Irene Battel

Background: Meals are central to daily life, health, and social participation, yet their safety and enjoyment can be compromised in people with oropharyngeal dysphagia (OD). Despite the broad impact of OD on physical and psychosocial well-being and daily functioning, structured guidance for comprehensive mealtime management in clinical practice is lacking. To address this gap, a set of expert consensus-based “Do’s and Don’ts” covering four meal-related domains was developed. Methods: A modified Delphi consensus study promoted by the Italian Society of Deglutology involved a multidisciplinary panel of 53 experts in OD and related disciplines. Experts developed “Do” and “Don’t” statements across four domains: nutrition-focused diet prescription, meal preparation, mealtime experience, and patient and caregiver education. After panel conveners’ review, 61 statements underwent two rounds of online voting using a 3-point ordinal scale plus an additional option ‘unable to express an opinion’. Consensus was predefined as ≥75% agreement. Statements were revised between rounds based on participants’ comments to ensure clinical accuracy and practical applicability. Results: The response rate was 85% for Round 1 and 97.8% for Round 2. After Round 2, 57 of 61 statements (93.4%) reached the consensus threshold (≥75% agreement). Conclusions: Mealtime management in OD should be individualized and person-centered, balancing swallowing safety, nutritional requirements, quality of life, and enjoyment of eating. Management should extend beyond compensatory strategies alone to include the social and relational dimensions of meals. Active involvement and education of patients and caregivers are essential to support therapeutic adherence and daily implementation of recommendations. Interprofessional collaboration and multimodal educational strategies are crucial to ensuring a coordinated, safe, and effective nutritional approach to OD care.

Cochrane Rehabilitation and the World Health Organization (WHO) Rehabilitation Programme have collaborated to produce four Cochrane overviews of systematic reviews synthesizing evidence from health policy and systems research (HPSR) in rehabilitation. Each overview focuses on one of the four HPSR pillars identified by the Cochrane Effective Practice and Organisation of Care (EPOC) taxonomy: delivery, financial, and governance arrangements; and implementation strategies. This overview addresses delivery arrangements, which Cochrane EPOC defines as how health services are organized and delivered, including who provides care, how care is coordinated and managed, and where services are provided. This overview aimed to synthesize current evidence on delivery arrangements in rehabilitation from an HPSR perspective. Our series of four overviews has the following overarching objectives. • To offer a broad synthesis of existing evidence on health policy and systems interventions' effects. • To direct end-users, including policymakers, towards systematic reviews that may address their health policy questions. • To identify current research gaps and set priorities for future primary HPSR. • To pinpoint needs and priorities for new evidence syntheses where no reliable, up-to-date systematic reviews currently exist. We searched Epistemonikos Health Systems Evidence databases and EPOC Group systematic reviews with no language limitations to identify reviews published between 2015 and 17 November 2024. We included Cochrane systematic reviews (CSRs) and non-CSRs of randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSIs) evaluating the effectiveness of health policy and systems interventions for rehabilitation in health systems, specifically related to delivery arrangements as defined in the EPOC taxonomy. All four overview teams screened reviews and extracted data. We used AMSTAR 2 to critically appraise the reviews, and we analyzed the results descriptively. We included 25 systematic reviews. Three overlapped, and for 17 the AMSTAR 2 rating was low or critically low confidence. Five systematic reviews (2 CSRs and 3 non-CSRs) contributed to our synthesis. Most outcomes focused on patients, caregivers, or service use (e.g. access to rehabilitation). Equity-related outcomes were absent, and quality of care, adverse events, and our important outcomes were rarely reported. Below, we report the results of three of the five reviews judged to have moderate to high confidence for our outcomes of interest, in which authors conducted meta-analysis and assessed the certainty of the evidence. Who provides care One review analyzed advanced practice physiotherapy (APP) models, which may result in little to no difference in health-related outcomes measured by the Pain Disability Index and EuroQol 5-Dimension questionnaire after the intervention, compared with usual care in adults with spinal pain (standardized mean difference [SMD] 0.05, 95% confidence interval [CI] -0.32 to 0.42; 2 studies, 225 participants; low certainty). Information and communication technology We included two reviews in this category. One compared telerehabilitation with usual care in older adults, finding that telerehabilitation may have little or no effect on quality of life after seven to 20 weeks (SMD -0.09, 95% CI -0.23 to 0.40; 3 studies, 179 participants; low certainty). There was very low-certainty evidence on mobility after seven to 26 weeks (SMD 0.63, 95% CI -0.25 to 1.51; 5 studies, 302 participants), strength after 12 and 26 weeks (SMD 0.73, 95% CI -0.10 to 1.56; 4 studies, 226 participants), and balance after seven to 26 weeks (SMD 0.40, 95% CI -0.35 to 1.15; 3 studies, 199 participants). Another review on stroke survivors living in the community found that telerehabilitation compared with usual care probably has little or no effect on independence in activities of daily living (ADL) after 24 weeks (SMD 0.00, 95% CI -0.15 to 0.15; 2 studies, 661 participants; moderate certainty), self-reported quality of life after six to 24 weeks (SMD 0.03, 95% CI -0.14 to 0.20; 3 studies, 569 participants; moderate certainty), and depression after six to 24 weeks (SMD -0.04, 95% CI -0.19 to 0.11; 6 studies, 1145 participants; moderate certainty); and may have little or no effect on upper limb function after 12 weeks (SMD 0.33, 95% CI -0.21 to 0.87; 2 studies, 54 participants; low certainty) and mobility after six weeks (mean difference 0.01, 95% CI -0.12 to 0.14; 1 study; 144 participants; low certainty). This review also compared telerehabilitation with in-person rehabilitation and found that there may be little to no difference in independence in ADL, measured with the Modified Barthel Index at four to 12 weeks (MD 0.59, 95% CI -5.50 to 6.68; 2 studies, 75 participants; low certainty); balance, measured with the Berg Balance Scale at four to 12 weeks (MD 0.48, 95% CI -1.36 to 2.32; 3 studies, 106 participants; low certainty); and upper limb function, evaluated with the Fugl-Meyer Assessment (Upper Extremity) four weeks after intervention (MD 1.23, 95% CI -2.17 to 4.64; 3 studies, 170 participants; low certainty). Current evidence on delivery arrangements in rehabilitation is limited, mostly of low certainty, and derived from high-income countries. Reviews covered five EPOC categories, but reliable evidence for our outcomes of interest was available for only two categories. Most evidence was on telerehabilitation. Compared with usual care, APP models may have little to no effect on health outcomes in adults with spinal pain. In people with stroke, telerehabilitation compared with usual care probably has little or no effect on independence in daily living, quality of life, and depression, and may have little to no effect on upper limb function and mobility. Compared with in-person care, telerehabilitation may have little to no effect on ADL, balance, and upper limb function. Further...

Background Cochrane Rehabilitation and the World Health Organization (WHO) Rehabilitation Programme have collaborated to produce four Cochrane overviews of systematic reviews that synthesize current available evidence from health policy and systems research (HPSR) in rehabilitation. Each overview focuses on one of the four pillars of HPSR as identified by the Cochrane Effective Practice and Organisation of Care (EPOC) taxonomy: delivery arrangements, financial arrangements, governance arrangements, and implementation strategies. This overview examined implementation strategies, defined by EPOC as interventions designed to bring about changes in healthcare organizations, the behavior of healthcare professionals, or the use of health services by healthcare recipients. Objectives This overview aimed to synthesize current evidence on implementation strategies in rehabilitation from a health policy and systems research (HPSR) perspective. Our series of four overviews have the following overarching objectives. • To offer a broad synthesis of the existing evidence on health policy and systems interventions' effects. • To direct end‐users, including policymakers, towards systematic reviews that may address their health policy questions. • To identify current research gaps and set priorities for future primary HPSR. • To pinpoint the needs and priorities for new evidence syntheses where no reliable, up‐to‐date systematic reviews currently exist. Methods We searched the Epistemonikos database, the Health Systems Evidence database, and EPOC Group systematic reviews to identify reviews published between 1 January 2015 and 17 November 2024. We applied no language limitations. We included Cochrane and non‐Cochrane systematic reviews of randomized controlled trials (RCTs) and non‐randomized studies of interventions (NRSIs) that evaluated the effectiveness of health policy and systems interventions for rehabilitation in health systems, specifically related to implementation strategies as defined in the EPOC taxonomy. All four overview teams collaborated to screen reviews and extract data. We used AMSTAR 2 to critically appraise the quality of the reviews. Results were analyzed descriptively and are based on reviews with ratings of high‐to‐moderate confidence, with low‐confidence reviews reported separately. Main results We identified 7882 systematic reviews, of which 15 met our inclusion criteria. Three reviews overlapped substantially with other reviews, and eight received low‐ or critically low‐confidence ratings. Ultimately, four moderate‐ to high‐confidence reviews contributed to the synthesis; two were Cochrane systematic reviews. Most primary studies were from high‐income countries; none were from low‐income countries. Most strategies targeting healthcare professionals (e.g. guideline dissemination, interactive workshops, opinion leaders, audit and feedback) or healthcare recipients (e.g. structured monitoring, telehealth support, counseling, motivational interviewing) included more than one component. Strategies targeting healthcare recipients' use of health services in cardiac rehabilitation may show small benefits in terms of participation (enrollment, adherence, completion), but effects on other outcomes are uncertain. The effects of strategies targeting older healthcare recipients via telehealth are uncertain. Strategies targeting healthcare professionals may have little to no effect on professional or patient and carer outcomes in stroke rehabilitation. For musculoskeletal conditions, there were no evidence‐certainty ratings, so intervention effects are unclear. We found no reviews of strategies targeting health service organizations or specific types of rehabilitation practice. The evidence certainty was generally low; evidence of adverse events was missing or uncertain; and reporting on organizational, implementation, economic, and equity outcomes was scarce. Authors' conclusions Current evidence on implementation strategies in rehabilitation is limited, mostly of low certainty, and derived from high‐income countries. Multicomponent, patient‐targeted strategies may modestly improve cardiac rehabilitation participation, but effects in other areas remain uncertain. Further high‐quality research using well‐defined frameworks is needed, especially in low‐ and middle‐income countries, to identify effective strategies and evaluate organizational, implementation, and equity outcomes. Future Cochrane overviews of reviews in HPSR should consider including a broader range of study designs, such as observational, qualitative, and mixed‐methods evidence, to better capture evidence on implementation strategies in rehabilitation. Funding This Cochrane review was funded by the Italian Ministry of Health (Ricerca Corrente). The funder played no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Registration The protocol was first published in the European Journal of Physical and Rehabilitation Medicine online on 27 January 2025. The manuscript was received on 11 November 2024 and was accepted on 26 November 2024. Protocol: DOI 10.23736/S1973‐9087.24.08833‐6.

Introduction Cochrane Rehabilitation recently developed a new definition of rehabilitation for research purposes with 80 global stakeholders, aiming to support and improve the production and reporting of primary and evidence synthesis rehabilitation studies. Objective 1. To compare how Cochrane Systematic Review (CSR) authors describe rehabilitation interventions against criteria derived from the new rehabilitation definition, and 2. To assess limitations or gaps in the rehabilitation definition. Methods: We analysed a sample of 124 randomly-selected CSRs tagged in the Cochrane Rehabilitation database. We converted the Cochrane Rehabilitation definition for research purposes into a set of 13 criteria grouped in the four PICO elements and searched for the corresponding key elements in each CSR. We verified if and where in the review these elements were present. Two reviewers rated each CSR, resolving disagreements a third author when needed. We analysed the findings using descriptive statistics. Results Eight (6.5%) out of 124 CSRs met all rehabilitation definition criteria. These were CSRs that investigated the effects of complex rehabilitation intervention. Three (2.4%) CSRs did not meet any PICO elements. Overall, the ”Intervention-General” element and disability criterion had the highest prevalence of absent and unclear reporting, while the “Intervention-Specific” and “Outcome” elements were most frequently reported, albeit not in the “Description of the intervention” section of the review. Discussion This study showed that the key elements of the new rehabilitation definition are almost always reported in publications identified as rehabilitation review, but not always consistently or clearly. The disability criterion was frequently unreported given that the main aim of rehabilitation is reducing disability. Also, the main elements of rehabilitation were frequently not reported. We did not find important gaps in the new definition. All elements of the new definition should be considered when writing review protocols and designing strategies and tools on rehabilitation topics.

Introduction: In 2022, Cochrane Rehabilitation developed a new definition of rehabilitation for research purposes with 80 global stakeholders, aiming to support and improve the production and reporting of primary and evidence‐synthesis rehabilitation studies.Objective: To compare how Cochrane Systematic Review (CSR) authors describe rehabilitation interventions against criteria derived from the new rehabilitation definition. To assess limitations or gaps in the rehabilitation definition. Methods: We analysed a sample of 124 randomly selected CSRs tagged in the Cochrane Rehabilitation database. We converted the Cochrane Rehabilitation definition for research purposes into a set of 13 criteria grouped according to the four PICO elements and searched for the corresponding key elements in each CSR. We verified if and where in the review these elements were present. Two reviewers rated each CSR, resolving disagreements with a third author when needed. We analysed the findings using descriptive statistics.Results: Eight (6.5%) of 124 CSRs met all rehabilitation definition criteria. These were CSRs that investigated the effects of complex rehabilitation interventions. Three (2.4%) CSRs did not meet any PICO elements. Overall, the “Intervention‐General” element and disability criterion had the highest prevalence of absent and unclear reporting, while the “Intervention‐Specific” and “Outcome” elements were most frequently reported, albeit not in the “Description of the intervention” section of the review.Discussion: This study showed that the key elements of the new rehabilitation definition are almost always reported in publications identified as rehabilitation reviews but not always consistently or clearly. The disability criterion was frequently unreported, given that the main aim of rehabilitation is reducing disability. Also, the main elements of rehabilitation were frequently not reported. We did not find important gaps in the new definition. All elements of the new definition should be considered when writing review protocols and designing strategies and tools on rehabilitation topics.

An abstract is unavailable. This article is available as a PDF only.

Background: Studies suggest swallow intervention programmes that incorporate visual biofeedback and motor programming principles can improve swallowing and quality of life for people with idiopathic Parkinson's disease (IPD) and dysphagia. Few studies have examined outcomes using instrumentation.Aims: Using fibreoptic endoscopic examination of swallowing (FEES), this study examines the effectiveness of a neurorehabilitation intervention involving biofeedback via surface electromyography (sEMG) to improve swallowing in people with IPD, and to explore the feasibility of the intervention approach.Methods & Procedures: We recruited 12 participants with IPD and dysphagia. A total of 10 completed the study. Intervention was delivered for 1 h per day, 5 days per week, for 4 weeks (20 h). Swallowing tasks using sEMG biofeedback incorporated principles of motor learning and neuroplasticity. Instrumental and non‐instrumental assessment, including quality‐of‐life measures carried out at four different time points (two pre‐treatment and two post‐treatment). The final assessment was at 3 months post‐intervention.Outcome & Results: Statistically significant improvement (p < 0.05) in oral intake methods (95% confidence interval (CI) = 4.70–5.50) and in pharyngeal residue from saliva (95% CI = 2.14–3.15) and solids (95% CI = 2.4–3.5) post‐intervention were confirmed using FEES with improvements at 3 months. The intervention protocol was well tolerated. Participants reported positive change in saliva control and duration of mealtimes as well as unanticipated improvements in voice and cognitive attention.Conclusions & Implications: An intensive neurorehabilitation with biofeedback shows positive effects in improving swallow function in IPD. This protocol is feasible with amendments to inform a larger clinical trial.What this paper adds: What is already known on the subject: Biofeedback has positive effects on increasing swallowing function and quality of life in people with IPD and dysphagia. sEMG is the most common method used to deliver swallowing biofeedback in this population. The quality of the evidence on the intervention, based on findings from a recent systematic review, is low. Included studies in this review were heterogeneous in terms of type and frequency of biofeedback, study design and outcome measures. The majority of outcome measures were subjective and higher quality studies to examine the efficacy of biofeedback using sEMG are needed. What this study adds: Recognizing the limitations of earlier studies, this within‐subject feasibility study examined the efficacy and effectiveness of an intensive biofeedback intervention using sEMG in a sample of people with dysphagia and IPD. Valid and reliable outcome measures were used and repeated after a 3‐month period. The feasibility of the methodological approach was also tested and a qualitative component was included in the study. Positive findings were evident. Qualitative information added new perspectives and provided direction for new outcomes to be included in future studies. This study helps to inform further research trials as well as clinical practice. Clinical implications of this study: This intensive intervention using principles of neuroplasticity and motor programming with sEMG biofeedback led not only to positive swallowing outcomes but also to unexpected benefits such as improved voice production and general attention skills. No adverse events were reported. Improvement in function was retained at 3 months post‐intervention. Despite the small sample size, participants described the benefits of the treatment, and enjoyed sEMG biofeedback tasks, especially using an sEMG game mode. This suggests that intensive biofeedback not only improved swallowing but also was acceptable to these participants. This intensive protocol has merit and is worth considering further in clinical practice.

Spinal and bulbar muscular atrophy (SBMA) is a late onset, X-linked neuromuscular disease. Bulbar symptoms are a main characteristic of the disease but a tool for their clinical evaluation still does not exist. The aim of this study was to design and test a new scale (6-K-scale) for evaluation of bulbar function in SBMA.

Outcome measures and scales translated into other languages according to conventions are important for international clinical research in dysphagia. Typically, assessments and scales are translated locally without cultural adaptation and validation. The Functional Oral Intake Scale (FOIS) is widely used in dysphagia research and clinical practice in English-speaking countries. Nevertheless, it is not available in Italian. The aim of this study was to translate the FOIS into Italian and validate it, allowing the FOIS to be available to speech-language pathologists (SLPs) and clinicians working with individuals with dysphagia in Italy. The FOIS was translated following 5 stages of cross-cultural adaptations. This involved (1) translation from English to Italian, (2) synthesis and solution of discrepancies between translators, (3) back-translation from Italian to English, (4) expert revisions, and (5) pretesting. To validate the translated scale, 10 SLPs were recruited from 3 different facilities across Italy. A questionnaire containing similar information to the FOIS and the Italian version of the FOIS (FOIS-It) was completed by SLPs for 227 people with dysphagia; the correlation was high (intraclass correlation coefficient [ICC] = 0.99). Interrater reliability, calculated for 2 blinded SLPs completing scales for 30 patients, was excellent (ICC = 0.99). In conclusion, the FOIS-It is now available for use in clinical practice and research studies in Italy.

Article: Efficacy of botulinum toxin type-A and swallowing treatment for oropharyngeal dysphagia recovery in a patient with lateral medullary syndrome - European Journal of Physical and Rehabilitation Medicine 2017 October;53(5):798-801 - Minerva Medica - Journals