Swallowing disorders after ischemic stroke

Prevalence and Risk Factors of Poststroke Dysphagia: A Meta-Analysis

INTRODUCTION

In patients with stroke, poststroke dysphagia (PSD) is a common complication that plays an important role in morbidity and mortality. The aim of this paper was to assess the prevalence and risk factors of PSD using a systemic review and meta-analysis.

METHODS

PubMed, Embase, Cochrane Library, and Web of Science databases were systematically searched for potentially eligible studies published until September 2023. Further, the pooled incidence and risk factors for PSD were determined using a random-effects model. Overall, 58 studies involving 37,404 patients with acute stroke were selected for the meta-analysis.

RESULTS

The pooled incidence of PSD in patients with acute stroke was 42% (95% confidence interval [CI]: 36-48%), which is the highest in South America (47%) and lowest in Asia (37%). Notably, older age (odds ratio [OR]: 2.13; 95% CI: 1.53-2.97; p < 0.001), hypertension (OR: 1.23; 95% CI: 1.06-1.44; p = 0.007), diabetes mellitus (OR: 1.22; 95% CI: 1.04-1.44; p = 0.014), stroke history (OR: 1.26; 95% CI: 1.04-1.53; p = 0.019), and atrial fibrillation (OR: 1.58; 95% CI: 1.02-2.44; p = 0.039) were found to be associated with an increased risk of PSD. Conversely, sex differences, smoking, alcoholism, obesity, hyperlipidemia, ischemic heart disease, stroke type, and the hemisphere affected were not associated with the risk of PSD.

CONCLUSION

The abstract reports the prevalence of PSD in patients with acute stroke and identified potential risk factors for PSD, including older age, hypertension, diabetes mellitus, stroke history, and atrial fibrillation.

Short-term and long-term effects of unilateral external carotid artery ligation on orofacial functions in rats

The external carotid artery (ECA) plays a major role in supplying blood to the head and neck. Although impeded blood flow in the ECA is expected to affect orofacial functions, few studies have shown how blood flow obstruction in the ECA contributes to impairment of these functions, including chewing and swallowing. This study was performed to investigate the effects of ECA ligation (ECAL) on immediate and long-term changes in masticatory and swallowing functions as well as the jaw-opening reflex evoked in the digastric muscle. The experiments were carried out using male Sprague-Dawley rats. In the acute experiment, the digastric reflex evoked by low-threshold electrical stimulation of the inferior alveolar nerve and the swallow reflex, identified by digastric and thyrohyoid electromyographic (EMG) bursts, were compared between before and 1 h after ECAL. The chronic experiment was conducted on freely moving rats. EMGs of the masseter, digastric, and thyrohyoid muscles were chronically recorded. The long-term effects of ECAL on behavior and muscle histology were compared between rats with an intact ECA and rats with ECAL. In the acute experiment, the peak amplitude of the digastric reflex on the ECAL side was significantly decreased 1 h after ECAL. In the chronic experiment, although most parameters of the masticatory and swallowing EMGs were not significantly different between the groups, the results suggest wide variation of the effect of ECAL on the muscles. Blood supply compensation from collaterals of the internal carotid artery may be permanent in some animals.NEW & NOTEWORTHY The inhibitory effect of unilateral external carotid artery ligation (ECAL) on the ipsilateral digastric reflex was small but evident. Most parameters of masticatory and swallowing muscle activity were not significantly different after ECAL. Wide variation was noted in the effect of ECAL on the ipsilateral muscle activity. Blood supply compensation from collaterals of the internal carotid artery may occur in response to the impaired blood flow.

Post-stroke dysphagia: Clinical characteristics and evolution in a single-primary stroke center

BACKGROUND

Dysphagia is a common manifestation after stroke and seems to play a major role in clinical and functional outcomes.

OBJECTIVES

To identify clinical predictors of higher degrees of dysphagia, as well as assess its burden in our hospital, in order to understand how to improve the approach to this symptom.

METHODS

We included 311 patients admitted in an acute stroke unit in a year-long period. The relationship of dysphagia with different outcomes, both in acute phase and within the first year after stroke, were investigated.

RESULTS

Using the Pearson Correlation Coefficient, NIHSS score at admission was positively correlated with the degree of dysphagia (r = 0,783; p <  0,001) and total anterior circulation infarcts and age (>  70 years) were also associated with higher risk of dysphagia (p <  0.001). During hospitalization both respiratory infections and mortality occurred at significantly higher rates for dysphagic patients (p <  0.001) and we observed an increasing trend towards a higher mortality rate, the higher the degree of dysphagia. These patients stayed longer in the stroke unit, with less chance to be discharged home and more frequently transferred to inpatient rehabilitation care. One year after admission, dysphagic patients were more frequently readmitted due to pneumonia and we observed a higher mortality rate compared to patients without dysphagia (p <  0.001).

CONCLUSION

The presence of the above-mentioned dysphagia predictive factors should alert us to the need for an early approach, starting in the stroke unit, but also after discharge, taking into account its impact on clinical outcomes, mortality and healthcare costs.

Risk factors of dysphagia in patients with ischemic stroke: A meta-analysis and systematic review

Background

Dysphagia is a common yet serious complication in stroke patients. We aimed to conduct a meta-analysis and systematic review to evaluate the risk factors of dysphagia in patients with ischemic stroke, to provide insights to the clinical treatment and nursing care of dysphagia.

Methods

We searched PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI) and Wanfang Database, China Biomedical Literature Database (CBM) for studies on dysphagia in patients with ischemic stroke up to January 31, 2022. The quality of the literature was evaluated using the Newcastle-Ottawa scale. Meta-analysis was performed using RevMan 5.3 software.

Results

A total of 10 studies involving 4637 ischemic stroke patients were included, 1183(25.51%) patients had dysphagia after stroke. The synthesized outcomes showed that elder age (SMD = 0.42, 95%CI:0.34–0.50), hypertension (OR = 1.96, 95%CI:1.48–2.61), diabetes (OR = 1.83, 95%CI:1.47–2.28), brainstem stroke (OR = 2.12, 95%CI:1.45–3.09) were associated with dysphagia in patients with ischemic stroke (all P<0.05). There was no significant difference in the gender between dysphagia and no dysphagia patients (OR = 1.07, 95%CI:0.91–1.27, P = 0.40). Egger regression tests indicated there were no significant publication biases in the synthesized outcomes (all P>0.05).

Conclusions

Elder age, hypertension, diabetes and brainstem stroke are associated with the development of dysphagia in patients with ischemic stroke. Attention should be paid to the assessment and early intervention of those risk factors for dysphagia to improve the prognosis of stroke patients.

Dysphagia is a strong predictor of death and functional dependence at three months post-stroke

BACKGROUND

Few Brazilian studies investigated risk factors for dysphagia and associated complications in a large cohort.

OBJECTIVE

To investigate frequency, predictors, and associated outcomes of dysphagia in patients up to three months post-stroke.

METHODS

Prospective cohort study of consecutively admitted patients in a specialized center for acute stroke. Patients with a transient ischemic attack, subarachnoid hemorrhage, cerebral venous thrombosis, hemorrhagic stroke with secondary cause, non-acute stroke, or those who did not consent to participate were excluded. Swallowing was evaluated by speech language pathologists using Volume-Viscosity Swallow Test. General function at three months post-stroke was assessed using the following instruments: Modified Rankin scale, Barthel Index and Functional Independence Measure.

RESULTS

A total of 831 patients were admitted and 305 patients were included according to the inclusion and exclusion criteria. The mean age of patients was 63.6±13.3 years, mean time from stroke to swallowing assessment was 4.2±4.1 days, and 45.2% of the patients had dysphagia. Age (OR=1.02; 95%CI 1.00-1.04; p=0.017), known medical history of obstructive sleep apnea (OR=5.13; 95%CI 1.74-15.15; p=0.003), and stroke severity at hospital admission (OR=1.10; 95%CI 1.06-1.15; p<0.001) were independently associated with dysphagia. Dysphagia (OR=3.78; 95%CI 2.16-6.61; p<0.001) and stroke severity (OR=1.05; 95%CI 1.00-1.09; p=0.024) were independently associated with death or functional dependence at three months.

CONCLUSIONS

Dysphagia was present in almost half of stroke patients. Age, obstructive sleep apnea, and stroke severity were predictors of dysphagia, which was independently associated with death or functional dependence at three months.

Potential Prognostic Impact of Dopamine Receptor D1 (rs4532) Polymorphism in Post-stroke Outcome in the Elderly

Background: Single-nucleotide polymorphisms (SNPs) may affect post-stroke motor recovery, and some SNPs have been implicated in swallowing disturbances after stroke. Certain SNPs may also have altered influences according to different age. Objective: This post-hoc study investigated whether SNPs have different effects on dysphagia recovery between the elderly vs. young stroke patients. Methods: Analysis was conducted from a previous study including 218 stroke subjects with dysphagia. They were stratified into two groups, aged <65 and aged ≥65 years. The primary outcome was persistence of nil per mouth (NPM) at 3 months post-stroke onset. Association between outcome and nine different SNPs were investigated. Results: The elderly group (50%, n = 103) showed poorer swallowing outcomes than the young group. The minor allele of the dopamine receptor D1 (DRD1, rs4532) polymorphism showed potential association (p = 0.022) with an increased risk of NPM at 12 weeks post-stroke in the elderly, both in the additive (OR, 2.94; 95% CI, 1.17-7.37) and dominant models (OR, 2.93; 95% CI, 1.04-8.23) but did not reach statistical significance after Bonferonni correction. Logistic regression analysis showed that in those aged ≥65 years, models including the minor allele of rs4532 predicted the risk of the poor outcome with good accuracies even after adjustment of clinical factors, such as previous pneumonia episodes (AUROC, 0.86; 95% CI, 0.79-0.93) or the National Institutes of Health Stroke Scale (AUROC, 0.82; 95% CI, 0.67-0.92). In contrast, those aged <65 years seemed not to be affected by the presence of the rs4532 polymorphism, and models that included intubation history (AUROC, 0.81; 95% CI, 0.73-0.90) or previous pneumonia episodes (AUROC, 0.77; 95% CI, 0.68-0.87) showed modest levels of accuracies in predicting NPM at 12 weeks poststroke. Conclusions: Our study suggests a possible association between the rs4532 and post-stroke swallowing recovery, primarily in those aged ≥65 years. Certain SNPs may lead to less favorable outcomes in the elderly. The gene-age interaction should be considered in post-stroke swallowing recovery. Clinical Trial Registration: https://www.clinicaltrials.gov, Unique identifier [NCT03577444].

Post-stroke dysphagia: frequency, risk factors, and topographic representation: hospital-based study

Background

The frequency of dysphagia varies considerably across literature. Post-stroke dysphagia is a common cause of increased morbidity and length of hospitalization. This study aimed to estimate the frequency, risk factors of dysphagia following first-ever ischemic or hemorrhagic stroke and its neuroradiological correlation.

Methods

Two hundred fifty patients (180 ischemic and 70 hemorrhagic strokes) with first-ever stroke were recruited within 72 h of onset. Detailed history, neurological examination, and computed tomography and/or magnetic resonance were done for each patient. Severity of stroke was evaluated by the National Institutes of Health Stroke Scale (NIHSS). Swallowing function was assessed by water swallowing test (WST) and dysphagia outcome severity scale (DOSS).

Results

Ninety-eight (39.2%) of all stroke patients had dysphagia, 57 (31.7%) of ischemic group, 41 (58.6%) of hemorrhagic group. The mean age of ischemic group with dysphagia was older than ages of non-dysphagic and older than hemorrhagic stroke with dysphagia group. The mean total NIHSS was higher in dysphagic group than non-dysphagic group in both ischemic and hemorrhagic stroke. Dysphagia in ischemic group was highly associated with diabetes mellitus (DM), hypertension (HTN), and atrial fibrillation (AF). Dysphagia was commonly associated with middle cerebral artery (MCA), brainstem, and capsular infarctions as well as with intracerebral hemorrhage (ICH) with ventricular extension. Stroke severity and lesion size were the main determinant of dysphagia severity.

Conclusions

The frequency of post-stroke dysphagia is consistent with other studies. Advanced age, DM, HTN, and AF were the main risk factors. MCA, brain stem, capsular infarctions, and ICH with ventricular extension were frequently associated with dysphagia. Stroke severity and lesion size were independent predictors of dysphagia severity.

Acupuncture for Poststroke Dysphagia: A Pilot, Nonrandomized, Self-Controlled Trial

Objective

To evaluate the effectiveness and safety of acupuncture treatment for dysphagia as a complication of stroke. Methods and Design. This is a multicenter, pragmatic, nonrandomized, self-controlled clinical trial. A total of 39 patients were recruited from several Chinese medicine outpatient clinics and hospital-affiliated speech therapy outpatient clinics in Hong Kong. 26 patients completed all the 24 sessions of acupuncture treatment within two months, and only 12 of them were used as self-control. For the self-control group, the retrospective clinical data was taken from the electronic patient records with patient consent. The descriptive swallowing function data were converted into the quantitative Royal Brisbane Hospital Outcome Measure for Swallowing (RBHOMS) scores by two registered speech therapists through a validation process. And the data were validated by reaching consensus between the two speech therapists. All subjects underwent a baseline assessment before commencement of treatment, and outcome assessments were conducted upon the completion of treatment. The primary outcome measure is the RBHOMS score, which is a swallowing disability rating scale for monitoring difficulties in daily swallowing function. Secondary outcome measures include the Chinese version of the Swallow Quality-of-Life Questionnaire and adverse events. All the primary and secondary outcomes were assessed at baseline as well as at the end of acupuncture treatment (month 2).

Results

A total of 39 participants aged 46 to 89 years were enrolled in the study, and the male-to-female ratio was 15 : 11. The mean baseline RBHOMS score of all 39 participants was 5.92 ± 2.23. The mean retrospective RBHOMS score of the 12 subjects who were used as self-control was 5.67 ± 1.72 before enrollment, while the mean RBHOMS score of the 26 participants who completed all the 24 sessions of treatment was 6.92 ± 2.07. There were statistically significant differences between the RBHOMS score at the completion of treatment and baseline (p=0.006), and retrospective data (p=0.042). Moreover, a significant difference was also found in terms of swallow quality-of-life score before and after acupuncture treatment (p < 0.01).

Conclusions

This pilot study provides preliminary evidence for the effectiveness of acupuncture for poststroke dysphagia. The findings from this trial can be used as a foundation for future full-scale randomized controlled clinical trials to assess the efficacy and safety of acupuncture for poststroke dysphagia. Ethics and Dissemination. The ethical approval of the clinical research study was granted by the Research Ethics Committee of both New Territories East and West Cluster of Hong Kong. Written informed consent was obtained from all participants, and the study was undertaken according to the ICH-GCP Guidelines. Trial Registration. This trial is registered with ChiCTR-TRC-12002621 and the registration date is 2012-10-26.

Post-stroke Complications and Mortality in Burkinabè Hospitals: Relationships with Deglutition Disorders and Nutritional Status

Stroke frequently causes deglutition disorders, leading to a decline in nutritional status and complications, and increasing mortality. Sub-Saharan data are scarce. The objectives of this study were to assess complications and mortality among hospitalized patients in Burkina Faso during the first two weeks after stroke, and to investigate associated factors. Patients with stroke were followed prospectively in Ouagadougou and Bobo-Dioulasso hospitals. Deglutition disorders and nutritional parameters were assessed at baseline (D0) and on Days 8 (D8) and 14 (D14). Complications and mortality were recorded up to D14. Factors associated with complications and mortality were investigated using multivariate analysis. Of the 222 patients included, 81.5% developed at least one complication, and mortality was 17.1%. At D0, D8, and D14, the rate of deglutition disorders was 37.4%, 28.4%, and 15.8%, respectively, and that of undernourishment 25.2%, 29.4%, and 31.0%, respectively. In multivariate analysis, only the presence of deglutition disorders was a risk factor for developing at least one complication (OR = 5.47, 95% CI 1.81-16.51). Factors predicting death were the presence of deglutition disorders at D0 (OR = 7.19, 95% CI 3.10-16.66), and at least one seizure during follow-up (OR = 3.69, 95% CI 1.63-8.36). After stroke, the rates of complications, death, and undernourishment were high compared to Western countries. Prevention and management of deglutition disorders, and specific follow-up of patients with seizures could reduce post-stroke mortality.

Achados videoendoscópicos da deglutição em diferentes consistências de alimento na Esclerose Lateral Amiotrófica

RESUMO Objetivo Este estudo teve por objetivo comparar os achados videoendoscópicos da deglutição orofaríngea em distintas consistências de alimento na Esclerose Lateral Amiotrófica (ELA). Método Estudo clínico retrospectivo com amostra de conveniência. Foram incluídos 20 indivíduos com diagnóstico de ELA e disfagia orofaríngea confirmada por avaliação clínica e objetiva de deglutição, independentemente do tipo, bulbar ou esquelética, e tempo de diagnóstico neurológico, 13 do sexo masculino e sete do sexo feminino, faixa etária variando de 34 a 78 anos, média de 57 anos. Foram analisados os achados da videoendoscopia de deglutição (VED) nas consistências líquida (N=18), líquida espessada (N=19) e pastosa (N=20) no volume de cinco ml. Os achados sobre escape oral posterior, resíduos faríngeos, penetração laríngea e/ou aspiração foram comparados nas três consistências de alimento e a análise estatística utilizou o teste ANOVA de Friedman. Resultados Não foi encontrada alteração na sensibilidade laríngea nessa população. Não houve diferença estatística significativa entre as consistências de alimento na presença de escape oral posterior, penetração e/ou aspiração. Houve diferença estatística significativa somente com resíduos faríngeos na consistência líquida espessada e pastosa na ELA. Conclusão Dentre os achados videoendoscópicos da deglutição na ELA, somente o resíduo faríngeo teve maior frequência na dependência da consistência de alimento.

Reduced tongue force and functional swallowing changes in a rat model of post stroke dysphagia

PURPOSE

Dysphagia is a common problem after stroke that is often associated with tongue weakness. However, the physiological mechanisms of post-stroke tongue muscle weakness and optimal treatments have not been established. To advance understanding of physiological mechanisms of post stroke dysphagia, we sought to validate the unilateral transient middle cerebral artery occlusion (MCAO) rat model of ischemic stroke as a translational model of post stroke dysphagia. Our goal was to establish clinically relevant measures and chronicity of functional deficits; criteria that increase the likelihood that findings will translate to the clinic. We hypothesized that MCAO would cause tongue weakness and functional swallowing changes.

METHODS

Maximum voluntary tongue forces and videofluoroscopic swallowing studies were collected in 8-week old male Sprague-Dawley rats prior to receiving either a left MCAO (N = 10) or sham (N = 10) surgery. Tongue forces and VFSS were reassessed at 1 and 8 weeks post-surgery.

RESULTS

Maximum voluntary tongue force, bolus area, and bolus speed were significantly reduced in the MCAO group at the 1 and 8-week timepoints.

CONCLUSION

Clinically relevant changes to swallowing and tongue force support the use of the MCAO rat model as a translational model of post stroke dysphagia. This model will allow for future studies to improve our understanding of the physiology contributing to these functional changes as well as the impact of therapeutic interventions on physiological targets and function.

Dysphagia and its relation with nutritional status and calorie/protein intake in the elderly

ABSTRACT Purpose: to evaluate the nutritional status associated with dysphagia, and compare the calorie and protein intake of dysphagic elderly patients to that of non dysphagic ones, during hospitalization. Methods: this is a cross-sectional study with elderly people ranging from 60 to 80 years old admitted as inpatients in a medical and neurological clinic of a public hospital. They formed two groups, according to the presence of dysphagia: dysphagic and non dysphagic ones. The inclusion criteria were: dysphagia secondary to stroke and exclusive oral feeding. Anthropometric measurements and the Mini-Nutritional Assessment (MNA) were applied. The 24-hour recall was used to analyze food consumption. The statistical analysis used the Fisher's exact test for the association of variables, and the Mann-Whitney test, for their comparison. Results: a total of 12 elderly people participated, whose mean age was 70.50 ± 7.77 years in the dysphagia group (n = 6), and 72.67 ± 5.01 years in the non dysphagia group (n = 6).There was an association between the presence of dysphagia and the risk of malnutrition, according to MNA (p = 0.028). No significant difference in calorie and protein intake was seen between the groups. The group with dysphagia had a lower water intake as compared to the non dysphagia group (p = 0.045). Conclusion: dysphagia was associated with the risk of malnutrition and lower fluid intake in dysphagic patients, thus, increasing their risk of dehydration.

Clinical Validation of the Nursing Outcome "Swallowing Status" in People with Stroke: Analysis According to the Classical and Item Response Theories

AIMS AND OBJECTIVES

To validate clinically the nursing outcome "Swallowing status".

METHODS

The adjustment of the nursing outcome was investigated according to the Classical and Item Response Theories. The models were compared regarding information loss, goodness-of-fit, and differential item functioning. Stability and internal consistency were examined.

RESULTS

The nursing outcome has the best fit in the generalized partial credit model with different discrimination parameters. Strong correlations among the scores of each indicator were observed. There was no differential item functioning of the outcome indicators. The scale presented high internal consistency (Cronbach's α = .954) and stability (and > .800).

CONCLUSIONS

This study presents a valid nursing outcome.

RELEVANCE TO CLINICAL PRACTICE

Most accurate monitoring of sensitivity to an intervention.

OBJETIVO

Validar clinicamente o resultado de enefermagem "Estado da Deglutição". MÉTODOS: O ajustamento do resultado foi investigado de acordo com as teorias Clássica e de Resposta ao Item. Os modelos foram comparados assumindo parâmetros de itens cruzados de igual discriminação. Investigaram-se as propriedades de bondade do ajuste, funcionamento diferencial dos itens, estabilidade e consistência interna.

RESULTADOS

O resultado se ajustou melhor a partir do Modelo de crédito parcial generalizado, o qual demonstrou unidimensionalidade do resultado e forte correlação entre os escores de cada indicador. Não houve funcionamento diferencial dos indicadores. A consistência interna para a escala global (Cronbach's α = .954) e a estabilidade (>.800) mantiveram-se elevadas. CONCLUSÃO: O estudo apresenta um resultado de enfermagem válido. RELEVÂNCIA PARA A PRÁTICA CLÍNICA: Maior acurácia para monitorar a sensibilidade da intervenção.

Association between neurological injury and the severity of oropharyngeal dysphagia after stroke

Purpose

To associate the degree of biomechanical impairment in the swallowing process with the severity (National Institute of Health Stroke Scale - NIHSS) and type of neurological injury in patients post stroke.

Methods

A cross-sectional, descriptive study conducted with 42 patients (22 females), aged 65.7 years on average diagnosed with stroke. All patients underwent clinical neurological evaluation and application of the NIHSS in the first 48 hours after stroke. The swallowing function was evaluated using the Functional Oral Intake Scale (FOIS) and the Protocol for the Investigation of Oropharyngeal Dysphagia in Adults. The Fisher's Exact Probability Test was used to assess the correlation between the degree of swallowing impairment and the severity (NIHSS score) and type of stroke. The study results were statistically analyzed at 5% significance level (p≤0.05).

Results

92.9% of the patients presented ischemic stroke; 59.5% presented impairment of the anterior cerebral circulation. Statistically significant correlation was found between the neurological scale (NIHSS) scores and the swallowing impairment scale (p=0.016).

Conclusion

An association between stroke severity and oropharyngeal dysphagia severity was observed. A high proportion of patients with ischemic stroke with circulation affected in the anterior cerebral region presented severe oropharyngeal dysphagia. No statistically significant correlation was observed between the FOIS scale and stroke severity.

Influence of repetitive peripheral magnetic stimulation on neural plasticity in the motor cortex related to swallowing

The aim of this study was to evaluate the effect of repetitive peripheral magnetic stimulation at two different frequencies (20 and 30 Hz) on cortical excitability in motor areas related to swallowing in healthy individuals. The study participants were 10 healthy normal volunteers (two women and eight men, age range 25-36 years). Repetitive peripheral magnetic stimulation was applied to the submandibular muscle using a parabolic coil at the site where contraction of the suprahyoid muscles was elicited. Stimulation was continued for 10 min (total 1200 pulses) at 20 Hz on 1 day and at 30 Hz on another day, with the stimulation strength set at 90% of the intensity that elicited pain. The motor-evoked potential amplitude of suprahyoid muscles was assessed before, immediately after, and 30 min after stimulation. Stimulations at both 20 and 30 Hz significantly increased motor-evoked potential amplitude (P<0.05), with the increase maintained until 30 min after stimulation. The motor-evoked potential amplitude immediately after stimulation was not significantly different between the 20 and 30 Hz frequencies. The results indicated that repetitive magnetic stimulation increased motor-evoked potential amplitude of swallowing muscles, suggesting facilitation of the motor cortex related to swallowing in healthy individuals.

Mirror therapy for upper limb rehabilitation in chronic patients after stroke

Abstract Introduction: Individuals with stroke sequelae present changes in the postural alignment and muscle strength associated with hemiplegia or hemiparesis. Mirror therapy is a technique that aims to improve the motor function of the paretic limb. Objective: The aim of this study was to evaluate the effect of mirror therapy, associated with conventional physiotherapy, for range of motion (ROM), degree of spasticity of the affected upper limb, and the level of independence in the activities of daily living (ADL) of chronic patients after stroke. Methods: This was a quasi-experimental (before and after) study. The study included ten stroke survivors undertaking physiotherapy and presenting with upper limb paresis. The following gauges were used for the present study: goniometry, the Modified Ashworth Scale, Fugl-Meyer and Barthel Index. Fifteen sessions were performed, each lasting 30 minutes, consisting of stretching of the flexor and extensor muscles of the wrist and elbow, pronators and supinators, followed by mirror therapy with gradual functional exercises. Results: Improvement was observed in all aspects studied, however with significant differences for ROM wrist extension (p = 0.04) and forearm supination (p = 0.03) Conclusion: It can be concluded that mirror therapy contributed to the participants' good performance in the aspects studied, mainly in relation to ROM of the affected upper limb.

Construction and validation of indicators and respective definitions for the nursing outcome Swallowing Status

OBJECTIVE

to develop indicators for the nursing outcome Swallowing Status and the respective conceptual and operational definitions validated by experts and in a clinical setting among patients after having experienced a stroke.

METHOD

methodological study with concept analysis and content and clinical validations. The Content Validation Index was verified for the scores assigned by 11 experts to indicators. Two pairs of nurses assessed 81 patients during the clinical validation: one pair used an instrument with definitions and the other used an instrument without definitions. The resulting assessments were compared using Intraclass Correlation Coefficient, Friedman's test, and Minimal Important Difference calculation.

RESULTS

All the indicators, with the exception of the indicator Ability to bring food to mouth, presented Content Validation Index above 0.80. The pair using the instrument with definitions presented an Intraclass Correlation Coefficient above 0.80 for all the indicators and similarity was found in all the assessments, according to the Minimal Important Difference calculation. The pair using the instrument without definitions presented a low coefficient (ρ<0.75) for all the indicators.

CONCLUSION

the results showed that greater uniformity and accuracy was achieved by the pair of nurses using the conceptual and operational definitions for the indicators of the nursing outcome Swallowing Status.

Clinical factors predicting risk for aspiration and respiratory aspiration among patients with Stroke

Objective:

to investigate the association of risk factors with the Risk for aspiration nursing diagnosis and respiratory aspiration.

Method:

cross-sectional study assessing 105 patients with stroke. The instrument used to collect data addressing sociodemographic information, clinical variables and risk factors for Risk for aspiration. The clinical judgments of three expert RNs were used to establish the diagnosis. The relationship between variables and strength of association using Odds Ratio (OR) was verified both in regard to Risk for aspiration and respiratory aspiration.

Results:

risk for aspiration was present in 34.3% of the patients and aspiration in 30.5%. The following stood out among the risk factors: Dysphagia, Impaired or absent gag reflex, Neurological disorders, and Impaired physical mobility, all of which were statistically associated with Risk for aspiration. Note that patients who develop such a diagnosis were seven times more likely to develop respiratory aspiration.

Conclusion:

dysphagia, Impaired or absent gag reflex were the best predictors both for Risk for aspiration and respiratory aspiration.

Program to diagnose probability of aspiration pneumonia in patients with ischemic stroke

Introduction Stroke is a major cause of death and disability worldwide, with a strong economic and social impact. Approximately 40% of patients show motor, language, and swallowing disorders after stroke. Objective To evaluate the use of software to infer the probability of pneumonia in patients with ischemic stroke. Methods Prospective and cross-sectional study conducted in a university hospital from March 2010 to August 2012. After confirmation of ischemic stroke by computed axial tomography, a clinical and flexible endoscopic evaluation of swallowing was performed within 72 hours of onset of symptoms. All patients received speech therapy poststroke, and the data were subsequently analyzed by the software. The patients were given medical treatment and speech therapy for 3 months. Results The study examined 52 patients with a mean age of 62.05 ± 13.88 years, with 23 (44.2%) women. Of the 52 patients, only 3 (5.7%) had a probability of pneumonia between 80 and 100% as identified by the software. Of all patients, 32 (61.7%) had pneumonia probability between 0 and 19%, 5 (9.5%) between 20 and 49%, 3 (5.8%) between 50 and 79%, and 12 (23.0%) between 80 and 100%. Conclusion The computer program indicates the probability of patient having aspiration pneumonia after ischemic stroke.

Associating factors regarding nasogastric tube removal in patients with Dysphagia after stroke

Objective

To demonstrate associating factors regarding nasogastric tube (NGT) removal in patients with dysphagia after stroke.

Methods

This study is a retrospective medical chart review. Patients were divided into non-brain stem (NBS) and brain stem (BS) groups. A videofluoroscopic swallowing study was conducted until swallowing functions were recovered. Initial disease status was measured using the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS). Risk factors related to stroke were evaluated. The penetration-aspiration scale (PAS) was used as the swallowing test. Functional status was measured by Mini-Mental Status Examination (MMSE) and Modified Barthel Index (MBI). Within each group, initial evaluations and their subsequent changes were compared according to the NGT removal status. Correlation between the NGT removal time and other initial factors were evaluated.

Results

Ninety-nine patients were allocated to the NBS group and 39 to the BS group. In NBS, age, PAS, MMSE, and MBI were significantly different according to the NGT removal status. In BS, smoking and PAS were significantly different. In NBS, changes in PAS, MMSE, and MBI were significantly different according to the NGT removal status. In BS, only PAS change was significantly different. In NBS, initial NIHSS, mRS, MMSE, and MBI were correlated with removal time.

Conclusion

In stroke patients with NTG, younger age, better initial disease and functional status seems to remove NGT in NBS stroke. Therefore, when deciding to remove NGT, those three factors should be considered discreetly.

Subjective dysphagia in older care home residents: a cross-sectional, multi-centre point prevalence measurement

BACKGROUND

Dysphagia has been found to be strongly associated with aspiration pneumonia in frail older people. Aspiration pneumonia is causing high hospitalization rates, morbidity, and often death. Better insight in the prevalence of (subjective) dysphagia in frail older people may improve its early recognition and treatment.

OBJECTIVE

First, to assess the prevalence of subjective dysphagia in care home residents in the Netherlands. Second, to assess the associations of subjective dysphagia with potential risk factors of dysphagia.

DESIGN

Retrospective data-analysis of a cross-sectional, multi-centre point prevalence measurement.

SETTING

119 care homes in the Netherlands.

PARTICIPANTS

Data of 8119 care home residents aged 65 years or older were included and analyzed.

METHODS

Subjective dysphagia was assessed by a resident's response to a dichotomous question with regard to experiencing swallowing problems. If a resident was not able to respond (e.g. residents with dementia or aphasia), the question was answered by the ward care provider, or the resident's file was consulted for registered swallowing complaints and/or dysphagia. Several residents' data were collected: gender, age, (number of) diseases, the presence of malnutrition, the Care Dependency Scale score, and the body mass index.

RESULTS

Subjective dysphagia was found in 751 (9%) residents. A final model for subjective dysphagia after multivariate backward stepwise regression analysis revealed eight significant variables: age (B -0.022), Care Dependency Scale score (B -0.985), 'malnutrition' (OR 1.58; 95% CI 1.31-1.90), 'comorbidity' (OR 1.07; 95% CI 1.01-1.14), and the disease clusters 'dementia' (OR 0.55; 95% CI 0.45-0.66), 'nervous system disorder' (OR 1.55; 95% CI 1.20-1.99), 'cardiovascular disease' (OR 0.81; 95% CI 0.67-0.99) and 'cerebrovascular disease/hemiparesis' (OR 1.74; 95% CI 1.45-2.10).

CONCLUSION

It seems justified to conclude that subjective dysphagia is a relevant care problem in older care home residents in the Netherlands. Care Dependency Scale score, 'malnutrition', and the disease clusters 'dementia', 'nervous system disorder', and 'cerebrovascular disease/hemiparesis' were associated with the presence of subjective dysphagia in this study. Age, 'comorbidity' and 'cardiovascular disease' showed very small influence.

Eficácia da eletroestimulação muscular expiratória na tosse de pacientes após acidente vascular encefálico

Indivíduos com sequelas de acidente vascular encefálico (AVE) apresentam como complicação comum a hipotonia de tronco com consequente fraqueza da sua musculatura, em especial, o reto abdominal que é o principal músculo acionado para a tosse. As correntes elétricas têm sido amplamente utilizadas para recrutamento de fibras musculares nas mais diversas patologias. O presente estudo teve como objetivo avaliar a eficácia da eletroestimulação transcutânea de média frequência (ETMF) na força muscular expiratória e tosse de pacientes com sequela de AVE. Trata-se de um estudo quase-experimental (antes e depois) onde foram selecionados 11 indivíduos pós-AVE entre 40 a 65 anos, ambos os sexos e estáveis hemodinamicamente. Os pacientes foram avaliados quanto a parâmetros clínicos e pneumofuncionais (ventilometria, pico de fluxo expiratório (PFE) e manovacuometria) e submetidos ao protocolo, que constava de ETMF no músculo reto abdominal com o aparelho de corrente Russa, frequência portadora de 2.500 Hz modulada a 40 Hz, durante 15 minutos, por 15 sessões. Na avaliação inicial observou-se diminuição da força muscular inspiratória e expiratória (Pimáx; Pemáx) e do PFE quando comparados aos valores de normalidade preditos na literatura. Após a ETMF houve incremento da Pimáx e Pemáx sem significância estatística (p=0,18 e p=0,29) já o PFE teve um acréscimo de 283,73 L/minuto para 347,27 L/minuto (p=0,03). Pode-se observar que a ETMF foi eficaz no incremento dos parâmetros avaliados, com o PFE sendo o de maior impacto e significância estatística, no entanto, mais estudos com populações maiores se fazem necessários para análise dessa nova abordagem terapêutica.