Oropharyngeal DysphagiaICI20/00117NCT05720871
Treatment of Chronic Post-stroke Oropharyngeal Dysphagia With Paired Stimulation
A study testing rTMS + capsaicin 150μM (natural TRPV1 agonist) and tDCS + capsaicin 150μM (natural TRPV1 agonist) in people with Oropharyngeal Dysphagia and Stroke, run by Hospital de Mataró at 1 site in Spain.
Trial summary
According WHO, oropharyngeal dysphagia (OD) is a prevalent post-stroke (PS) condition involving the digestive system (ICD-10: I69.391) and an independent risk factor for malnutrition and pulmonary infection; and leads to greater morbimortality and healthcare costs and poorer quality of life (QoL). Read more about this study
- Who is it for?
- Ages 18 years and older
- Conditions the study is for
- Oropharyngeal Dysphagia, Stroke, Stroke, Complication
- What is being tested?
- rTMS + capsaicin 150μM (natural TRPV1 agonist) and tDCS + capsaicin 150μM (natural TRPV1 agonist)
- Type of treatment
- Medical device
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 200 participants
- Where
- 1 siteSpain
- Study dates
- 28 Nov 2022to Sep 2025
- Phase
- Interventional
- Are there results?
- None posted in the registry
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 18 years and older
- All sexes
- No healthy volunteers
- Adult, Older adult
Who may be able to join
- Chronic (>3 and <24 months) unilateral hemispheric stroke adult patients.
- Patients with impaired safety of swallow with a penetration-aspiration score (PAS) ≥ 2 with videofluoroscopy (VFS).
- Patient able to follow the study protocol and give the written informed consent.
Who cannot join
- Pregnancy.
- Life expectancy less than 3m or palliative care.
- Neurodegenerative disorder.
- Previously diagnosed oropharyngeal dysphagia (dysphagia not related to stroke).
- Implanted electronic device.
- Epilepsy.
- Metal in the head.
- Participation in another clinical trial in the previous month.
Trial locations and contacts
1 site in 1 country.
Spain1 site, 1 recruiting
- Recruiting
Hospital de Mataró. Consorci Sanitari del Mareme.
Mataró, Barcelona, 08304
Omar Ortega Fernández, PhD, +34 93 7417700 ext. 2284, oortega@csdm.cat
Pere Clavé, MD, PhD, +34 93 7417700 ext. 1046, pclave@csdm.cat
About this study
Official title: Treatment of Chronic Post-stroke Oropharyngeal Dysphagia With Paired Stimulation Through Peripheral TRVP1 Agonists and Non-invasive Brain Stimulation
According WHO, oropharyngeal dysphagia (OD) is a prevalent post-stroke (PS) condition involving the digestive system (ICD-10: I69.391) and an independent risk factor for malnutrition and pulmonary infection; and leads to greater morbimortality and healthcare costs and poorer quality of life (QoL). Currently, OD therapy is mainly compensatory, with low rates of compliance and small benefit, and there is no pharmacological treatment, so new treatments that improve patients' condition are crucial. PS-OD patients present both oropharyngeal sensory and motor deficits, so neurorehabilitation treatments which target both could be optimum. Benefits of paired peripheral sensory stimulation with oral capsaicin and of central motor noninvasive brain stimulation techniques such as transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) will be studied. Pairing pharmacological peripheral and central stimulation may produce greater benefits. The main aim of the project is to study the efficacy of two novel protocols of paired stimulation on PS-OD patients. The investigators will assess whether 5-day application of tDCS/capsaicin or rTMS/capsaicin in the chronic phase of stroke, will improve PS-OD. One RCT (200 patients in the chronic stroke phase divided in 4 study arms) will assess changes in swallow safety, biomechanics and neurophysiology of the swallow response, hospital stay, respiratory and nutritional complications, mortality and QoL.
Read the detailed description
- Main hypothesis: Paired neurorehabilitation treatment targeting both pharyngeal sensory and motor components simultaneously through a peripheral pharmacological stimulant (Transient Receptor Potential Cation Channel [TRPV1] agonist, capsaicin) and central stimulation (NIBS) strategies (rTMS or tDCS) can improve swallowing function in chronic PS-OD patients by promoting cortical plasticity, their QoL and reduce OD associated complications.
- Main aim: To assess the effects on swallowing of 2 neurostimulation strategies applied for 5 days to treat PS-OD in the chronic phase (>3 months from stroke onset) of ambulatory patients, the application of rTMS + capsaicin vs. tDCS + capsaicin in two independent RCTs. The main outcome measure for these three RCTs will be changes in prevalence of impaired safety of swallow assessed by videofluoroscopy.
- Secondary aims To assess: 1) safety and adverse events; 2) the effects on safety of swallow with a standardized protocol of swallowing evaluation; 3) clinical outcomes at 3 months follow up; 4) the effect of the treatments on SSF and responsiveness to treatment according to stroke characteristics; 5) the effect in the chronic phase on: i) assessment of afferent and efferent pathways with sensory and motor evoked-potentials to electrical pharyngeal stimulation and TMS, respectively; ii) prevalence of signs of impaired safety/efficacy on videofluoroscopy (VFS), the penetration-aspiration score (PAS) (Rosenbek scale) and the biomechanics of the swallow response; and iii) specific clinical outcomes such as mid-term complications, readmission rate and QoL.
- Design: Single-center, double-blinded, two-arm, double-randomization RCT. Patients are distributed into two parallel subgroups (each with its own sham group) according to intervention type.Blinding will be applicable for clinical and instrumental assessments for investigators, and for intervention condition for patients. Patients undergo V-VST, biomechanical (VFS) and neurophysiological (sEMG and evoked potentials) swallowing evaluation, and double randomization, first for intervention type (tDCS or rTMS) and then for intervention condition (active or sham), using the same software as Task1. Treatment is applied for 5 consecutive days using either rTMS (G1: active rTMS+capsaicin; G2: sham rTMS+placebo) or tDCS (G1: active tDCS+capsaicin; G2: sham tDCS+placebo) as NIBS procedures. Finally, patients are reevaluated as before and clinical outcome at 3 months.
- Study population: 200 Chronic PS-OD ambulatory patients.
- Inclusion criteria: Chronic (>3 and <24 months) unilateral hemispheric stroke adult patients; ISS (V-VST); can follow the study protocol and give written informed consent.
- Exclusion criteria: Pregnancy; life expectancy <3m or palliative care; neurodegenerative disorder or previous OD; implanted electronic device; epilepsy; metal in the head; participation in another clinical trial in the previous month.
- Sample size/power calculation: The main outcome measure is the prevalence of patients with ISS according to VFS at post-treatment visit. To compare the prevalence between groups, using the arcsinus approximation, accepting an alpha risk of 0.05 and a beta risk of 0.2 in a 2-sided test, 50 patients/group are needed for each NIBS procedure, 2 for rTMS and 2 for tDCS (4 groups=total of 200 patients) to find a significant difference in the proportion of 0.4 in the control group and 0.7 in treated group (drop-out rate of 15%).
- Recruitment: Patients will be consecutively recruited and randomly allocated to the groups, according first to NIBS procedure (1:1, tDCS/rTMS) and then to intervention condition (1:1, active/sham).
- Study Intervention: tDCS: G1: Active treatment consists of swallowing 10mL capsaicin (150μM) and, just after, of applying 30min of 2.0mA tDCS (DC-Stimulator Plus, NeuroConn, Germany) with the anode placed over the pharyngeal primary motor cortex (M1) of the unaffected hemisphere (3.5cm lateral / 1cm anterior to the vertex) and the cathode over the opposite supraorbital region. Treatment applied over 5 consecutive days. rTMS: G1: each session (5 consecutive days) of active treatment consists of swallowing 10mL capsaicin (150μM) and, just after, of applying focal (alpha D70 coil) rTMS (Magstim Rapid2, UK) over the pharyngeal M1 hotspot of the unaffected hemisphere. Neuronavigation (Brainsight TMS navigation, UK) ensures the exact hotspot over 5 days. A total of 500 pulses/session are delivered consisting of 10 5Hz-trains of 10s of 50 pulses each (total 2500 pulses), with a 1min interval between trains at an intensity of 90% of the resting motor threshold (RMT). G2: Sham rTMS+oral placebo (10mL of potassium sorbate). The same protocol will be applied, but with the coil tilted 90º from the tangent of the skull, as a standard method for sham rTMS application.
- Swallowing assessment (pre- and post-intervention): Patients with impaired safety of swallow will be screened with volume-viscosity swallowing test (V-VST), and videofluoroscopy (VFS) recordings are obtained in a lateral projection (25 frames/s). Swallow biomechanics are analyzed at VFS with Swallowing Observer (Image\&Physiology SL, Spain). The spontaneous swallowing frequency (SSF) during 10min will be measured with surface electromyography (sEMG) over the digastric-mylohyoid complex.
- Pharyngeal sensory evoked potentials (pSEPs) are recorded with a 32-electrode electroencephalographic (EEG) recording cap (10/20 system) during a series of electrical stimuli (4 sets of 50 pulses of 0.2ms at 0.2Hz, intensity of 75% tolerance threshold; Digitimer DS7A \& DG2A pulse generator, UK) applied to the pharynx with an intra-pharyngeal catheter (Gaeltec Ltd, Scotland).
- Pharyngeal motor evoked potentials (pMEPs) and RMTs for both hemispheres are recorded with the same catheter to TMS (20 pulses to each hotspot at intensity +20%RMT; Magstim Bistim2, UK).
Primary outcomes: Pre- vs post-intervention changes in VFS signs of safety and efficacy of swallow, PAS scoring, timing of swallow response and amplitude and latency of pSEPs and pMEPs.
- Secondary outcomes: Pre/post-intervention changes in sEMG for SSF, safety (adverse events rate), clinical outcomes during admission and at 3-month follow-up (length of stay, aspiration pneumonia, nutritional [MNA-sf] and functional status [Rankin scale, Barthel], readmissions and mortality), and V-VST at 3 months.
- Additional secondary outcomes: differences in the magnitude of the effect in primary outcomes found in chronic PS phase between the tDCS (+capsaicin) and rTMS (+capsaicin) interventions.
- Being tested
- rTMS + capsaicin 150μM (natural TRPV1 agonist), tDCS + capsaicin 150μM (natural TRPV1 agonist)
- Keywords
- Non-Invasive Brain Stimulation, Sensory Stimulation, Transcranial Magnetic Stimulation, Transcranial Direct Current Stimulation, TRPV1 agonists, Capsaicin
- Medical subject headings
- Deglutition Disorders, Stroke
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
rTMS + capsaicin 150μM (natural TRPV1 agonist)Device
Also called Repetitive transcranial magnetic stimulation (rTMS) (MagStim, UK) + TRPV1 natural agonist capsaicin at 150μM
Repetitive transcranial magnetic stimulation (non-invasive brain stimulation) + Capsaicin.
5 consecutive days of active treatment consists of swallowing 10mL capsaicin (150μM) and, just after, of applying focal (alpha D70 coil) rTMS (Magstim Rapid2, UK) over the pharyngeal M1 hotspot of the unaffected hemisphere. A total of 500 pulses/session are delivered consisting of 10 5Hz-trains of 10s of 50 pulses each (total 2500 pulses), with a 1min interval between trains at an intensity of 90% of the resting motor threshold (RMT).
The intervention has its respective sham rTMS+placebo group that is also applied over 5 consecutive days.
tDCS + capsaicin 150μM (natural TRPV1 agonist)Device
Also called Transcranial direct current stimulation (tDCS) (Neuroconn, Germany) + TRPV1 natural agonist capsaicin at 150μM
Transcranial direct current stimulation (non-invasive brain stimulation) + Capsaicin.
Treatment consists of swallowing 10mL capsaicin (150μM) and, just after, of applying 30min of 2.0mA tDCS (DC-Stimulator Plus, NeuroConn, Germany) with the anode placed over the pharyngeal primary motor cortex (M1) of the unaffected hemisphere (3.5cm lateral / 1cm anterior to the vertex) and the cathode over the opposite supraorbital region.
The intervention has its respective sham tDCS+placebo group that is also applied over 5 consecutive days.
| Study group | Role | What they receive |
|---|---|---|
| Active rTMS + capsaicin 150μM | Experimental | Each session (5 consecutive days) of active treatment consists of swallowing 10mL capsaicin (150μM) and, just after, of applying focal (alpha D70 coil) rTMS (Magstim Rapid2, UK) over the pharyngeal M1 hotspot of the unaffected hemisphere. Receives: Device: rTMS + capsaicin 150μM (natural TRPV1 agonist) |
| sham rTMS + placebo | Other | The same protocol will be applied, swallowing 10mL of placebo (potassium sorbate) but with the coil tilted 90º from the tangent of the skull, as a standard method for sham rTMS application. Receives: Device: rTMS + capsaicin 150μM (natural TRPV1 agonist) |
| active tDCS + capsaicin 150μM | Experimental | Active treatment consists of swallowing 10mL capsaicin (150μM) and, just after, of applying 30min of 2.0mA tDCS (DC-Stimulator Plus, NeuroConn, Germany) with the anode placed over the pharyngeal primary motor cortex (M1) of the unaffected hemisphere (3.5cm lateral / 1cm anterior to the vertex) and the cathode over the opposite supraorbital region. Receives: Device: tDCS + capsaicin 150μM (natural TRPV1 agonist) |
| sham tDCS + placebo | Other | The same protocol will be applied, swallowing 10mL of placebo (potassium sorbate) but tDCS current is ramped up over 30s in order to simulate the active tDCS and then turned off for 30min23. Setup characteristics otherwise invariable. Receives: Device: tDCS + capsaicin 150μM (natural TRPV1 agonist) |
What is being measured
The primary outcome is the main question the study is designed to answer.
Changes in the videofluoroscopy (signs of safety and efficacy of swallow)
Pre- vs post-intervention changes in:
- Frequency of videofluoroscopic (VFS) signs of safety and efficacy of swallow.
Measured: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
Changes in the videofluoroscopy (Penetration-Aspiration scale)
Pre- vs post-intervention changes in:
- Penetration-Aspiration scale (PAS). The scales goes from 1 (safe swallow) to 8 (silent aspiration). The severity increases as the score increases.
Measured: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
Timing of oropharyngeal swallow response (total deglutition time) with videofluoroscopy
- Total deglutition time (ms).
Measured: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
Timing of oropharyngeal swallow response (time to laryngeal vestibule closure) with videofluoroscopy
- Time to laryngeal vestibule closure (ms).
Measured: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
Timing of oropharyngeal swallow response (time to upper esophageal sphincter opening) with videofluoroscopy
- Time to upper esophageal sphincter opening (ms).
Measured: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
Timing of oropharyngeal swallow response (bolus velocity) with videofluoroscopy
- Bolus velocity (m·s-1).
Measured: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
Timing of oropharyngeal swallow response (Kinetic energy) with videofluoroscopy
- Kinetic energy of the bolus (mJ).
Measured: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
Changes in neurophysiology of swallow (sensory pathway) latency
- Latency of pharyngeal sensory evoked potentials to intrapharyngeal electrical stimulation.
Measured: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
Changes in neurophysiology of swallow (sensory pathway) amplitude
- Amplitude of pharyngeal sensory evoked potentials to intrapharyngeal electrical stimulation.
Measured: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
Changes in neurophysiology of swallow (motor pathway) latency
- Latency of pharyngeal motor evoked potentials to transcranial magnetic stimulation.
Measured: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
Changes in neurophysiology of swallow (motor pathway) amplitude
- Amplitude of pharyngeal motor evoked potentials to transcranial magnetic stimulation.
Measured: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
Secondary outcomes (10)
Changes in spontaneous swallowing frequency
Pre/post-intervention changes in spontaneous swallowing frequency (swallows/minute)
Measured: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
Safety of the treatment
Safety of the treatment applied (adverse events rate) during all the study period.
Measured: Baseline (basal visit) to 3 months follow-up
Length of stay
Length of hospital stay.
Measured: Baseline (basal visit) to 3 months follow-up
Aspiration pneumonia admission
Admissions due to aspiration pneumonia during the study and at 3-month follow-up.
Measured: Baseline (basal visit) to 3 months follow-up
Nutritional status
Nutritional status (MNA-sf) at baseline and at 3-month follow-up.
Measured: Baseline (basal visit) to 3 months follow-up
Functional status
Functional status (Barthel index) at baseline and at 3-month follow-up.
Measured: Baseline (basal visit) to 3 months follow-up
Functional status associated to stroke
Rankin scale at baseline and at 3-month follow-up.
Measured: Baseline (basal visit) to 3 months follow-up
General hospital readmissions for any cause
Hospital readmissions during the study (from baseline (basal visit) to 3 months follow-up).
Measured: Baseline (basal visit) to 3 months follow-up
Mortality
Mortality over the study period (from baseline (basal visit) to 3 months follow-up).
Measured: Baseline (basal visit) to 3 months follow-up
Swallowing clinical evaluation
Volume-viscosity swallowing test (V-VST) parameters comparison between post-treatment visit (+5 days) and 3 months follow-up visit.
Measured: Immediately after the intervention to 3 months follow-up visit
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted9 Feb 2023
- Study start28 Nov 2022
- Primary completionDec 2024 (estimated)
- Study completionSep 2025 (estimated)
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (12)Papers the sponsor has linked to this study.
- Other trials for Oropharyngeal DysphagiaStudies of the same condition, open and under way.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase N/A
- Primary purpose
- Treatment
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Model description
- Single-center, double-blinded, two-arm, double-randomization RCT to assess the effect of paired sensory (capsaicin vs placebo) and motor stimulation (rTMS vs tDCS) for post-stroke patients with oropharyngeal dysphagia.
- Masking
- Triple blind
- Who is masked
- Participant, Care provider, Outcomes assessor
- Enrolment
- 200 participants (estimated)
Sponsor and investigators
- Lead sponsor
- Hospital de Mataró
- Sponsor type
- University, hospital or other
- Collaborators
- Consorci Sanitari del Maresme, Instituto de Salud Carlos III
- Responsible party
- Principal investigator, Pere Clave, Hospital de Mataró
- Investigators
- Pere Clavé, MD, PhD, Principal investigator, Consorci Sanitari del Maresme
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT05720871
- Sponsor's protocol ID
- STROD_ICI_C
- Acronym
- ICI20/00117
- Status last verified
- Feb 2023
- First submitted
- 17 Jan 2023
- Last updated
- 13 Feb 2023
- Results posted
- No
- Data monitoring committee
- No
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- No: No IPD will be available to other researchers.
Publications
Cabib C, Ortega O, Kumru H, Palomeras E, Vilardell N, Alvarez-Berdugo D, Muriana D, Rofes L, Terre R, Mearin F, Clave P. Neurorehabilitation strategies for poststroke oropharyngeal dysphagia: from compensation to the recovery of swallowing function. Ann N Y Acad Sci. 2016 Sep;1380(1):121-138. doi: 10.1111/nyas.13135. Epub 2016 Jul 11.
PubMed 27398981Cabib C, Nascimento W, Rofes L, Arreola V, Tomsen N, Mundet L, Palomeras E, Michou E, Clave P, Ortega O. Short-term neurophysiological effects of sensory pathway neurorehabilitation strategies on chronic poststroke oropharyngeal dysphagia. Neurogastroenterol Motil. 2020 Sep;32(9):e13887. doi: 10.1111/nmo.13887. Epub 2020 May 24.
PubMed 32449296Cabib C, Nascimento W, Rofes L, Arreola V, Tomsen N, Mundet L, Muriana D, Palomeras E, Michou E, Clave P, Ortega O. Neurophysiological and Biomechanical Evaluation of the Mechanisms Which Impair Safety of Swallow in Chronic Post-stroke Patients. Transl Stroke Res. 2020 Feb;11(1):16-28. doi: 10.1007/s12975-019-00701-2. Epub 2019 Apr 2.
PubMed 30941716Cabib C, Ortega O, Vilardell N, Mundet L, Clave P, Rofes L. Chronic post-stroke oropharyngeal dysphagia is associated with impaired cortical activation to pharyngeal sensory inputs. Eur J Neurol. 2017 Nov;24(11):1355-1362. doi: 10.1111/ene.13392. Epub 2017 Sep 5.
PubMed 28872738Nascimento W, Tomsen N, Acedo S, Campos-Alcantara C, Cabib C, Alvarez-Larruy M, Clave P. Effect of Aging, Gender and Sensory Stimulation of TRPV1 Receptors with Capsaicin on Spontaneous Swallowing Frequency in Patients with Oropharyngeal Dysphagia: A Proof-of-Concept Study. Diagnostics (Basel). 2021 Mar 7;11(3):461. doi: 10.3390/diagnostics11030461.
PubMed 33799960Wang Z, Wu L, Fang Q, Shen M, Zhang L, Liu X. Effects of capsaicin on swallowing function in stroke patients with dysphagia: A randomized controlled trial. J Stroke Cerebrovasc Dis. 2019 Jun;28(6):1744-1751. doi: 10.1016/j.jstrokecerebrovasdis.2019.02.008. Epub 2019 Apr 5.
PubMed 30956054Tomsen N, Ortega O, Alvarez-Berdugo D, Rofes L, Clave P. A Comparative Study on the Effect of Acute Pharyngeal Stimulation with TRP Agonists on the Biomechanics and Neurophysiology of Swallow Response in Patients with Oropharyngeal Dysphagia. Int J Mol Sci. 2022 Sep 15;23(18):10773. doi: 10.3390/ijms231810773.
PubMed 36142680Tomsen N, Ortega O, Rofes L, Arreola V, Martin A, Mundet L, Clave P. Acute and subacute effects of oropharyngeal sensory stimulation with TRPV1 agonists in older patients with oropharyngeal dysphagia: a biomechanical and neurophysiological randomized pilot study. Ther Adv Gastroenterol. 2019 Apr 30;12:1756284819842043. doi: 10.1177/1756284819842043. eCollection 2019.
PubMed 31068978Hamdy S, Aziz Q, Rothwell JC, Crone R, Hughes D, Tallis RC, Thompson DG. Explaining oropharyngeal dysphagia after unilateral hemispheric stroke. Lancet. 1997 Sep 6;350(9079):686-92. doi: 10.1016/S0140-6736(97)02068-0.
PubMed 9291902Kumar S, Wagner CW, Frayne C, Zhu L, Selim M, Feng W, Schlaug G. Noninvasive brain stimulation may improve stroke-related dysphagia: a pilot study. Stroke. 2011 Apr;42(4):1035-40. doi: 10.1161/STROKEAHA.110.602128. Epub 2011 Mar 24.
PubMed 21441148Park JW, Oh JC, Lee JW, Yeo JS, Ryu KH. The effect of 5Hz high-frequency rTMS over contralesional pharyngeal motor cortex in post-stroke oropharyngeal dysphagia: a randomized controlled study. Neurogastroenterol Motil. 2013 Apr;25(4):324-e250. doi: 10.1111/nmo.12063. Epub 2012 Dec 23.
PubMed 23279198Kobayashi M, Pascual-Leone A. Transcranial magnetic stimulation in neurology. Lancet Neurol. 2003 Mar;2(3):145-56. doi: 10.1016/s1474-4422(03)00321-1.
PubMed 12849236
Study at a glance
From the registry record, last updated by the sponsor on 13 Feb 2023. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Treatment of Chronic Post-stroke Oropharyngeal Dysphagia With Paired Stimulation Through Peripheral TRVP1 Agonists and Non-invasive Brain Stimulation
- ClinicalTrials.gov ID
- NCT05720871
- Acronym / sponsor ID
- ICI20/00117 / STROD_ICI_C
- Keywords
- Non-Invasive Brain Stimulation, Sensory Stimulation, Transcranial Magnetic Stimulation, Transcranial Direct Current Stimulation, TRPV1 agonists, Capsaicin
- Study type
- Interventional
- Recruitment status
- Unknown status
- Enrolment
- 200 participants (estimated)
- Lead sponsor
- Hospital de MataróUniversity, hospital or other
- Collaborators
- Consorci Sanitari del Maresme, Instituto de Salud Carlos III
- Study start
- 28 Nov 2022 (actual)
- Primary completion
- Dec 2024 (estimated)
- Study completion
- Sep 2025 (estimated)
- First posted
- 9 Feb 2023 (actual)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
According WHO, oropharyngeal dysphagia (OD) is a prevalent post-stroke (PS) condition involving the digestive system (ICD-10: I69.391) and an independent risk factor for malnutrition and pulmonary infection; and leads to greater morbimortality and healthcare costs and poorer quality of life (QoL). Currently, OD therapy is mainly compensatory, with low rates of compliance and small benefit, and there is no pharmacological treatment, so new treatments that improve patients' condition are crucial. PS-OD patients present both oropharyngeal sensory and motor deficits, so neurorehabilitation treatments which target both could be optimum. Benefits of paired peripheral sensory stimulation with oral capsaicin and of central motor noninvasive brain stimulation techniques such as transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) will be studied. Pairing pharmacological peripheral and central stimulation may produce greater benefits. The main aim of the project is to study the efficacy of two novel protocols of paired stimulation on PS-OD patients. The investigators will assess whether 5-day application of tDCS/capsaicin or rTMS/capsaicin in the chronic phase of stroke, will improve PS-OD. One RCT (200 patients in the chronic stroke phase divided in 4 study arms) will assess changes in swallow safety, biomechanics and neurophysiology of the swallow response, hospital stay, respiratory and nutritional complications, mortality and QoL.
Detailed description
- Main hypothesis: Paired neurorehabilitation treatment targeting both pharyngeal sensory and motor components simultaneously through a peripheral pharmacological stimulant (Transient Receptor Potential Cation Channel [TRPV1] agonist, capsaicin) and central stimulation (NIBS) strategies (rTMS or tDCS) can improve swallowing function in chronic PS-OD patients by promoting cortical plasticity, their QoL and reduce OD associated complications.
- Main aim: To assess the effects on swallowing of 2 neurostimulation strategies applied for 5 days to treat PS-OD in the chronic phase (>3 months from stroke onset) of ambulatory patients, the application of rTMS + capsaicin vs. tDCS + capsaicin in two independent RCTs. The main outcome measure for these three RCTs will be changes in prevalence of impaired safety of swallow assessed by videofluoroscopy.
- Secondary aims To assess: 1) safety and adverse events; 2) the effects on safety of swallow with a standardized protocol of swallowing evaluation; 3) clinical outcomes at 3 months follow up; 4) the effect of the treatments on SSF and responsiveness to treatment according to stroke characteristics; 5) the effect in the chronic phase on: i) assessment of afferent and efferent pathways with sensory and motor evoked-potentials to electrical pharyngeal stimulation and TMS, respectively; ii) prevalence of signs of impaired safety/efficacy on videofluoroscopy (VFS), the penetration-aspiration score (PAS) (Rosenbek scale) and the biomechanics of the swallow response; and iii) specific clinical outcomes such as mid-term complications, readmission rate and QoL.
- Design: Single-center, double-blinded, two-arm, double-randomization RCT. Patients are distributed into two parallel subgroups (each with its own sham group) according to intervention type.Blinding will be applicable for clinical and instrumental assessments for investigators, and for intervention condition for patients. Patients undergo V-VST, biomechanical (VFS) and neurophysiological (sEMG and evoked potentials) swallowing evaluation, and double randomization, first for intervention type (tDCS or rTMS) and then for intervention condition (active or sham), using the same software as Task1. Treatment is applied for 5 consecutive days using either rTMS (G1: active rTMS+capsaicin; G2: sham rTMS+placebo) or tDCS (G1: active tDCS+capsaicin; G2: sham tDCS+placebo) as NIBS procedures. Finally, patients are reevaluated as before and clinical outcome at 3 months.
- Study population: 200 Chronic PS-OD ambulatory patients.
- Inclusion criteria: Chronic (>3 and <24 months) unilateral hemispheric stroke adult patients; ISS (V-VST); can follow the study protocol and give written informed consent.
- Exclusion criteria: Pregnancy; life expectancy <3m or palliative care; neurodegenerative disorder or previous OD; implanted electronic device; epilepsy; metal in the head; participation in another clinical trial in the previous month.
- Sample size/power calculation: The main outcome measure is the prevalence of patients with ISS according to VFS at post-treatment visit. To compare the prevalence between groups, using the arcsinus approximation, accepting an alpha risk of 0.05 and a beta risk of 0.2 in a 2-sided test, 50 patients/group are needed for each NIBS procedure, 2 for rTMS and 2 for tDCS (4 groups=total of 200 patients) to find a significant difference in the proportion of 0.4 in the control group and 0.7 in treated group (drop-out rate of 15%).
- Recruitment: Patients will be consecutively recruited and randomly allocated to the groups, according first to NIBS procedure (1:1, tDCS/rTMS) and then to intervention condition (1:1, active/sham).
- Study Intervention: tDCS: G1: Active treatment consists of swallowing 10mL capsaicin (150μM) and, just after, of applying 30min of 2.0mA tDCS (DC-Stimulator Plus, NeuroConn, Germany) with the anode placed over the pharyngeal primary motor cortex (M1) of the unaffected hemisphere (3.5cm lateral / 1cm anterior to the vertex) and the cathode over the opposite supraorbital region. Treatment applied over 5 consecutive days. rTMS: G1: each session (5 consecutive days) of active treatment consists of swallowing 10mL capsaicin (150μM) and, just after, of applying focal (alpha D70 coil) rTMS (Magstim Rapid2, UK) over the pharyngeal M1 hotspot of the unaffected hemisphere. Neuronavigation (Brainsight TMS navigation, UK) ensures the exact hotspot over 5 days. A total of 500 pulses/session are delivered consisting of 10 5Hz-trains of 10s of 50 pulses each (total 2500 pulses), with a 1min interval between trains at an intensity of 90% of the resting motor threshold (RMT). G2: Sham rTMS+oral placebo (10mL of potassium sorbate). The same protocol will be applied, but with the coil tilted 90º from the tangent of the skull, as a standard method for sham rTMS application.
- Swallowing assessment (pre- and post-intervention): Patients with impaired safety of swallow will be screened with volume-viscosity swallowing test (V-VST), and videofluoroscopy (VFS) recordings are obtained in a lateral projection (25 frames/s). Swallow biomechanics are analyzed at VFS with Swallowing Observer (Image\&Physiology SL, Spain). The spontaneous swallowing frequency (SSF) during 10min will be measured with surface electromyography (sEMG) over the digastric-mylohyoid complex.
- Pharyngeal sensory evoked potentials (pSEPs) are recorded with a 32-electrode electroencephalographic (EEG) recording cap (10/20 system) during a series of electrical stimuli (4 sets of 50 pulses of 0.2ms at 0.2Hz, intensity of 75% tolerance threshold; Digitimer DS7A \& DG2A pulse generator, UK) applied to the pharynx with an intra-pharyngeal catheter (Gaeltec Ltd, Scotland).
- Pharyngeal motor evoked potentials (pMEPs) and RMTs for both hemispheres are recorded with the same catheter to TMS (20 pulses to each hotspot at intensity +20%RMT; Magstim Bistim2, UK).
Primary outcomes: Pre- vs post-intervention changes in VFS signs of safety and efficacy of swallow, PAS scoring, timing of swallow response and amplitude and latency of pSEPs and pMEPs.
- Secondary outcomes: Pre/post-intervention changes in sEMG for SSF, safety (adverse events rate), clinical outcomes during admission and at 3-month follow-up (length of stay, aspiration pneumonia, nutritional [MNA-sf] and functional status [Rankin scale, Barthel], readmissions and mortality), and V-VST at 3 months.
- Additional secondary outcomes: differences in the magnitude of the effect in primary outcomes found in chronic PS phase between the tDCS (+capsaicin) and rTMS (+capsaicin) interventions.
Study design
- Primary purpose
- Treatment
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Triple blind (participant, care provider, outcomes assessor)
- Number of arms
- 4
- Model description
- Single-center, double-blinded, two-arm, double-randomization RCT to assess the effect of paired sensory (capsaicin vs placebo) and motor stimulation (rTMS vs tDCS) for post-stroke patients with oropharyngeal dysphagia.
| Arm | Type | Receives |
|---|---|---|
| Active rTMS + capsaicin 150μM | Experimental | Device: rTMS + capsaicin 150μM (natural TRPV1 agonist)Each session (5 consecutive days) of active treatment consists of swallowing 10mL capsaicin (150μM) and, just after, of applying focal (alpha D70 coil) rTMS (Magstim Rapid2, UK) over the pharyngeal M1 hotspot of the unaffected hemisphere. |
| sham rTMS + placebo | Other | Device: rTMS + capsaicin 150μM (natural TRPV1 agonist)The same protocol will be applied, swallowing 10mL of placebo (potassium sorbate) but with the coil tilted 90º from the tangent of the skull, as a standard method for sham rTMS application. |
| active tDCS + capsaicin 150μM | Experimental | Device: tDCS + capsaicin 150μM (natural TRPV1 agonist)Active treatment consists of swallowing 10mL capsaicin (150μM) and, just after, of applying 30min of 2.0mA tDCS (DC-Stimulator Plus, NeuroConn, Germany) with the anode placed over the pharyngeal primary motor cortex (M1) of the unaffected hemisphere (3.5cm lateral / 1cm anterior to the vertex) and the cathode over the opposite supraorbital region. |
| sham tDCS + placebo | Other | Device: tDCS + capsaicin 150μM (natural TRPV1 agonist)The same protocol will be applied, swallowing 10mL of placebo (potassium sorbate) but tDCS current is ramped up over 30s in order to simulate the active tDCS and then turned off for 30min23. Setup characteristics otherwise invariable. |
Who may qualify
- Ages
- 18 years and older
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
Key inclusion criteria (3 listed)
- Chronic (>3 and <24 months) unilateral hemispheric stroke adult patients.
- Patients with impaired safety of swallow with a penetration-aspiration score (PAS) ≥ 2 with videofluoroscopy (VFS).
- Patient able to follow the study protocol and give the written informed consent.
Key exclusion criteria (8 listed)
- Pregnancy.
- Life expectancy less than 3m or palliative care.
- Neurodegenerative disorder.
- Previously diagnosed oropharyngeal dysphagia (dysphagia not related to stroke).
- Implanted electronic device.
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| rTMS + capsaicin 150μM (natural TRPV1 agonist)Also: Repetitive transcranial magnetic stimulation (rTMS) (MagStim, UK) + TRPV1 natural agonist capsaicin at 150μMRepetitive transcranial magnetic stimulation (non-invasive brain stimulation) + Capsaicin. 5 consecutive days of active treatment consists of swallowing 10mL capsaicin (150μM) and, just after, of applying focal (alpha D70 coil) rTMS (Magstim Rapid2, UK) over the pharyngeal M1 hotspot of the unaffected hemisphere. A total of 500 pulses/session are delivered consisting of 10 5Hz-trains of 10s of 50 pulses each (total 2500 pulses), with a 1min interval between trains at an intensity of 90% of the resting motor threshold (RMT). The intervention has its respective sham rTMS+placebo group that is also applied over 5 consecutive days. | Device | Active rTMS + capsaicin 150μM, sham rTMS + placebo |
| tDCS + capsaicin 150μM (natural TRPV1 agonist)Also: Transcranial direct current stimulation (tDCS) (Neuroconn, Germany) + TRPV1 natural agonist capsaicin at 150μMTranscranial direct current stimulation (non-invasive brain stimulation) + Capsaicin. Treatment consists of swallowing 10mL capsaicin (150μM) and, just after, of applying 30min of 2.0mA tDCS (DC-Stimulator Plus, NeuroConn, Germany) with the anode placed over the pharyngeal primary motor cortex (M1) of the unaffected hemisphere (3.5cm lateral / 1cm anterior to the vertex) and the cathode over the opposite supraorbital region. The intervention has its respective sham tDCS+placebo group that is also applied over 5 consecutive days. | Device | active tDCS + capsaicin 150μM, sham tDCS + placebo |
Primary outcome
Changes in the videofluoroscopy (signs of safety and efficacy of swallow)
Time frame: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
Pre- vs post-intervention changes in: - Frequency of videofluoroscopic (VFS) signs of safety and efficacy of swallow.
Changes in the videofluoroscopy (Penetration-Aspiration scale)
Time frame: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
Pre- vs post-intervention changes in: - Penetration-Aspiration scale (PAS). The scales goes from 1 (safe swallow) to 8 (silent aspiration). The severity increases as the score increases.
Timing of oropharyngeal swallow response (total deglutition time) with videofluoroscopy
Time frame: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
- Total deglutition time (ms).
Timing of oropharyngeal swallow response (time to laryngeal vestibule closure) with videofluoroscopy
Time frame: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
- Time to laryngeal vestibule closure (ms).
Timing of oropharyngeal swallow response (time to upper esophageal sphincter opening) with videofluoroscopy
Time frame: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
- Time to upper esophageal sphincter opening (ms).
Timing of oropharyngeal swallow response (bolus velocity) with videofluoroscopy
Time frame: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
- Bolus velocity (m·s-1).
Timing of oropharyngeal swallow response (Kinetic energy) with videofluoroscopy
Time frame: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
- Kinetic energy of the bolus (mJ).
Changes in neurophysiology of swallow (sensory pathway) latency
Time frame: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
- Latency of pharyngeal sensory evoked potentials to intrapharyngeal electrical stimulation.
Changes in neurophysiology of swallow (sensory pathway) amplitude
Time frame: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
- Amplitude of pharyngeal sensory evoked potentials to intrapharyngeal electrical stimulation.
Changes in neurophysiology of swallow (motor pathway) latency
Time frame: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
- Latency of pharyngeal motor evoked potentials to transcranial magnetic stimulation.
Changes in neurophysiology of swallow (motor pathway) amplitude
Time frame: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
- Amplitude of pharyngeal motor evoked potentials to transcranial magnetic stimulation.
10 secondary outcomes
Changes in spontaneous swallowing frequency
Time frame: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)
Safety of the treatment
Time frame: Baseline (basal visit) to 3 months follow-up
Length of stay
Time frame: Baseline (basal visit) to 3 months follow-up
Aspiration pneumonia admission
Time frame: Baseline (basal visit) to 3 months follow-up
Nutritional status
Time frame: Baseline (basal visit) to 3 months follow-up
Functional status
Time frame: Baseline (basal visit) to 3 months follow-up
Functional status associated to stroke
Time frame: Baseline (basal visit) to 3 months follow-up
General hospital readmissions for any cause
Time frame: Baseline (basal visit) to 3 months follow-up
Mortality
Time frame: Baseline (basal visit) to 3 months follow-up
Swallowing clinical evaluation
Time frame: Immediately after the intervention to 3 months follow-up visit
Results and safety
Results are not available in the source record.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 13 Feb 2023.
- Results publication: PubMed 27398981Cabib C, Ortega O, Kumru H, Palomeras E, Vilardell N, Alvarez-Berdugo D, Muriana D, Rofes L, Terre R, Mearin F, Clave P. Neurorehabilitation strategies for poststroke oropharyngeal dysphagia: from compensation to the recovery of swallowing function. Ann N Y Acad Sci. 2016 Sep;1380(1):121-138. doi: 10.1111/nyas.13135. Epub 2016 Jul 11.
- Results publication: PubMed 32449296Cabib C, Nascimento W, Rofes L, Arreola V, Tomsen N, Mundet L, Palomeras E, Michou E, Clave P, Ortega O. Short-term neurophysiological effects of sensory pathway neurorehabilitation strategies on chronic poststroke oropharyngeal dysphagia. Neurogastroenterol Motil. 2020 Sep;32(9):e13887. doi: 10.1111/nmo.13887. Epub 2020 May 24.
- Results publication: PubMed 30941716Cabib C, Nascimento W, Rofes L, Arreola V, Tomsen N, Mundet L, Muriana D, Palomeras E, Michou E, Clave P, Ortega O. Neurophysiological and Biomechanical Evaluation of the Mechanisms Which Impair Safety of Swallow in Chronic Post-stroke Patients. Transl Stroke Res. 2020 Feb;11(1):16-28. doi: 10.1007/s12975-019-00701-2. Epub 2019 Apr 2.
- Results publication: PubMed 28872738Cabib C, Ortega O, Vilardell N, Mundet L, Clave P, Rofes L. Chronic post-stroke oropharyngeal dysphagia is associated with impaired cortical activation to pharyngeal sensory inputs. Eur J Neurol. 2017 Nov;24(11):1355-1362. doi: 10.1111/ene.13392. Epub 2017 Sep 5.
- Results publication: PubMed 33799960Nascimento W, Tomsen N, Acedo S, Campos-Alcantara C, Cabib C, Alvarez-Larruy M, Clave P. Effect of Aging, Gender and Sensory Stimulation of TRPV1 Receptors with Capsaicin on Spontaneous Swallowing Frequency in Patients with Oropharyngeal Dysphagia: A Proof-of-Concept Study. Diagnostics (Basel). 2021 Mar 7;11(3):461. doi: 10.3390/diagnostics11030461.
- Results publication: PubMed 30956054Wang Z, Wu L, Fang Q, Shen M, Zhang L, Liu X. Effects of capsaicin on swallowing function in stroke patients with dysphagia: A randomized controlled trial. J Stroke Cerebrovasc Dis. 2019 Jun;28(6):1744-1751. doi: 10.1016/j.jstrokecerebrovasdis.2019.02.008. Epub 2019 Apr 5.
- Results publication: PubMed 36142680Tomsen N, Ortega O, Alvarez-Berdugo D, Rofes L, Clave P. A Comparative Study on the Effect of Acute Pharyngeal Stimulation with TRP Agonists on the Biomechanics and Neurophysiology of Swallow Response in Patients with Oropharyngeal Dysphagia. Int J Mol Sci. 2022 Sep 15;23(18):10773. doi: 10.3390/ijms231810773.
- Results publication: PubMed 31068978Tomsen N, Ortega O, Rofes L, Arreola V, Martin A, Mundet L, Clave P. Acute and subacute effects of oropharyngeal sensory stimulation with TRPV1 agonists in older patients with oropharyngeal dysphagia: a biomechanical and neurophysiological randomized pilot study. Ther Adv Gastroenterol. 2019 Apr 30;12:1756284819842043. doi: 10.1177/1756284819842043. eCollection 2019.
- Results publication: PubMed 9291902Hamdy S, Aziz Q, Rothwell JC, Crone R, Hughes D, Tallis RC, Thompson DG. Explaining oropharyngeal dysphagia after unilateral hemispheric stroke. Lancet. 1997 Sep 6;350(9079):686-92. doi: 10.1016/S0140-6736(97)02068-0.
- Results publication: PubMed 21441148Kumar S, Wagner CW, Frayne C, Zhu L, Selim M, Feng W, Schlaug G. Noninvasive brain stimulation may improve stroke-related dysphagia: a pilot study. Stroke. 2011 Apr;42(4):1035-40. doi: 10.1161/STROKEAHA.110.602128. Epub 2011 Mar 24.
- Results publication: PubMed 23279198Park JW, Oh JC, Lee JW, Yeo JS, Ryu KH. The effect of 5Hz high-frequency rTMS over contralesional pharyngeal motor cortex in post-stroke oropharyngeal dysphagia: a randomized controlled study. Neurogastroenterol Motil. 2013 Apr;25(4):324-e250. doi: 10.1111/nmo.12063. Epub 2012 Dec 23.
- Results publication: PubMed 12849236Kobayashi M, Pascual-Leone A. Transcranial magnetic stimulation in neurology. Lancet Neurol. 2003 Mar;2(3):145-56. doi: 10.1016/s1474-4422(03)00321-1.
- Individual participant dataSharing planned: No. No IPD will be available to other researchers.
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Pere Clavé, MD, PhD principal investigator
Consorci Sanitari del Maresme
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A study testing rTMS + capsaicin 150μM (natural TRPV1 agonist) and tDCS + capsaicin 150μM (natural TRPV1 agonist) in people with Oropharyngeal Dysphagia and Stroke, run by Hospital de Mataró at 1 site in Spain.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 3 inclusion and 8 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: status not confirmed, as of the sponsor's last update on 13 Feb 2023. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site in Spain. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
Results are not available in the source record.
How can a doctor refer a patient or contact the research team?
Contact Pere Clavé, MD, PhD (+34937417700 ext. 1046, pclave@csdm.cat), or a site near the patient. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Changes in the videofluoroscopy (signs of safety and efficacy of swallow) (time frame: 5 days (changes between basal visit, time 0, and post-treatment visit, time + 5 days)). The study lists 11 primary outcomes in all. It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT05720871, which also lists 12 linked publications.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 13 Feb 2023.