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Evidence suggests a standardized program for screening, diagnosis and treatment of dysphagia following acute stroke results in reductions in the incidence of pneumonia, feeding tube dependency and length of hospital stay (Hinchey et al. 2005, Lakshminarayan et al. 2010). Bedside screening may include components related to a patient’s level of consciousness, an evaluation of the patient’s oral motor function and oral sensation, as well as the presence of a cough. It may also include trials of fluid. Coughing during and up to one minute following test completion, and/or “wet” or hoarse voice are suggestive of an abnormal swallow. Silent aspiration may occur in patients who do not cough or complain of any problems with swallowing or have no wet-sounding voice. If there is silent aspiration, the patient may not display any signs or symptoms on the trial swallows. It is possible for them to not demonstrate obvious problems during the initial screen and still be aspirating. Therefore, all stroke patients, regardless of their screening result, should be informally monitored during their hospital stay for symptoms of swallowing problems.
The effectiveness of a variety of treatments for dysphagia management was recently the subject of a Cochrane review (Geeganage et al. 2012). The results from 33 RCTs examining acupuncture, behavioural interventions, drug therapy, neuromuscular electrical stimulation, pharyngeal electrical stimulation, physical stimulation (thermal, tactile), transcranial direct current stimulation, and transcranial magnetic stimulation, were included. Pooling of results was not possible due to the small number of studies available evaluating similar interventions/outcomes. Death or dependency at end of trial was the primary outcome, although only two RCTs were included in the pooled result. The results were not significant (OR=1.05, 95% CI 0.63 to 1.75, p=0.86). Acupuncture and behavioural modifications were associated with a reduction in the incidence of dysphagia at the end of treatment. No significant treatment effect was associated with subgroup analysis by therapy type (behavioural interventions, drug therapy, and electrical stimulation) for the outcome of chest infections. These findings appear to be inconsistent with those from an earlier systematic review by Speyer et al. (2010), who concluded that a variety of treatments available for the management of dysphagia are generally effective. However, given the inclusion of patients with non-stroke etiologies of dysphagia and relatively small number of RCTs, these findings should not be compared directly with those reported by Geeganage et al. (2012).
Dietary modifications, including altered textured solids and fluids and the use of restorative swallowing therapy, and compensatory techniques, are the most commonly used treatments for the management of dysphagia in patients who are still safe to continue oral intake. Unfortunately, there is little direct evidence of their benefit. The effectiveness of behavioural modifications and dysphagia therapy has been examined in two RCTs. Carnaby et al. (2006) randomized 306 patients with dysphagia admitted to hospital within 7 days of acute stroke, to receive usual care, standard low-intensity intervention (composed of environmental modifications, safe swallowing advice and appropriate dietary modifications), or standard high-intensity intervention and dietary prescription (daily direct swallowing exercises, dietary modification), for up to one month. When the results from the high-intensity and low-intensity groups were combined and compared with the usual care group, patients in the active therapy group regained functional swallow sooner and had a lower risk of chest infections at 6 months. There were no differences between groups for the risk of death, death or dependency, death or institutionalization, or return to normal diet within 6 months. De Pippo et al. (1994) did not report a reduction in the incidence of pneumonia, dehydration, recurrent upper-airway obstruction or death associated with daily sessions with a speech language therapist during hospitalization on a stroke rehabilitation unit.
Enteral feeding is used when patients’ swallowing impairment precludes safe oral feeding. In the early days following stroke, treatment decisions usually centre on the type of feeding type to use (i.e., nasogastric or enteric feeding tubes). The evidence relating to the superiority of one type is lacking. In one arm of the FOOD trial (2005), patients were randomized to receive either a percutaneous endoscopic gastrostomy (PEG) or nasogastric (NG) feeding tube within 3 days of enrolment into the study. PEG feeding was associated with an absolute increase in risk of death of 1.0% (–10.0 to 11.9, p=0.9) and an increased risk of death or poor outcome of 7.8% (0.0 to 15.5, p=0.05). In a later systematic review by Foley et al. (2008), the authors (on the basis of 3 RCTs including the FOOD trial) concluded that NG feeding tube is not associated with a higher risk of death compared with PEG feeding. However, they suggested that PEG feeding is associated with fewer tube failures and fewer declines in nutritional status.
Treatment with neuromuscular electrical stimulation may be effective in the rehabilitation of dysphagia, although it is a treatment option not commonly used in clinical practice in Canada. Carnaby-Mann & Crary et al. (2007) conducted a systematic review and meta-analysis, which included the results from 7 studies of patients with oropharyngeal dysphagia secondary to stroke, cancer or other disease. A moderate treatment effect was reported for the outcome of change in swallowing score assessed using the Mann Assessment of Swallowing Ability score or the Functional Oral Intake Scale (SMD=0.66, 95% CI 0.47 to 0.85, p<0.001). Evidence of improvement in swallowing ability associated with NMES treatment has also been reported in RCTs which included only patients recovering from stroke (Kim et al. 2009, Xia et al. 2011, and Park et al. 2013).
Oral supplementation can be used for patients who are not able to consume sufficient energy and protein to maintain body weight, or for those with premorbid malnutrition. The FOOD trial (2005) aimed to establish whether routine oral nutritional supplementation in patients who could safely swallow and were prescribed a regular hospital diet, was associated with improved outcome after stroke. A total of 4,023 patients were randomized to receive or not receive an oral nutritional supplement (540 Kcals) in addition to a regular hospital diet, provided for the duration of their entire hospital stay. At 6 month follow-up, there were no significant differences between groups on the primary outcome of death or poor outcome (OR=1.03, 95% CI 0.91 to 1.17, p>0.05). The absolute risk of death or poor outcome was 0.7%, 95% CI -2.3 to 3.8. Only 314 (8%) patients were judged to be undernourished at baseline. The anticipated 4% absolute benefit for death or poor outcome from routine oral nutritional supplements was not evident. The FOOD trial results would be compatible with a 1% to 2% absolute benefit or harm from oral supplements. Results from RCTs examining nutrition-related outcomes suggest that oral supplements can increase the amount of energy and protein patients consume, and prevent unintentional weight loss (Gariballa et al. 1998, Ha et al. 2010).
It is also suggested that lifestyle modifications help improve an individual’s nutritional and physiological status. A recent RCT by Kono et al. (2013) demonstrated that 35 patients with stroke randomized to receive lifestyle modifications, in the form of education, counselling, and regular exercise, showed significantly lower salt intake (p=0.018), blood pressure (p<0.001), and HDL-C levels (p=0.022) compared to those receiving advice only (n=35). Lifestyle modifications are an important part of the rehabilitation process post stroke; all health care professions should advocate for appropriate lifestyle modifications that are individualized and appropriate for their patients.