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    Stroke - a disease for all people, of all ages

    Stroke is one of the most widespread diseases in the world and can strike at any time in life, from newborn to the elderly. In the UK someone suffers a stroke every 5th minute, which totals to more than 100,000 people every year. [15] Around 50% require speech and language therapy, and suffer swallowing difficulties dysphagia as a result of their stroke [15], but 20% regain their ability naturally during the first three weeks after the event. The remaining 30% or more have severe long-term eating- and swallowing difficulties. [2, 3, 4] Statistics suggest however, an underestimate of the actual incidence: possibly because of missed diagnosis and the absence of validated examination methods. [2] Recent research also shows that every individual that suffers dysphagia after a stroke will also suffer facial paralysis central facialis pares. [5, 6]

    In the UK, there are more than 1.2m stroke survivors [15], many of whom have residual swallowing difficulties and who may not be receiving treatment for this condition. Yet, research shows that although it might have been several years ago that the stroke ocurred, you can still regain a normal swallowing ability and significantly improve your facial paralysis through treatment with IQoro®. [5, 7, 8] IQoro® is a new and unique neuromuscular treatment method that requires just 30 seconds’ exercise, three times per day.

    In this section, we explain how stroke occurs, how you can quickly tell if someone has been affected, what problems can arise after the onset and how some of these weaknesses can be improved through training with IQoro®.

     

     

    What is a stroke?

    Stroke is an umbrella term for brain infarction: a blockage in the in the brain, or cerebral haemorrhage.

    In England, Wales and Northern Ireland the average age for men to have a stroke is 74 and the average age for women to have a stroke is 80. In Scotland, the average age for men to have a stroke is 71 and the average age for women to have a stroke is 76. Men are at higher risk of having a stroke at a younger age than women, but there are a greater number of stroke related deaths in women because they live longer than men. Around a quarter of strokes happen in people of working age. [15]

    Because these people are often in the middle of their careers and even possibly have small children, the consequences are magnified many times. People of working age who have had a stroke are two to three times more likely to be unemployed 8 years after their stroke. [15]

    The most common reason for stroke is a background heart and circulation problem. In both varieties of stroke the brain suffers from oxygen deficiency which causes nerve death in the brain in the affected areas.
     

    Ischaemic stroke

    In an ischaemic stroke, a blood clot blocks the blood vessel, causing the supply of blood and oxygen to the brain and the cells to be stopped. A common reason for this is hardening of the arteries which makes the blood vessels more and more narrow until in the end the blood cannot pass normally. About 85% of all strokes in the UK are ischaemic. [15]
     

    Haemorrhagic stroke

    In a cerebral haemorrhage, a blood vessel in the brain, or on its surface, bursts. This can be due to an external trauma usually caused by subdural or extramural haematomas, the anuerysms bursting causing subarachnoid haemorrhage, or a so-called aneurysm caused by weakened blood vessels in the brain bursting due to hypertension. In either case the bleeding creates a leakage of blood and a pressure that injures the brain. About 15% of all strokes in the UK are haemorrhagic. [15]

     Read more here: “Trauma to the head and neck region”.
     

    TIA

    A TIA, Transient Ischaemic Attack, is a small clot or attack which usually dissolves within 24 hours. It should, however, be seen as a warning that the blood supply is not working properly, but not so degraded that an injury was caused. The symptoms are the same as for a stroke but exist only for a short period, from a few minutes to a few hours. 46,000 people in the UK have a first incidence of TIA every year, and approximately 15% of ischaemic strokes are preceded by a TIA.[15] 

     

     

    Common conditions after stroke
    – dysphagia and central facial paralysis

    Because all our bodily functions are controlled by the brain, the symptoms will vary depending on where in the brain the stroke occurred and the degree and scope of the damage. The symptoms will be both physical and psychological, and include impairment of the cognitive functions. These will be either obvious or invisible to relatives, e.g. swallowing difficulties dysphagia, facial paralysis, speech difficulties, impaired bodily functions, disturbed memory patterns, concentration deficit and learning difficulties.

    During the early months after the stroke attack a degree of natural recovery usually takes place. It should be emphasised that it is never too late to begin a rehabilitation programme and that improvements can be achieved long after the stroke. [7, 8, 10, 11, 13]
     

    Swallowing difficulties - dysphagia

    Around 50% suffer swallowing difficulties dysphagia as a result of their stroke, but 20% regain their ability naturally during the first three weeks after the event. It is important to know that the quicker rehabilitation starts, the more the self healing is accelerated.

    Residual dysphagia problems affect at least 30% of the 1.2 million stroke survivors living in the UK and Northern Ireland, which is equivalent to 360,000 people. [2, 3, 4, 15] To this, can be added the many patients untreated because of a lack of access to optimal treatment, or because the problem was not discovered. In research, people that have had severe swallowing difficulties up to 10 years after their attack have been included in the studies referenced on this website . This scientific research shows that you can start your treatment at any time with equally positive outcomes. [5, 7, 8] Now it is possible to get optimal treatment.

    Swallowing difficulties after a stroke are often a problem with swallowing liquids and thin drinks. Often this manifests itself in that the liquid ’goes down the wrong hole’ (food aspiration) which in its turn can lead to pneumonia. Good oral hygiene is therefore of great importance to inhibit bacteria coming into the lungs as a result of misdirected swallowing. Poor oral hygiene is actually the most common cause of pneumonia – not the misdirected swallowing in itself.

    Swallowing problems vary and can affect some, or all, phases of the swallowing process.

     Read more about different types of dysphagia here.

     Read more about the swallowing process here.
     

    Common symptoms of dysphagia after stroke:

    • Difficulty in swallowing liquids.
    • Food, saliva and drinks leak out of the mouth.
    • Drooling.
    • Inability to transport the food backwards to the pharynx, and to stop liquids running uncontrolled down into the throat and the airways, causing coughing as a result.
    • Gurgling and wheezy voice.
    • Coughing and suffocation attacks at mealtimes.
    • Pneumonia, bronchitis.
    • Inability to open the mouth, close the mouth or chew.
    • Speech difficulties.
    • Impaired movement or feeling in the face, mouth and throat.
    • Food or drink leaking up to the nose.
    • Weight loss.
    • Food fragments coming up to the mouth several hours, or even a day, later.
    • A need to spit out saliva that cannot be swallowed away. An accumulation of saliva in the mouth also makes it difficult to speak properly.
    • Extended mealtimes – must eat slowly and cannot take large bites.
    • Avoiding social gatherings.

    If it is difficult even to swallow food of firm consistency, not just liquids, an earlier hiatus hernia can be the reason, in combination with reduced swallowing ability after stroke. Hiatus hernia affects one in 10 persons that are otherwise fit, and is therefore the most common cause of dysphagia.

    Read more here on hiatus hernia and its common symptoms.
     

    Facial paralysis central facialis pares 
    - affects all that suffer from dysphagia after stroke

    100% of those that suffer from swallowing difficulties after stroke have central facial paralysis in the lower quadrant of the face on the opposite side to the brain hemisphere which is damaged. Often one can see that one side of the mouth is hanging a little and and it doesn’t rise quite as much as the other when smiling.

    According to research, 74% also have impaired muscle function in one of the face’s two upper quadrants, and 52% have reduced function in all four quadrants. [5- 8] This is new research which is important to take note of in order to be able to decide the correct individual care plan for a patient after stroke.

     Read more here about the scientific research
     

    Common symptoms of a central facial paralysis dysfunction

    Paralysis in the throat or pharynx will often cause the symptoms described above under the title ”Common conditions after stroke”. We describe below some of the symptoms of central facial paralysis:

    • Crooked or uneven face and stiff facial expression.
    • Drooling or dribbling.
    • Food and drink leak out of the mouth.

    Difficulties with:

    • Switching from the ”o” sound to the ”e” sound and back, vigorously and using distinct lip movements.
    • Squeezing the eyes shut hard, with the same force in both eyes.
    • Raising the eyebrows so that distinct wrinkles appear on the forehead.
    • Puffing up the cheeks for a few seconds without air leaking out through the nose or mouth.
    • Licking quickly and smoothly around the lips several times in succession.

    To treat both swallowing difficulties and central facial paralysis at the same time read more about treatment with IQoro®. IQoro® is a new and unique neuromuscular treatment method that requires just 30 seconds’ exercise, three times per day.

     

     

    Other functional impairments after a stroke

    Paralysis of some parts of the body and pharynx

    Paralysis to varying degrees in arms and legs, often only on one side of the body, is common after stroke. Paralysis can manifest itself as anything from total paralysis to the patient’s feeling numbness or muscle weakness in one part of the body, which affects balance and postural control.

    Paralysis of this severity can also cause paralysis in the tongue, which leads to difficulties with speech, and paralysis in the pharynx can result in the patient being unable to eat via the mouth at all. The paralysis of the pharynx often causes the symptoms described above under, ’Common symptoms of dysphagia after stroke’.
     

    Aphasia – communication difficulties

    This means difficulties in talking, but can also mean a difficulty to understand, read, write and count despite the patient’s intellect not being impaired. Collectively this is called aphasia.

    Read more here on how you can train the musculature in your face and mouth to improve your ability to form sounds correctly.
     

    Hidden functional impairments

    Other, less obvious, functional impairments can be tiredness, poor memory, difficulties in concentrating, a problem with doing more than one thing at same time; for example eating at the same time as the TV is on. Other symptoms can be dizziness, poor balance and mood swings. In many cases these hidden impairments lead to depression because social contacts suffer.

     

     

    Treatment – dysphagia, paralysis in the face and pharynx

    After suffering a stroke you will meet many different professionals within the healthcare sphere: doctors, speech therapists, dentists, physiotherapists and others. It is important to treat and stimulate the whole body and to work at exercising: even when it is difficult. Stick with it in the early days! This is important because discipline now will ease your return to a normal everyday life.
     

    Treatment with IQoro® after stroke

    IQoro® is a new and unique neuromuscular treatment method that requires just 30 seconds’ exercise, three times per day. Because the training sessions are short and effective it is an exercise regime that you can keep to, even on those days when perhaps your resolve is low. The treatment is scientifically proven to have a lasting effect on swallowing difficulties, paralysis of the face or pharynx after stroke. Note that it is never too late to start your IQoro® treatment. You can read below that, despite not beginning for one to ten years after the event, the treatment has been equally effective for all patients. [7, 8, 11]

    IQoro® acts on, and regenerates, the entire swallowing process. It stimulates the sensory nerves in the mouth, and by doing this reaches the brain’s control system for the swallowing process, which is closely linked to the control systems for other bodily functions, including breathing, the ability to make speech sounds, facial expression, postural control [13], stomach and intestine functions, and more. This explains why exercising with IQoro® can have a positive effect on so many different functions.

     After 5 to 13* weeks’ training with IQoro® you will see a lasting positive effect on:

    • Swallowing difficulties, dysphagia.
    • Drooling and dribbling.
    • Paralysis in the throat and face.
    • Weak face-, lip-, jaw- and tongue musculature.
    • Postural control.

    * The training period can vary depending upon the exact nature of the condition.
     

    Swallowing capacity

    97% of stroke survivors using IQoro® are improved, and 71% enjoy a normal swallowing capacity with enduring results after 5 to 13 weeks’ training, according to research. [10, 11]
     

    Central facial paralysis

    At the same time, training with IQoro® gives a significant improvement of paralysis in all four quadrants of the face. [7] In the best case the paralysis disappears entirely, or is otherwise just improved giving a more symmetrical face and increased control. Because everyone with dysphagia after stroke also has a central facial paralysis, exercising with IQoro® will improve both functions.
     

    Positive effect on speech – the ability to make speech sounds

    IQoro® can also have a positive effect on speech difficulties as the exercise strengthens the musculature in the lips, cheeks, tongue and throat which are important to make speech sounds. This can help with communication difficulties, for example slurred speech, or in some cases aphasia after stroke.
     

    Nutrition via PEG - it doesn’t have to be forever

    Research, and long clinical experience, have shown that feeding directly into the stomach through a PEG (Percutaneous Endoscopic Gastrostomy) does not always have to be a solution for life. The study ”Effect of IQoro® training on impaired postural control and oropharyngeal motor function in patients with dysphagia after stroke” included five individuals with PEGs, of which all five could eat and drink via the mouth when the 13 weeks IQoro® training came to an end. Further, four of the five PEGs could be removed at this point, the other being removed at a later date. At a long-term follow-up visit 18 months later, without continued training in the interim, it could be concluded that the cure was still in effect. [13]

    Even in those cases where the PEG cannot be replaced for different reasons, it is still of great importance to maintain the muscle functions which are involved in the entire swallowing process: from mouth to stomach. This is to optimise the stomach’s ability to receive normal amounts of nutrient and to avoid long, drawn-out mealtimes - which can take longer than 30 minutes via a PEG.

    Training with IQoro® before being fed via a PEG, and stimulating the taste function – perhaps with a net of varying tastes and consistencies in the mouth - during the PEG session, contribute to stimulating and maintaining the muscle functions that are involved in the swallowing process. Taken together, these actions can improve the conditions for PEG continuing to work.

     See here how you train with IQoro®.
     

    Exercising in the cases of significant paralysis or reduced mobility

    Stroke victims with significant paralysis or reduced mobility - for example in the arms - can still make use of the IQoro® methodology with good results. This is achieved with the help of a so-called assisted ‘jaw grip’ provided by a health worker or a relative.

     Even if you have difficulty in closing your lips - See here how you can exercise with IQoro®.

     You may even need assistance in exercising - See here.
     

    How soon can I see the results?

    After 5 to 13 weeks is the short answer, that is to say from one to few months. And you will see that the results endure for a long time according to our long-term follow-up studies [7, 8, 10, 13] The period that you need to exercise can be longer if there are other conditions that affect your health.

    For example it is common that stroke aggravates an earlier hiatus hernia, which until the stroke, may have only caused milder symptoms. In such a case a training period of 6 to 8 months or longer may be needed.
     

    Results with IQoro® - equally effective

    whether you start immediately or many years later

    Irrespective of when your stroke attack occurred, it is never too late - according to research – to begin your IQoro® treatment for problems like swallowing difficulties and paralysis in the pharynx and face. Despite treatment not beginning for one to ten years after the event, the treatment has been equally effective for these late-start patients as it was for those that began exercising immediately just 1 to 4 weeks after the stroke event. [7, 8, 10, 11, 13] Further, neither patient age, nor sex, has any effect on the result [11]. This means that even if you have suffered with your problem for many years since your stroke you still have the same possibility for improvement.
     

    The correct treatment immediately speeds rehabilitation.

    Nevertheless, getting the right treatment as soon as possible is to be recommended for a quicker recovery, early discharge from hospital and return to a normal life as smoothly as possible. A life with, for example, the ability to show your emotions on your face, to smile, to eat together with others, to participate in social events, and - in time - to return to work.

     See here how you exercise with IQoro®.  
     

    When can training start?

    Exercise with IQoro® can be introduced as soon as the most critical phase has passed, which is usually within 1 to 2 weeks. After stroke a person can be more sensitive in the face and mouth. If this is the case, let the patient first become acquainted with his or her IQoro® merely by touching and tasting it.
     

    Tips before you train

    Create a routine with three exercise sessions per day, preferably before mealtimes in order to prepare the swallowing process, and in this way to enjoy an increased effect of the training. In the first sessions the ’pulling’ motion described in ’How to train with your IQoro®, can be shortened to just a couple of seconds, and then increased successively to a maximum of 10 seconds per pull. In cases of extreme sensitivity it can be enough from the beginning to merely place the IQoro® behind the lips.

    Other tips for introducing the training regime can be to give a pleasant scalp or face massage before the exercise starts. This relaxes any possible tension and associates the training with a positive event. In all cases the training should be designed for the individual’s needs. Initially a stroke patient will need a little assistance with the training, especially if he has difficulties in closing his lips or has reduced mobility in the arms. But it is important that the patient does as much as he can himself, only providing that he can close his lips tightly against the flat handle for at least five seconds.

     See here how you exercise with IQoro®.  

     

     

    Modified food and liquids

    – until the full effect of the treatment has been realised

    A person who has suffered a stroke can have one or a combination of several different types of dysphagia diagnoses. The treatment time with IQoro® is short: from one to a few months, but even so during this period it is important to keep up nourishment to be able to continue with rehabilitation.

    For each of the different types of dysphagia that a stroke survivor may have, there are useful tips on what you should consider in order to take in food and drink to ease the swallowing process.

     Find out more about the different types of dysphagia here.
     

    Pre oral dysphagia – from the plate to the mouth [12]

    Problems in this phase can manifest themselves as motor difficulties with transporting the food from the plate to the mouth, or difficulties in concentrating; which can make the person too tired to manage to eat a sufficient quantity at a mealtime.
     

    Action

    Try to arrange a good sitting position: close to the table, with good support for the back, one arm and the feet. The setting must be calm and relaxed. If one arm and hand are weak, a family member or a carer can help to guide the hand to the mouth, but every attempt should be made to have the patient hold the spoon himself. Nowadays there are tools available to assist in helping those with arms and hands with reduced function, to eat independently. See one example here.
     

    Oral dysphagia – difficulties in chewing and swallowing [12]

    In this phase the problem can be that the tongue is difficult to control and direct. As well as causing speech difficulties this will create problems in the process of manoeuvring food portions backwards to the pharynx, which means that the swallowing reflex will not be triggered. Liquids can easily run into the pharynx before the person tries to swallow and end up in the air pathways with coughing and choking as a result.
     

    Action

    Give smooth, mashed food, purees, or jellied meals that are easier to move around in the mouth. Avoid runny liquids: use a thickening agent. It is also important to not mix food with different consistencies in the same bite. For example, if you eat a bowl of chopped fruit in its syrup or juice, you should eat the fruit chunks and drink the juice separately.
     

    Pharyngeal dysphagia – food
    ends up in the air pathways and nose [12]

    Paralysis of the pharynx musculature causes food and saliva to remain in the lower part of the pharynx. After a swallow, the air pathway is opened again and the residue remaining in the pharynx risks emptying into the air pathways. The voice becomes gurgling and unclear. The patient often coughs through mealtimes.
     

    Action

    Avoid tilting the head backwards or eating when lying down. Instead, sit upright, leaning slightly forwards and with your chin down towards your chest. Breathe deeply and hold your breath before swallowing. After each swallow, cough to clear your throat and then breathe out. Pay attention to oral hygiene in order that any material that does leak down to the lungs does not cause pneumonia.

     

     


    Stroke - a disease of the people

     

     

     

     

    Bengt Kedner

    FIVE STROKES AND ONE IQoro® LATER

    For Bengt Kedner, who has been afflicted by stroke five times, the IQoro® neuromuscular training device, delivers quality of life in a daily battle with his swallowing difficulties and snoring. Most recently, his mobility in his right-hand side has been restored.

    Bengt Kedner has been severely tested. After his first stroke in 1997 he has been afflicted by four more in the space of a few years. If you ask him how he’s managed to pick himself up time after time he says...
     

     Read patients' own stories here

     

     

     

     

    Eine Sellman

    ‘Never ill’ Eine struck by stroke

    Back in 2011 Eine fell so badly that she struck her head and suffered a stroke. That led to a problem with speech, balance and swallowing difficulties. Thanks to a new treatment method however, Eine could soon begin to speak and swallow again, and today is fit again.

    Eine and Lars Sellman work as a team, finishing each others’ sentences and agreeing with each other. The atmosphere around them is electric and you can’t miss the warmth between them. The couple had left the hurly burly of the big city for a peaceful village in the countryside.
     

     Read patients' own stories here


    Text by: Dr. Mary Hägg, Doctor of Medicine, Post-doctoral researcher at Uppsala University specialising in orofacial medicine, Head of Department at the Speech and Swallowing Faculty: Ear, Nose and Throat Clinic at Hudiksvall Hospital, Sweden. Registered Dentist. In cooperation with MYoroface. October 2016
     

    (Translation from the original Swedish text by T.W.Morris, MYoroface.)


    Sources:

    1. Stroke - Riksförbundet,(2015), Vad är stroke?, http://www.strokeforbundet.se/show.asp?si=442&go=Vad%20%E4r%20stroke

      (English translation, “What is a stroke?”)
       

    2. Stockholms läns landsting, Fokusrapport dysfagi, 2005, ISBN 91-85211-00-1

      (English translation, “Focus report dysphagia”)
       

    3. S. Broadley, A. Cheek, S. Salonikis et al., Predicting prolonged dysphagia in acute stroke: the Royal Adelaide Prognostic Index for Dysphagic Stroke (RAPIDS), Dysphagia, vol. 20, no. 4, pp. 303–310, 2005.
       
    4. R. T. Sorensen, R. S. Rasmussen, K. Overgaard, A. Lerche, A. M. Johansen, and T. Lindhardt, Dysphagia screening and intensified oral hygiene reduce pneumonia after stroke, Journal of Neuroscience Nursing, vol. 45, pp. 139–146, 2013.
       
    5. Hägg M.,Tibbling L. Four-quadrant Facial Function in Dysphagic Patients after Stroke and in Healthy Controls. Neurology Research International Volume 2014, Article ID 672685, 5 pages, http://dx.doi.org/10.1155/2014/672685
       
    6. Cumhur E., Gaye E., et al. Orbicularis oculi muscle activation during swallowing in humans. Exp Brain Res (2013) 224:79–91 , DOI 10.1007/s00221-012-3290-6
       
    7. Hägg M., Tibbling L. Effect of oral IQoro® and palatal plate training in post-stroke, four-quadrant facial dysfunction and dysphagia: A comparison study. Acta Otolaryngol. 2015 Sep;135(9):962-8. doi:10.3109/00016489.2015.1042043. Epub 2015 May 7. PMID: 25947252
       
    8. Hägg MK., Tibbling LI. Effects on facial dysfunction and swallowing capacity of intraoral stimulation early and late after stroke. NeuroRehabilitation. 2015;36(1):101-6. doi: 10.3233/NRE-141197. PMID: 25547771
       
    9. Hjärt- och Lungfonden, (2015), Hjärtrapporten 2015 – En sammanfattning av hjärthälsoläget i Sverige, https://www.hjart-lungfonden.se/Documents/Rapporter/Hj%C3%A4rtrapporten_2015_web.pdf

      (English translation, “Heart report 2015 – A summary of heart health status in Sweden”)

    10. Hägg M, Tibbling L. Longstanding effect and outcome differences of palatal plate and oral screen training on stroke-related dysphagia. The Open Rehabilitation Journal, 2013, 6, pp 26-33.
       
    11. Hägg M, Anniko M. Lip muscle training in stroke patients with dysphagia. ActaOto-Laryngologica, 128 (9): pp1027-1033, 2008.
       
    12. Text: Tibbling Grahn, Lita, ÖL, MD, professor emerita.
       
    13. Hägg M., Tibbling L. Effect of IQoro® training on impaired postural control and oropharyngeal motor function in patients with dysphagia after stroke. Acta Otolaryngol 2016; 136 (7):742-748. DOI:10.3109/00016489.2016.1145797 http://dx.doi.org/10.3109/00016489.2016.1145797.
       
    14. Ekberg O, (2011), Röntgendiagnostiska avdelningen, Universitetssjukhuset MAS, Malmö, Normal sväljning inklusive anatomi och fysiologi, (pdf). Hämtad 2015-12-05,
      (English translation:” Normal swallowing including anatomy and physiology”).
       
    15. Stroke association, (2017) State of the nation, Stroke statistics,

      https://www.stroke.org.uk/sites/default/files/state_of_the_nation_2017_final_1.pdf

     

     

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