and treatment, no useful practical guidelines exist for application to current patient management. Many authors have discussed the various treatment protocols available to treat this entity, but only a handful of dated, clinical studies supporting these treatments are available. More recent studies applying treatment protocols including vasodilators, plasma expanders, anti-coagulants, and carbogen inhalations have shownno improvement over the rate of spontaneous recovery without therapy. Except in cases of therapy directed toward known predisposing factors, there is insufficient evidence in the literature to support medical treatment for SHL, although steroid therapy appears to be useful in selected patients. Our own review of 14 patients with SHL is presented. A standard diagnostic and therapeutic approach based on a comprehensive review of the literature is described that can be applied to most patients presenting with SHL.     

Pharmacotherapy for severe, disabling, subjective, idiopathic tinnitus: 2005-2006

We present a tinnitus-targeted therapy (TTT), a combined treatment of medication and instrumentation focusing on pharmacotherapy. It embodies ongoing clinical experience (since 1977) in an excess of 8,500 patients with subjective idiopathic tinnitus of the severe disabling type (SIT). All have visited the Tinnitus Clinic of the Downstate Medical Center at the State University of New York (DMC/SUNY) and the Martha Entenmann Tinnitus Research Center, Inc. Since 1989, as a result of our evolving experience with single-photon emission computed tomography (SPECT) of brain, we have defined tinnitus as a sensory disorder of auditory perception exhibiting an aberrant auditory signal produced by interference in the excitatory-inhibitory process or processes involved in neurotransmission. This definition is considered to be dynamic: It embodies the integration of clinical observations and advances reported from neuroscience and nuclear medicine. These investigations have sought to identify an underlying mechanism of tinnitus production and have assisted in the establishment of the medical significance of tinnitus. In general, the goal of tinnitus therapy in 2005-2006 is to attempt to provide tinnitus relief for all clinical types of subjective idiopathic tinnitus (SIT). Although no cure for SIT exists currently, available protocols for diagnosis and treatment increase the efficacy of therapeutic modalities for attempting tinnitus relief. The strategies of TTT are based on the clinical translation of fundamentals of sensory physiology, extrapolation of underlying neurochemistry from nuclear medicine imaging results with SPECT in SIT patients, hypotheses of mechanisms of tinnitus production, and the innovative application of drug therapies designed for indications other than tinnitus. Such strategies have contributed to the development of a new discipline, tinnitology, an integrated multidiscipline of basic science, neuroscience, and clinical medicine attempting to understand an aberrant auditory phenomenon, unrelated to an external source of sound, and how it becomes transformed into one of affect. The goal of increasing accuracy of the SIT diagnosis is the impetus for increased efficacy of therapeutic modalities recommended for tinnitus relief.     

The genetic bases of speech sound disorders: evidence from spoken and written language.

The purpose of this article is to review recent findings suggesting a genetic susceptibility for speech sound disorders (SSD), the most prevalent communication disorder in early childhood. The importance of genetic studies of SSD and the hypothetical underpinnings of these genetic findings are reviewed, as well as genetic associations of SSD with other language and reading disabilities. The authors propose that many genes contribute to SSD. They further hypothesize that some genes contribute to SSD disorders alone, whereas other genes influence both SSD and other written and spoken language disorders. The authors postulate that underlying common cognitive traits, or endophenotypes, are responsible for shared genetic influences of spoken and written language. They review findings from their genetic linkage study and from the literature to illustrate recent developments in this area. Finally, they discuss challenges for identifying genetic influence on SSD and propose a conceptual framework for study of the genetic basis of SSD.     

我国失语症治疗研究的计量学分析

目的对国内失语症治疗研究进行计量学分析,了解失语症治疗的研究前沿和趋势。方法采用文献研究方法,在中国知网(CNKI)数据库中输入检索式:主题词搜索为失语症,主题词下搜索为康复、治疗、干预、疗法、训练,采用Cite Space软件对文献作者、机构、关键词进行计量学分析。结果本研究共检索214篇文献。首篇文章发表于1992年,2004年达到第一高峰期(15篇),其后波动明显,2014年发文量(17篇)最高。暨南大学附属第一医院与首都医科大学宣武医院专业团队在此领域发文最多。脑损伤、meta分析、神经机制、脑卒中、脑卒中后、重复经颅磁刺激、计算机辅助、经颅直流电刺激、运动性失语、语言病理学为失语症治疗研究的热点。脑卒中、重复经颅磁刺激、经颅直流电刺激为失语症治疗的研究前沿与趋势。结论我国失语症治疗研究领域的核心作者群尚未形成,对于失语症研究尚需大量专业人员进行深入探索。     

Giant mandibular exostosis. Apropos of a case. Description, therapeutic approach. Review of the literature

The authors present a cases of localised exostosis of the angle and the ascending ramus of the mandible. They stress the technical problems posed by this giant exostosis and they propose an original operative approach together with a complete review of the literature.     

Current data on barotraumatic ear disease with isolated vestibular expression during apnea diving]

The authors have taken an interest in isolated vertiginous symptoms observed from free diving patients. In order to achieve a current bibliographic synthesis, they resume, on basis of 6 cases, the basic principles of the physics theories and the etiopathogenic mechanisms. They try so to help in the understanding of the vestibular clinical signs observed in this successful sport.     

Nasopharyngeal hamartoma: importance of routine complete nasal examination

The authors report clinical experience in managing an 82-year-old female presenting with long-standing bilateral nasal obstruction resulting from a nasopharyngeal mass. The patient had undergone a number of treatments including surgery. The previous examinations, investigations and treatment had all been performed within the previous 10 years and although examination had been documented there was no evidence on review of the notes that the nasopharynx had been inspected either by nasendoscopy or indirectly. The mass was removed via a combined nasal and oral approach. Histopathological examination of the specimen was consistent with mesenchymal hamartoma. In addition to describing a rare presentation the authors believe this case highlights the importance of complete examination in all patients with nasal symptoms.     

Platelet-rich plasma for regeneration of neural feedback pathways around dental implants:a concise review and outlook on future possibilities

Along with the development of new materials, advanced medical imaging and surgical techniques, osseointegrated dental implants are considered a successful and constantly evolving treatment modality for the replacement of missing teeth in patients with complete or partial edentulism. The importance of restoring the peripheral neural feedback pathway and thus repairing the lack of periodontal mechanoreceptors after tooth extraction has been highlighted in the literature. Nevertheless, regenerating the nerve fibers and reconstructing the neural feedback pathways around osseointegrated implants remain a challenge. Recent studies have provided evidence that platelet-rich plasma (PRP) therapy is a promising treatment for musculoskeletal injuries. Because of its high biological safety, convenience and usability, PRP therapy has gradually gained popularity in the clinical field. Although much remains to be learned, the growth factors from PRP might play key roles in peripheral nerve repair mechanisms. This review presents known growth factors contributing to the biological efficacy of PRP and illustrates basic and (pre-)clinical evidence regarding the use of PRP and its relevant products in peripheral nerve regeneration. In addition, the potential of local application of PRP for structural and functional recovery of injured peripheral nerves around dental implants is discussed.     

Single subject controlled experiments in aphasia: the science and the state of the science

This paper discusses the use of single subject controlled experimental designs for investigating the effects of treatment for aphasia. A brief historical perspective is presented, followed by discussions of the advantages and disadvantages of single subject and group approaches, the basic requirements of single subject experimental research, and crucial considerations in design selection. In the final sections, results of reviews of published single subject controlled experiments are discussed, with emphasis on internal validity issues, the number of participants enrolled in published studies, operational specification of the dependent and independent variables, and reliability of measurement. LEARNING OUTCOMES: As a result of reading this paper, the participant will: (1) understand the mechanisms required for demonstration of internal and external validity using single subject controlled experimental designs, (2) become familiar with the basic requirements of single subject controlled experimental research, (3) understand the types of single subject controlled experimental designs that are the most appropriate for studying the effects of treatment for aphasia, and (4) become familiar with trends in the published aphasia treatment literature in which single subject controlled experimental designs have been used.     

Evolution of phonemic word fluency performance in post-stroke aphasia

In this longitudinal study, quantitative and qualitative changes in responses of people with aphasia were examined on a phonemic fluency task. Eighteen patients were tested at 3-month intervals on the letters F-A-S while they received comprehensive, intensive treatment from 3 to 12 months post-stroke. They returned for a follow-up evaluation at an average of 10 months post-intervention. Mean group scores improved significantly from beginning to end of treatment, but declined post-intervention. Patients produced a significantly greater number and proportion of modifiers (adjectives and adverbs) between the beginning and end of treatment, with no decline afterwards, implying that they had access to a wider range of grammatical categories over time. Moreover, patients used significantly more phonemic clusters in generating word lists by the end of treatment. These gains may be attributed to the combined effects of time since onset and the linguistic and cognitive stimulation that patients received in therapy. LEARNING OUTCOMES: Readers of this paper should (1) gain a better understanding of verbal fluency performance in the assessment of aphasia, (2) recognize the importance of analyzing qualitative aspects of single word production in aphasia, and (3) contribute to their clinical judgment of long term improvement in aphasia.     

Revision facial nerve surgery

Transection of the facial nerve can result from blunt or penetrating trauma to the face or temporal bone. It can also occur accidentally during surgery, or as a planned surgical procedure carried out in the interest of eradicating disease. If transection is recognized at surgery, direct anastomosis or cable grafting is the procedure of choice. This article presents two cases with neither clinical nor electrical evidence of recovery. The authors review current understanding of the changes that occur in the neuron, axon, and muscle after injury to the nerve and the underlying pathology that led to graft failure in these cases. They also evaluate surgical options and diagnostic test results that help in selecting appropriate surgical procedures.     

Balance and aging.

OBJECTIVES/HYPOTHESIS: To provide a basic science and clinical review of normal balance changes with age, and to provide a current review for the evaluation and treatment of elderly patients with balance disorders. As we age, we lose balance function through loss of sensory elements, the ability to integrate information and issue motor commands, and because we lose musculoskeletal function. Diseases common in aging populations lead to further deterioration in balance function in some patients. Treatment of balance dysfunction in aging populations is based on the knowledge of normal aging processes and on an evaluation of the individual's balance loss and remaining balance elements. Prevention and rehabilitation play a major role in treatment; medical and surgical therapy also have a place. STUDY DESIGN AND METHODS: Review of literature, personal research and observations. RESULTS AND CONCLUSIONS: Although older patients may be subject to most of the common balance disorders of younger patients, they have more problems with chronic disequilibrium and falls. Prevention and rehabilitation play an important role in treating these patients.     

Review of neuroendocrine carcinomas of the larynx

Neuroendocrine carcinomas of the larynx are uncommon tumors of considerable scientific interest and clinical importance. They include typical carcinoid tumors, atypical carcinoid tumors, and small cell neuroendocrine carcinomas. This paper considers these neoplasms from a personal experience and reviews the relevant medical literature. About 200 cases of neuroendocrine carcinomas of the larynx have been reported. The diagnosis is based on light microscopy and is confirmed by ultrastructural evidence of neurosecretory granules. Histochemical and immunocytochemical investigations may support it. Paraneoplastic syndromes associated with laryngeal neuroendocrine carcinomas have been reported occasionally. The histogenesis, treatment, and prognosis of these lesions also are discussed.     

Audiovestibular manifestations of sarcoidosis: a review of the literature

OBJECTIVE/HYPOTHESIS: Sarcoidosis is a multisystem disease of unknown etiology. Audiovestibular involvement is rare but has been reported in a number of cases. The objective of this review is to provide an evidence-based summary of the audiovestibular manifestations of sarcoidosis by collating the findings of these case reports. STUDY DESIGN: Retrospective review of 48 published case reports and 2 cases recently encountered in audiovestibular medicine clinics. METHODS: Case reports were identified using a key word search of Medline database. Clinical details, audiovestibular test results, and radiological findings were recorded for each patient when available. RESULTS: When type of hearing loss (HL) was recorded, all losses were sensorineural, with only two patients found to have an additional conductive loss. The severity of HL ranged from mild to profound. Median thresholds were moderately raised. The HL was bilateral in 75% of patients and asymmetrical in 75% of these cases. Seventy percent of HLs demonstrated some recovery. Many of the patients with recovery were treated with corticosteroids, but no statistically significant association between treatment and HL outcome was observed. Symptoms of vestibular impairment were common. Vestibular testing was performed in 24 cases and was abnormal in 23. Eighty-one percent of patients had additional features of neurosarcoidosis. Six patients had radiological evidence of a retrocochlear lesion. CONCLUSION: In taking into account the evidence from the clinical features, audiovestibular testing, radiological investigations, and postmortem findings, it is concluded that the audiovestibular manifestations of sarcoidosis are likely to be primarily a result of vestibulocochlear nerve neuropathy.