Approaches to the rehabilitation of dysphagia in acute poststroke patients.

Approaches to the Rehabilitation of Dysphagia in Acute Poststroke Patients

ABSTRACT

Dysphagia occurs frequently following stroke and may result in serious health consequences including pneumonia, malnutrition, dehydration, and mortality. Prevention of these negative health outcomes requires early identification and treatment of dysphagia. The speechlanguage pathologist, as part of a multidisciplinary team, holds the primary responsibility for selection of an effective dysphagia rehabilitation program for these patients. Because much research has focused on patients with chronic dysphagia, this review will focus on treatment of patients within the acute phase of recovery poststroke. Although some acute patients may experience transient dysphagia that resolves spontaneously, many will go on to develop chronic dysphagia that may be prevented with provision of early and intensive treatment. An overview of dysphagia following stroke will be provided with information regarding incidence, complications, evaluation, and causes of dysphagia. A thorough discussion of evidence supporting varying approaches to dysphagia rehabilitation will follow with inclusion of several current, novel, and experimental techniques. The importance of the multidisciplinary team and regular reevaluation will be emphasized as well. KEYWORDS: Dysphagia, stroke, acute, rehabilitation, evidence

Learning Outcomes: As a result of this activity, the reader will be able to (1) report the incidence of dysphagia as well as its complications; (2) list several risk factors for dysphagia following stroke; (3) discuss evidence for the various approaches to dysphagia treatment in acute stroke patients; and (4) identify the importance of early intervention.

1

Geriatric Research Education and Clinical Center (GRECC), William S. Middleton Memorial Veterans Hospital; 2Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. Address for correspondence: Nicole Rogus-Pulia, Ph.D., CCC-SLP, William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison GRECC (11G), Room D5216, Madison, WI 53705 (e-mail: [email protected]).

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Early Intervention for Acquired Neurological Disorders; Guest Editor, Lyn S. Turkstra, Ph.D. Semin Speech Lang 2013;34:154–169. Copyright # 2013 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 5844662. DOI: http://dx.doi.org/10.1055/s-0033-1358368. ISSN 0734-0478.

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Nicole Rogus-Pulia, Ph.D., CCC-SLP,1,2 and JoAnne Robbins, Ph.D., CCC-SLP, BRS-S1,2

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very 40 seconds, on average, someone in the United States experiences a stroke.1 Due to the advancing age of the U.S. population, projections indicate that by 2030, an additional 4 million people will have had a stroke, a 21.9% increase in prevalence from 2013.1 Stroke results in many complications, one of the most life threatening of which may be dysfunctional swallowing or dysphagia. Patients with dysphagia are at increased risk for aspiration or the entry of food or fluid into the lungs. Therefore, dysphagia has many critical negative health consequences such as pneumonia, malnutrition, dehydration, and mortality. Speech-language pathologists (SLPs) are responsible, along with key multidisciplinary team members, for the diagnosis and treatment of dysphagia following stroke. Various rehabilitation approaches have been developed for the treatment of dysphagia after stroke with novel techniques emerging in recent years. Whereas many studies have examined patients with chronic dysphagia following stroke, this review will focus on the best approaches to early management of patients in the acute phase poststroke, when patient survival is most critical.

PREVALENCE AND INCIDENCE Prevalence of dysphagia following stroke has been reported to be up to 56%.2 Although the incidence of dysphagia following stroke is known to be high, the actual numbers vary based on method of identification, time after stroke, and lesion location.3 Mann et al reported incidences separately for occurrence of dysphagia versus aspiration, as not all patients with dysphagia were found to aspirate.4 There was clinical and videofluoroscopic evidence of a swallowing disorder in 51 and 64% of patients, respectively, and aspiration in 49 and 22% of patients, respectively.4

PROLONGED DYSPHAGIA While dysphagia may resolve within 14 days poststroke, with a mean time of 8.5 days,5 up to 42% of patients will develop dysphagia lasting beyond 14 days,6 with 11% demonstrating persistent problems at 6 months.7 Smithard

and colleagues examined 95 patients at 2 days poststroke as well as 1 month. Twenty-one (22%) aspirated on the initial assessment and 12 (15%) were still aspirating at 1 month. Interestingly, only four of those patients had persistent dysphagia; the remaining eight had not been previously identified. This study showed that dysphagia may persist, recur, or develop in patients later in the history of their stroke.8

COMPLICATIONS OF DYSPHAGIA AFTER STROKE Overall, dysphagia after stroke is associated with increased risk of mortality, disability, longer hospital stay, and increased need for rehabilitation services and institutional care.7,9,10 The presence of dysphagia during the acute phase specifically is associated with a higher likelihood for patients to reside in a nursing home and also a higher risk for mortality within the first 3 months poststroke.11,12

Malnutrition and Dehydration Dysphagia has been found to be associated with the development of malnutrition and dehydration after stroke.9,13,14 Undernutrition is common in stroke patients at the time of their admission (8 to 28%) and worsens during their hospital stay.15 Dehydration may be a consequence of a tendency by patients on modified diets to reduce intake of fluids.16 Both malnutrition and dehydration affect progress and response to treatment, length of stay, unplanned readmission, development of infection, and mortality.15,17

Pneumonia Dysphagic patients are at increased risk of developing aspiration pneumonia,18 a respiratory infection that is caused when food or fluids enter the lungs. Specifically, the development of pneumonia is over seven times greater in stroke patients who aspirate versus those who do not,3 and it is six times greater in patients who aspirate silently as compared with those who cough upon aspiration.19 Johnson and colleagues reported that 50% of stroke patients

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with dysphagia, who underwent videofluoroscopic evaluation of swallowing, developed aspiration pneumonia.18,20

SCREENING AND EVALUATION To avoid these complications of dysphagia after stroke, dysphagia needs to be detected early and managed effectively.21 It is crucial to assess swallowing status before any oral intake and within 24 hours of hospital admission to ensure nutrition and hydration needs are promptly managed.22 Early detection of dysphagia may reduce subsequent pulmonary complications in patients with stroke by as much as threefold.21 Masrur et al conducted a large study of acute ischemic stroke patients showing that dysphagia screening was performed in only two-thirds of eligible patients.23 Many studies have attempted to identify specific characteristics that can be gathered at the bedside to improve clinical predictive abilities regarding the presence of aspiration.24 Although various behaviors have been found to be associated with aspiration, Daniels et al25 concluded after a thorough systematic review that the best combination of items on a screening protocol remains to be elucidated. Multiple instruments have been developed for SLPs, nurses, and emergency department staff for screening stroke patients at the bedside for dysphagia.18,26–31 The Toronto Bedside Swallowing Screening Test (TOR-BSST) was developed and found to be both sensitive and predictive of dysphagia in patients with stroke in both acute and rehabilitation settings.32 The four items that constitute the final version of the TOR-BSST are a sequence: voice before water swallow, tongue movement, water swallow, and voice after water swallow.32 The bedside clinical examination has its limitations including subjectivity, lack of reliability, the chance to miss patients who are aspirating, as well as an inability to view pharyngeal events and the cause of aspiration.24,33 It is known that patients with dysphagia following a stroke may have laryngopharyngeal sensory deficits and a decreased cough reflex that result in silent aspiration,34,35 meaning aspiration with no

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apparent sign or response (“silently”), in 30 to 60% of patients.36 It is important to use instrumental examination in the form of videofluoroscopy or endoscopy to thoroughly examine swallowing.37,38

SWALLOWING DYSFUNCTION AFTER STROKE Videofluoroscopic findings in patients poststroke include poor tongue control, increased oral and pharyngeal transit times,39,40 longer stage transition durations,41 delayed initiation of laryngeal closure,42 reduced laryngeal closure duration,42 reduced range of motion of the hyoid bone,43 decreased laryngeal elevation,36 and worse penetration-aspiration scale scores as compared with normal controls.44 Sensory deficits also are common following stroke leading to silent aspiration.34 Oral sensory deficits also may occur making it difficult for a patient to adequately control the bolus or to initiate a swallow. A complete oral mechanism examination with cranial nerve testing is necessary to determine the type and severity of sensory deficits.

RISK FACTORS FOR DEVELOPMENT OF DYSPHAGIA During evaluation as well as treatment planning, it is important to be aware of known factors that may increase the likelihood that dysphagia will develop after a stroke.

Age Advanced age has been identified as a major risk factor with 75% of all strokes occurring in people over age 65 and the incidence of stroke rising with age.45 Swallowing disorders in the elderly are associated with increased development of pneumonia and mortality.46,47

Cognition Dysphagia and aspiration also occur more often during the acute stage of a stroke due to abnormal cognition.37 An increased ability of a patient to answer orientation questions correctly and to follow single-step verbal


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commands is predictive of lower odds of aspiration of both liquid and pureed consistencies.48

Stroke Severity The severity of a patient’s stroke, as determined by the National Institutes of Health Stroke Severity (NIHSS) scale, also has been found to increase the risk of dysphagia in acute stroke patients and the risk of nonoral status 48 hours after onset.23,49 Specifically, a score of 10 or higher on the NIHSS scale was reported to be an independent predictor for development of pneumonia.23

Lesion Location Daniels25 and Flowers et al50 performed a systematic review to identify lesion sites observed on magnetic resonance imaging that predict the presence of dysphagia in acute stroke patients. When examining infratentorial strokes only, pontine, medial medullary, and lateral medullary lesions predicted an increased risk of dysphagia.50 Gonzalez-Fernandez et al identified supratentorial regions of interest that might be related to clinically important dysphagia in acute stroke patients, focusing on subcortical structures.51 Significantly increased odds of dysphagia were found in subjects with internal capsule involvement. Other supratentorial areas that may be associated with dysphagia include the primary somatosensory motor and motor supplementary areas; orbitofrontal cortex; and the putamen, caudate, and basal ganglia areas.51 Bilateral hemispheric strokes, multiple lesion loci, brain stem lesions (especially lateral medullary stroke), and hemorrhagic stroke types all greatly increase the risk for dysphagia and its consequencies.37,52–55

Concurrent Medical Conditions Finally, concurrent medical conditions, specifically hypertension, diabetes mellitus, and smoking, have all been identified as risk factors for the development of dysphagia poststroke.53 Also, dysphagia is known to be associated with certain types of speech or language impairments including dysarthria, aphasia, and apraxia.56

MANAGEMENT In the acute phase after stroke, when the stroke has ceased its evolution, early screening and identification of dysphagia allows for early intervention by the SLP, which has been associated with reduced risk of aspiration pneumonia and improved cost effectiveness.57,58 Although it is known that swallowing may improve spontaneously within the acute phase for a subset of patients, it is critical that the patient be seen as early as possible to avoid muscle weakness or atrophy that can occur with disuse.37 In addition, there is growing evidence that the neural networks for swallowing are capable of experience-dependent neural plasticity that may be possible to induce through nonbehavioral and behavioral swallowing interventions.59,60 When selecting the optimal approaches to rehabilitation, it is necessary to use detailed information from the videofluoroscopic evaluation study as a guide. Knowledge of the presence of aspiration alone will not provide insight into the cause of swallowing dysfunction. It is most critical to determine the physiologic abnormalities that occur during the swallow that result in aspiration or limited bolus clearance. There are multiple factors that clinicians should consider when choosing an approach to intervention, including a patient’s life circumstances, preferences, coping mechanisms, and cooccurring medical issues.24 Evidence-based practice should be the cornerstone of all clinical decision making and clinicians should always ask themselves whether the particular treatment under consideration should work or not, based on the evidence.61 In the acute phase poststroke, challenging questions regarding whether a particular treatment will enhance recovery of swallowing, how long to leave a patient without oral intake on parenteral fluids only, or when to start tube feeding may arise.62 In the following subsections, multiple approaches to management and treatment of the acute stroke patient will be discussed and considered.

Nonoral Intake For patients in the acute phase poststroke when prevention of aspiration pneumonia is the main

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concern, nonoral intake by way of nasogastric (NG) tube, gastrostomy tube, or jejunostomy tube often is recommended. However, tube feeding has not been shown to reduce the risk of aspiration or pneumonia. A patient whose dysphagia is apparent during oral eating will probably continue to aspirate when nutrition is delivered directly to the stomach or beyond. Feeding tubes do not prevent (1) aspiration of contaminated oral secretions or (2) regurgitated gastric contents—both are well-documented causes of aspiration pneumonia.63 Despite this, some patients may need nonoral nutrition for a short period of time or long-term to ensure that nutrition and hydration needs are met.24 The Feed Or Ordinary Diet (FOOD) trials consisted of three multicenter randomized controlled trials, two of which included dysphagic stroke patients. The first trial showed that, for patients enrolled within 7 days of admission, there was a nonsignificant absolute difference in terms of risk of death in favor of those patients who received early enteral tube feeding versus those who did not. However, the improved survival was offset by a 4 to 7% excess of patients surviving with poor quality of life after early enteral tube feeding.64 In the second trial, patients were assigned to percutaneous endoscopic gastrostomy (PEG) or NG feeding. There were again no significant differences in outcomes but there was an absolute difference in death or poor outcome in favor of NG feeding. NG tubes are associated with more risks related to tube failures and declines in nutritional status.65 Interestingly, only 28% of patients who received NG tube feeding in the second trial later required a PEG tube, so it does not appear that placement of an NG tube earlier inevitably leads to PEG tube placement. However, as compared with long-term NG feeding, PEG tubes may be a safer option.66

Ethical Considerations Ethical considerations must be considered when making the decision regarding nonoral intake. It is critical that the patient and/or care providers are included in the decision-making process to the maximum of his or her ability.

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There may be times when a patient refuses nonoral nutritional management despite the fact that there may be a good chance they will achieve an acceptable quality of life.67 Clear and thorough objective discussion of alternative methods is the major role of the SLP in this sensitive yet critical process.

TREATMENT Options for swallowing intervention can be divided into three categories: compensatory strategies, indirect rehabilitation strategies, and direct rehabilitation strategies.68 Compensatory strategies are aimed at keeping the patient safe with oral intake without long-term changes to swallowing physiology. These strategies often are used as temporary measures in the interim until recovery or improvement with rehabilitation techniques occurs. Rehabilitation strategies in general are directed at accelerating the recovery process and enacting change in the physiology,68 including sensory stimulation as well as motoric redirection of the bolus. Indirect strategies include stimulation of the oral and pharyngeal structures without the specific task of swallowing or “sensorimotor without swallowing” exercises to improve range of motion and strengthening of swallowing musculature. Direct rehabilitation strategies involve active exercises, often rigorous, during the specific task of swallowing; “sensorimotor with swallowing.”

Neuroplasticity A main premise of neural plasticity is that it occurs with experience-specific conditions, so it seems that exercise involving the act of swallowing would be most effective.59 However, evidence exists that swallowing musculature may be strengthened with nonswallow exercise.69 Whether or not an approach that involves the act of swallowing is employed depends upon the patient’s ability to swallow his or her own secretions safely. With those patients for whom swallowing is not safe or feasible even without a bolus (saliva swallows), indirect strategies may be a useful alternative to rehabilitation techniques that involve swallowing.


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Behavioral Plasticity POSTURES

Compensatory techniques include postures such as chin tuck, head rotation, head tilt, head back, and side lying. By altering the position of the head through postural adjustments, gravity can influence bolus flow. These postures are not meant as a permanent solution but rather a temporary option to allow for safe oral intake while the patient undergoes active rehabilitation and recovery. Nonetheless, these postures must be implemented for each swallow and may diminish the pleasure associated with dining. Frequent reevaluation of a patient is important to ensure a patient does not need to continue use of a posture on every swallow past the point of necessity. Few studies have examined the efficacy of the use of postures in alleviating symptoms of dysphagia. The chin-down posture involves tucking the chin toward the neck, which is thought to increase the size of the vallecular space, invert the epiglottis into a more protective position, and reposition the base of tongue closer to the posterior pharyngeal wall allowing for improved contact and intrabolus pressure generation.68 Terre´ and Mearin found that use of a chin-down posture prevented aspiration in 55% of patients with neurogenic dysphagia secondary to brain injury (stroke and trauma).68 The authors concluded that this posture may increase swallow safety for a significant group of patients but is not applicable to all dysphagic patients.68

DIET MODIFICATION

When reintroducing oral intake to dysphagic patients, the primary goal is to establish the safest possible consistencies to prevent aspiration and optimize nutrition. Diet modification is a commonly used compensatory technique that is meant as a temporary solution and, for quality of life reasons, is recommended as a last option after attempting other techniques first.24 Modifications typically include alterations in dietary textures and fluid viscosities.3 In the few studies that have examined the effects of diet modification on aspiration rates, the results have been conflicting.70,71 Also, many patients or their families reject thickened liquids as an intervention and prefer to risk aspiration pneumonia. Robbins et al followed a subset of 711 patients in a randomized clinical trial for 3 months and reported a more than twofold increase in pneumonia incidence in patients who received a honey-thick liquid (3000 centipoise) versus nectar-thick liquid (300 centipoise).72 Those patients who became ill and were hospitalized and were treated with honeythick beverages spent three times as many days in the hospital as those using chin tuck or nectar-thick liquid. Therefore, if a patient aspirates thickened liquids, they are more likely to develop pneumonia as thicker viscosities, in this case starch based, may be more difficult to eject from the airway. If a modified diet is determined to be an appropriate intervention for patients poststroke, it is important that the specific thickness of fluids or consistency of solids is communicated clearly to the nursing staff, patient, and patient’s family. Often, varying terms are used to describe different types of modified diets22; therefore, it is critical to be clear with all persons involved in the patient’s care. EATING STRATEGIES

Due to fatigue, planning 30 minutes of rest including oral rest (limited conversation) before eating may be helpful. Creation of an eating environment free from distraction, optimizing sitting position when eating, and making sure patients take small, controlled bites or sips may all be useful.73 Involvement of other members of the team, including the physical therapist for work on improving trunk stability and sitting


Compensatory Techniques These treatment techniques are intended to alter the circumstances of the swallow instead of the swallow patterns themselves. Therefore, compensatory techniques are thought to be behavioral and to induce behavioral plasticity. Some may have anticipated temporary effects,59 whereas others such as heightened sensory characteristics of the bolus (taste, temperature, bolus volume) may have more longterm effects. These techniques may be combined with more rigorous interventions once the patient’s ability to participate in active therapy emerges.

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balance as well as the occupational therapist for adjustment and selection of eating devices or practice of upper extremity movements during eating, also may be important.73 ORAL HYGIENE

Recently, there has been an increased awareness that consistent oral health care decreases the risk for developing aspiration pneumonia in the stroke patient.24 Professional oral care is associated with lower incidence of fevers and death from pneumonia.24 Oral care has been found to elevate the serum concentration of substance P, a neurotransmitter that is involved in cough and swallowing response.74 However, it also is known that the acute stroke population often is unable to perform adequate oral care.75 Xerostomia (mouth dryness), commonly caused by nothing per oral status, lower levels of consciousness, mouth breathing, prolonged oxygen therapy, and medication effects may be an additional factor in the development of aspiration pneumonia because decreased quantity of saliva along with alterations in quality of saliva may lead to increased levels of microorganisms in the oral cavity.75 Some techniques to improve oral health and decrease pneumonia risk after stroke include moistening the patient’s mouth every 2 to 4 hours with a water soluble moisturizer, brushing the patient’s teeth or dentures twice daily to prevent plaque formation, rinsing the patient’s mouth with an antimicrobial mouth rinse (chlorhexidine), lubricating the lips with a water soluble lubricant, and elevating the head of the bed greater than 60 degrees or sitting upright for at least a half hour after eating.75

Indirect Rehabilitation Techniques: Sensory Enhancement Sensory abnormalities have been documented in patients with dysphagia following stroke.34 To address these sensory deficits, multiple techniques have been developed to increase sensory input during the swallow.76

Bolus Alterations One fairly simple way to provide heightened sensory information during swallowing is to change characteristics of the liquid or food

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being swallowed (bolus). Several studies have shown effects of taste, temperature, volume, and viscosity on various measures of swallowing function, including pharyngeal transit time and pharyngeal delay times.77–79 Although there is some evidence to support the effects of alterations to the bolus, studies did not consistently include a control group and had small numbers. In addition, it is unclear how long these effects last after the sensory bolus is presented. Therefore, these effects require further investigation.

Oral Stimulation: Thermal-Tactile Stimulation Thermal-tactile stimulation is a technique used to improve triggering of the pharyngeal phase of the swallow and to increase the speed of swallowing.59 Traditionally, a size 00 laryngeal mirror is chilled on ice and then rubbed on each of the anterior faucial arches four to five times prior to the swallow. Several studies have shown temporary effects on the timing of the pharyngeal swallow response but penetration-aspiration scores were not affected.80–82 Larger trials that include the acute stroke population are necessary to determine which parameters (thermal versus tactile) are most critical.

Oropharyngeal Air-Pulse Application Recently, a novel treatment, oropharyngeal airpulse application, has been developed in which manually generated air-pulse trains are delivered to the peritonsillar region of the oropharynx. Studies in normal subjects revealed increased rates of swallowing and activation in brain regions that correlate with the swallowing network after this treatment.83 In 2013, Theurer et al examined effects of oropharyngeal air-pulse application on resting swallow following hemispheric stroke and reported an increase in resting swallowing rates associated with unilateral oropharyngeal air-pulse application.83 It appears that various types of oral stimulation may have a role in enacting temporary changes in the swallow, but the long-term effects of these treatments, most effective types of stimulation and intensity, and influence of individual components (i.e., thermal versus


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Sensorimotor without Swallow These types of exercises are developed to improve range of motion and strength of oropharyngeal structures without requiring patients to actually swallow a bolus. This allows patients to progress through the exercises safely without limitations due to the need to swallow a bolus.59

Lingual Strength Training Patients with dysphagia poststroke have been found to generate lower average maximal tongue pressures than those without dysphagia, and tongue pressure production has been found to be closely related to poststroke dysphagia.84 Lingual strength training is known to result in behavioral plasticity of swallowing.59 Robbins et al examined effects of lingual exercise on various aspects of swallowing recovery poststroke including lingual anatomy.69 An isometric lingual exercise regimen resulted in significantly increased isometric and swallowing pressures as well as change in tongue volume measured with anatomic magnetic resonance imaging. Airway invasion was reduced for liquids, and the two subjects with lingual volume measures demonstrated increased lingual volume indicating neuromuscular plasticity accompanying behavioral changes.69

Direct Rehabilitation Strategies: Sensorimotor Exercises with Swallowing/Neuromuscular Plasticity Motor exercises accomplished during swallowing are based on the assumption that, to enact changes in muscle strength and range of motion or to facilitate adaptation, exercises need to be task specific. The goal of these exercises is to reduce abnormalities within the swallow response itself. This category of exercises comprises swallow maneuvers such as the Mendelsohn, supraglottic swallow, super-

supraglottic swallow, effortful swallow, tongue hold, and double swallow.59 MENDELSOHN MANEUVER

The Mendelsohn maneuver, or voluntary prolongation of hyolaryngeal elevation at the peak of the swallow, has been used both as an exercise and a compensatory strategy to increase laryngeal elevation, hyoid displacement, and duration of upper esophageal sphincter (UES) opening.85 Several studies have examined effects of various exercise regimens consisting of the Mendelsohn maneuver along with surface electromyography for biofeedback on various aspects of swallowing in patients poststroke.85–87 Results have shown improvements in oral intake, extent of hyoid movement and UES opening, and coordination of structural movements with each other as well as with bolus flow.85–87 SUPRAGLOTTIC AND SUPER-SUPRAGLOTTIC MANEUVERS

A study by Chaudhuri et al suggested that the use of the supraglottic and super-supraglottic swallowing techniques that create the Valsalva maneuver may need to be avoided in patients with a history of stroke.88 In patients with history of stroke with or without coronary artery disease, abnormal cardiac findings while performing these techniques were observed in 87% of patients.88 Therefore, these maneuvers that require a breath hold may be contraindicated in this population. INFORMATION OF PERFORMANCE OR BIOFEEDBACK

Providing information of performance or biofeedback as a supplement to traditional swallow exercises has been explored in patients with chronic dysphagia.89–92 Several studies previously discussed have included the addition of surface electromyography to a more traditional exercise regimen with encouraging results.85–87 However, none of these studies included a group of patients who did not receive the adjunct biofeedback, so the additional effects of biofeedback are difficult to determine. Due to the lack of existing evidence, the Royal College of Physicians (RCP) National Clinical Guidelines for Stroke recommends that biofeedback should not currently be used outside of the context of clinical trials.33


tactile) have yet to be understood. Also, according to Robbins et al, depending on the location of stimulation, a particular treatment’s intensity may have indifferent, therapeutic, or contratherapeutic effects.59

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Recently, Stepp et al described a novel system to pair surface electromyography biofeedback with video gaming for dysphagia rehabilitation.93 A small initial feasibility study of the system in an individual with dysphagia and six unimpaired individuals demonstrated that all individuals studied were able to use the system. The patient with dysphagia reported improved management of secretions and the therapist noted subjectively an increase in the speed of voluntarily initiated laryngeal elevation.93 NEUROMUSCULAR ELECTRICAL STIMULATION

Transcutaneous neuromuscular electrical stimulation (NMES) is hypothesized to target strengthening of the oropharyngeal musculature in disuse atrophy while also providing sensory feedback to the central pattern generator in the brain stem as well as the cortical/ subcortical swallowing centers.94–96 This treatment approach has received much attention in the literature.97–100 Yet, evidence of its efficacy remains limited with many studies being poorly controlled or with small numbers.97,101–103 Some studies have shown it to have no additional benefit over standard treatment.104–106 Kushner et al recently designed a casecontrol study in poststroke patients within the acute phase to evaluate the efficacy of NMES when added to a traditional dysphagia treatment (TDT) protocol in comparison with the traditional protocol alone during inpatient rehabilitation.94 Patients assigned to the NMES plus TDT group had significantly higher functional oral intake scale scores than those in the TDT only group. There were several limitations to this study, including uneven numbers in each group that could have biased results toward the NMES plus TDT group, selection bias in assigning patients to groups, a lack of blinded design, and missing videofluoroscopic swallowing studies for some patients.94

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are both becoming of value for dysphagia research by allowing a quantifiable measurement of changes in cortical activity that can then be correlated with actual measures of swallowing function taken from videofluoroscopy or manometry.107 Hamdy and colleagues were the first to conduct a series of studies using TMS.108 They reported that dysphagia after a cortical stroke results when the hypothesized swallowing-dominant hemisphere is affected. Recovery occurs as the cortical swallowing areas expand into the nondamaged hemisphere.108 Although preliminary results are encouraging, the tDCS and repetitive TMS techniques are certainly still worth investigating, and the most effective stimulation parameters in terms of hemisphere targeted, intensity, duration of the treatment, long-term effects, or the optimal population that could benefit from the therapy are unknown.109 See Table 1 for summary of research using repetitive TMS or tDCS in acute patients poststroke. ACUPUNCTURE

Several studies have reported on the use of acupuncture for stroke recovery and specifically to treat dysphagia following stroke.110–113 It is hypothesized that acupuncture may stimulate diseased muscles, nerves, tissues, or organs and/ or improve circulatory parameters.114 Xie et al performed a systematic review to determine the therapeutic effect of acupuncture for dysphagia after acute stroke compared with placebo, sham, or no acupuncture intervention.114 Only one study of 66 participants with acute stroke met inclusion criteria.111 Adding acupuncture to standard Western medical treatment was associated with an insignificant increase in full resolution of dysphagia in the short term.111,114 At this time, no clear evidence is available to support routine use of acupuncture in acute patients poststroke. CONTROLLED SYSTEMATIC APPROACHES VERSUS COMBINED STRATEGIES FOR

Other Treatment Approaches TRANSCRANIAL MAGNETIC STIMULATION AND TRANSCRANIAL DIRECT CURRENT STIMULATION

Transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS)

TREATMENT

In summary, there are multiple treatment options available for patients with dysphagia poststroke. However, there is still much research needed to determine the most efficient and effective approach, which may vary by patient. The best approach to treatment is likely to be a


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18 patients (10 males; 8 females) randomly assigned to experimental or control group

30 patients (17 males; 13 females) randomly assigned to sham, low-frequency, or high-frequency group

26 patients (10 males; 16 females) randomly assigned to real or sham group

22 patients (16 males; 6 females) randomly assigned to real or sham group

14 patients (7 males; 7 females) randomly assigned to stimulation or sham group

20 patients (14 males; 6 females) randomly assigned to stimulation or sham group

Park et al121

Kim et al122

Khedr et al123

Khedr and Abo-Elfetoh124

Kumar et al125

Shigematsu et al126

rTMS

< 3 mo since onset; unilateral hemispheric brain lesion

tDCS

tDCS

>1 mo after onset

rTMS

24 to 168 h after onset; subacute unilateral hemispheric infarction

3–6 wk after onset; lateral medullary syndrome or brain stem infarction

rTMS

rTMS

> 1 mo since onset; unilateral hemispheric

Between 5 and 10 d after onset; unilateral hemispheric stroke

rTMS or tDCS

Stroke Details

Anodal tDCS to unaffected hemisphere over 5 consecutive days along with concurrent swallowing maneuvers 10 sessions lasting 20 min each of either 1 mA anodal tDCS to ipsilesional hemisphere or sham along with conventional swallowing therapy

10 trains of 3-Hz stimulation, each lasting 10 s; repeated every minute; positioned over esophageal cortical area of the affected hemisphere; applied for 10 min every day for 5 consecutive days 300 pulses at 3 Hz to each hemisphere for 5 consecutive days

Low frequency ¼ 1 Hz; high frequency ¼ 5 Hz for 10 s repeated every minute; 2 wk (5 d/wk, 20 min per session)

5 Hz over unaffected pharyngeal motor cortex, 10 min/d for 2 wk

Details of Stimulation

Greater improvement in DOSS scores in real group than sham maintained over 2 mo of follow-up Higher DOSS scores in stimulation group versus sham after controlling for multiple variables DOSS scores improved in stimulation group but not in sham group

Decreases in videofluoroscopic dysphagia scale scores and penetration-aspiration scale scores in experimental group Improvements in functional dysphagia scale scores and penetration-aspiration scale scores in low-frequency group only Greater improvement in DOSS scores and Barthel Index scores in real group than sham maintained over 2 mo of follow-up

Result(s) Following Stimulation


Abbreviations: DOSS, Dysphagia Outcome and Severity Scale; rTMS, repetitive transcranial magnetic stimulation; tDCS, transcranial direct current stimulation; TMS, transcranial magnetic stimulation.

Sample

Author(s)

Table 1 TMS and tDCS Studies in Patients with Dysphagia Poststroke


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combined approach incorporating multiple techniques including both sensory and motor aspects to facilitate adaptation. Systematic reviews assessing therapeutic interventions for adults recovering from dysphagia after stroke found significant heterogeneity of intervention and an overall need for studies with improved design and larger numbers of subjects.15,115 European survey data also indicate highly variable clinical practice patterns with lack of standardized outcome measures. The most commonly reported treatment approach was supervised swallow trials, which may avoid disuse atrophy but are not an exercise that challenges the system beyond typical use. Clinicians also reported seeing their patients for direct dysphagia therapy at a lower frequency than has been recommended.33 The results of this study are both concerning and supportive of a need for clinicians to carefully review standing evidence before choosing a treatment approach or combination of treatments with patients.

EARLY INTERVENTION IS KEY Regardless of the approach taken, as mentioned previously, early intervention is known to be particularly important for patients with dysphagia after stroke. Carnaby and colleagues conducted a randomized controlled trial with 306 patients with acute stroke and dysphagia.116 Patients were randomly assigned to receive usual care prescribed by an attending physician, standard low-intensity intervention comprising swallowing compensatory techniques and diet prescription three times weekly for up to a month, or standard high-intensity intervention and dietary prescription at least daily for up to a month. The primary outcome measure was survival free of an abnormal diet at 6 months. Compared with usual care and low-intensity therapy, high-intensity therapy was associated with an increased proportion of patients who returned to a normal diet and recovered swallowing by 6 months.116

MULTIDISCIPLINARY APPROACH It is known that dysphagia poststroke is best addressed through a systematic management plan.2 Stroke units reduce mortality and are the cornerstones of stroke care.117 The combina-

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Table 2 Stroke Rehabilitation Multidisciplinary Team Members Speech-language pathologist Occupational therapists

Social workers Dentists

Physical therapists

Pharmacists

Physicians Nurses

Dietitians Psychologists

tion of acute treatment and early rehabilitation seems to be one of the most important factors for effective stroke unit care and is extremely relevant to the treatment of dysphagia.117 It is necessary to include dysphagia-specific management as part of standard protocols in stroke management.114 See Table 2 for a summary of multidisciplinary team members. This list is not comprehensive as other team members may be included depending on each patient’s needs.

REEVALUATION Many times patients are recommended to use a certain compensatory strategy or treatment approach as an inpatient but, once discharged, are not followed closely enough. In a study by Heckert et al,118 medical records of 226 acute stroke patients were examined. Eleven percent of patients with dysphagia would not have been identified without reassessment and 12% required diets more conservative than prescribed in acute care.118 Resolution of dysphagia occurs over the days, weeks, and months following stroke, which may allow for resumption of a regular diet.119 It also is important to ensure the recommended treatment for dysphagia is still effective following discharge. Pneumonia associated with dysphagia is an all too frequent reason patients are readmitted within a short period. Those acute stroke patients experiencing readmissions within 30 days have much poorer survival over the following year than those who are not readmitted,120 so preventing this with close follow-up and reevaluation is critical.

CONCLUSIONS Due to its serious consequences if left untreated, early identification and intervention for dysphagia


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following stroke is critical. Chronic dysphagia may be prevented if patients in the acute phase are provided early in their recovery with a clear rehabilitation plan. SLPs treating these patients have various rehabilitation approaches from which to choose but, in most cases, a combined approach will be most effective. Compensatory strategies may be employed as an interim solution if patients are unable to participate in treatment or in conjunction with a treatment approach that requires active participation. These patients have great potential to regain swallowing function following stroke if intervention is provided early, accurately, and often. The SLP carries the primary responsibility for treating these patients in order for the patients to avoid serious health consequences and to once again enjoy the process of eating. ACKNOWLEDGMENTS

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Poststroke Communication Disorders and Dysphagia.

Rehabilitation of poststroke cognition.

Dysphagia Rehabilitation in Japan.

The individualized rehabilitation interventions for dysphagia: a multidisciplinary case control study of acute stroke patients.

The incidence of dysphagia in patients receiving cerebral reperfusion therapy poststroke.

Nursing interventions in dysphagia rehabilitation.

Ethnic differences in poststroke rehabilitation outcomes.

Neuropharmacologic Approaches to Cognitive Rehabilitation.

Longitudinal changes in poststroke spatiotemporal gait asymmetry over inpatient rehabilitation.

Static Facial Slings: Approaches to Rehabilitation of the Paralyzed Face.

Bringing holistic treatments to the attention of medicine: acupuncture as an effective poststroke rehabilitation tool.

Approaches to Predicting Outcomes in Patients with Acute Kidney Injury.

Effect of dysphagia rehabilitation on oral intake in elderly patients with aspiration pneumonia.

Two cases of acute dysphagia.

Feasibility of Focused Stepping Practice During Inpatient Rehabilitation Poststroke and Potential Contributions to Mobility Outcomes.

Approach to patients with esophageal Dysphagia.

National Institutes of Health Stroke Scale (NIHSS) as An Early Predictor of Poststroke Dysphagia.

Upper Limb Immobilisation: A Neural Plasticity Model with Relevance to Poststroke Motor Rehabilitation.

BDNF Genotype Interacts with Motor Function to Influence Rehabilitation Responsiveness Poststroke.

Pilot randomized controlled trial of self-regulation in promoting function in acute poststroke patients.

subacute ischemic stroke patients with Dysphagia.

Telerehabilitation and emerging virtual reality approaches to stroke rehabilitation.

Current concepts and future approaches to vestibular rehabilitation.

Isolated acute dysphagia due to varicella-zoster virus.