Natural History of Swallow Function during the Three-Month Period after Stroke

Effects of Home-Based Daily Respiratory Muscle Training on Swallowing Outcomes in Patients with Chronic Stroke: Protocol for a Randomized Controlled Trial

(1) Background: Swallowing disorders are common following a stroke. This study aims to evaluate the effects of a home-based daily intervention focused on inspiratory and expiratory muscle training on swallowing outcomes in patients with chronic stroke. (2) Methods: This manuscript presents the protocol of a single-blind randomized clinical trial. Patients with chronic stroke will be randomly assigned to either an experimental or a control group. The experimental group will undergo daily home-based respiratory muscle training in addition to standard speech and language therapy, while the control group will receive only the standard intervention. The main outcome measures will include the aspiration risk, the strength of respiratory muscles, and peak cough flow. (3) Results: It is hypothesized that patients receiving home-based respiratory training in addition to standard therapy will achieve significant improvements in aspiration risk, respiratory muscle strength, and cough efficacy in comparison with those included in the control group. The results will be published as a manuscript. (4) Conclusions: This study aims to provide evidence on the effectiveness of home-based respiratory muscle training in enhancing swallowing function and respiratory parameters in patients with chronic stroke.

Predictors of Complete Oral Intake in Patients With Stroke After Tracheostomy

BACKGROUND

Tracheostomy procedures inhibit swallowing, although details of subsequent recovery of oral intake remain unknown. This retrospective cohort study aimed to investigate factors influencing dysphagia improvement in patients with subacute stroke after tracheostomy.

METHODS AND RESULTS

The study included 117 patients who underwent tracheostomy after subacute stroke, cerebral hemorrhage, or endogenous subarachnoid hemorrhage and received care at 2 convalescent rehabilitation wards in urban and suburban Japan between 2015 and 2022. The primary outcome measure was the achievement of complete oral intake. Patient demographics, Functional Independence Measure scores, body mass index, food intake level scale scores, and the presence of severe white matter hyperintensities on imaging were retrospectively collected from medical records. Statistical analysis involved univariate logistic regression to identify potential predictors and multivariate logistic regression to refine the model while accounting for multicollinearity. In total, 47% of patients achieved complete oral intake on discharge. Sex, days from onset to admission, Functional Independence Measure motor and cognitive scores, body mass index, food intake level scale scores, and severe white matter hyperintensities were identified as potential predictors in the univariate analysis. However, multivariate logistic regression identified only food intake level scale scores (odds ratio [OR], 3.687 [95% CI, 1.519-8.949]; P=0.004) and severe white matter hyperintensities (OR, 0.302 [95% CI, 0.096-0.956]; P=0.042) as significant predictors of complete oral intake.

CONCLUSIONS

In patients with subacute stroke undergoing tracheostomy, the level of oral intake on admission and severe white matter hyperintensities on imaging may be better predictors of complete oral intake. However, prospective studies with larger sample sizes and more comprehensive data are warranted to confirm these findings.

Economic Evaluation of Clinical, Nutritional and Rehabilitation Interventions on Oropharyngeal Dysphagia after Stroke: A Systematic Review

Background: Post-stroke oropharyngeal dysphagia (PS-OD) and its complications increase healthcare costs, suggesting that its appropriate management is cost-effective. We aimed to assess the efficiency of healthcare interventions in PS-OD management. Methods: A systematic review was conducted following PRISMA recommendations. Four databases were searched from inception through 30 June 2021. Outcome measures were cost-effectiveness and cost-savings of healthcare interventions. English and Spanish literature were included. Narrative and tables were used to present and synthesise evidence. Quality was evaluated using the CHEERS Statement. Results: A total of 244 studies were identified, and 10 were included. Screening and diagnosis of PS-OD studies found: (1) adjusted reduction in hospitalisation costs when assessed during the first admission day; (2) non-significant reduction in hospitalisation costs with OD management after thrombolysis; and (3) videofluoroscopy as the most cost-effective screening method (compared to bedside evaluation and a combination of both). Two studies showed cost-effective rehabilitation programmes, including OD management. Pelczarska et al. showed an incremental cost–utility ratio of texture-modified diets using a gum-based thickener of 20,977 PLN (4660€) following a dynamic model, and Kotecki et al. commercially prepared thickened fluids that were 44% to 59% less expensive than in situ prepared fluids. Elia et al. showed home enteral nutrition was cost-effective (£12,817/QALY), and Beavan et al. showed higher nutrient intake and low increase in hospitalisation costs using looped-nasogastric tubes (£5.20 for every 1% increase). Heterogeneity between studies precluded a quantitative synthesis. Conclusions: Included studies suggest that healthcare interventions aiming to prevent OD complications are cost-effective. However, studies assessing novel strategies are needed.

Status of knowledge, attitude and practice of poststroke dysphagia in neurological nurses in China: A cross-sectional study

OBJECTIVES

To explore the status and related factors of knowledge, attitude, and practice (KAP) of poststroke dysphagia among neurological nurses in China.

METHODS

Neurological nurses from 40 tertiary hospitals in Southwest China were invited to complete a survey on the knowledge, attitude, and practice of the nursing of poststroke dysphagia. We used a questionnaire to collect the participants' information including the basic characteristics and the KAP Questionnaire on poststroke dysphagia in the neurological ward. A sample of 707 participants completed the survey.

RESULTS

The knowledge, attitude, and practice scores for the nursing of poststroke dysphagia were 12.00±4.09, 71.99±11.00, 52.22±9.08, respectively. The total score of knowledge towards the nursing of poststroke dysphagia was significantly different among nurses with different ages, working time of nursing, working time of nursing in neurology, the highest level of education, professional title, position, the method of training, the number of dysphagia-related nursing trainings, the total length of dysphagia nursing training, and the nursing basis of patients with dysphagia. The total score of attitudes towards the nursing of poststroke dysphagia was significantly different among nurses with the way they were trained, and the nursing basis for patients with dysphagia. The total score of practice towards poststroke dysphagia was significantly different among nurses with the number of dysphagia-related nursing trainings, the total length of dysphagia nursing training, the training method, and the basis of nursing patients with dysphagia.

CONCLUSION

Neurological nurses' knowledge score in poststroke dysphagia is relatively low, and the knowledge level needs improvement. The attitude and practice score of neurological nurses in dysphagia after stroke was much better than the knowledge score. Managers and nursing researchers should develop and offer effective training for neurological nurses to improve their knowledge, attitude and practice towards poststroke dysphagia, and then improve patients' health outcomes.

A Systematic and Universal Artificial Intelligence Screening Method for Oropharyngeal Dysphagia: Improving Diagnosis Through Risk Management

Oropharyngeal dysphagia (OD) is underdiagnosed and current screening is costly. We aimed: (a) to develop an expert system (ES) based on machine learning that calculates the risk of OD from the electronic health records (EHR) of all hospitalized older patients during admission, and (b) to implement the ES in a general hospital. In an observational, retrospective study, EHR and swallowing assessment using the volume-viscosity swallow test for OD were captured over 24 months in patients > 70 yr admitted to Mataró Hospital. We studied the predictive power for OD of 25,000 variables. ES was obtained using feature selection, the final prediction model was built with non-linear methods (Random Forest). The database included 2809 older patients (mean age 82.47 ± 9.33 yr), severely dependent (Barthel Index 47.68 ± 31.90), with multiple readmissions (4.06 ± 7.52); 75.76% had OD. The psychometrics of the ES built with a non-linear model were: Area under the ROC Curve of 0.840; sensitivity 0.940; specificity, 0.416; Positive Predictive Value 0.834; Negative Predictive Value 0.690; positive likelihood ratio (LH), 1.61 and negative LH, 0.146. The ES screens in 6 s all patients admitted to a 419-bed hospital, identifies patients at greater risk of OD, and shows the risk for OD in the clinician's workstation. It is currently in use at our institution. Our ES provides accurate, systematic and universal screening for OD in real time during hospital admission of older patients, allowing the most appropriate diagnostic and therapeutic strategies to be selected for each patient.

The Feasibility of Home-Based Treatment Using Vibratory Stimulation in Chronic Severe Dysphagia

PURPOSE

Previously, externally placed vibratory laryngeal stimulation increased rates of swallowing in persons with and without dysphagia. This study examined the feasibility of using a vibratory device on the skin over the thyroid cartilage for home-based swallowing rehabilitation in long-standing dysphagia.

METHOD

Only participants with long-standing dysphagia (> 6 months) following cerebrovascular accident or head/neck cancer who had not previously benefited from dysphagia therapy participated. The device had two modes used daily for 90 days. In automatic mode, participants wore the device when awake, which vibrated for 4-8 s every 5 min to trigger a volitional swallow. In manual mode, participants practiced by activating vibration while swallowing rapidly. Study-related adverse events, such as pneumonia, and device-recorded adherence were tracked. Swallowing function on a modified barium swallow study was assessed at baseline and after 3 months of device use. Outcome measures included the Dysphagia Outcome and Severity Scale (DOSS), Penetration-Aspiration Scale (PAS), and swallowing timing measures. Participants' perceptions of the vibratory device and training were obtained.

RESULTS

The intent to treat analysis showed seven of 11 participants completed the study, all with severe chronic dysphagia. Of those seven participants completing the study, two developed respiratory complications (possibly due to pneumonia) that cleared after antibiotic intervention. For prescribed practice trials, adherence was 80% or greater in four of seven participants (57%) whereas prescribed automatic stimulations were met in only two of seven participants (29%). Three participants (43%) had a modest benefit on DOSS. The time to vestibule closure after the bolus passed the ramus was reduced in five participants (71%) on the modified barium swallow study.

CONCLUSION

Overall, the results have indicated that intensive home-based practice with stimulation may provide limited functional benefits in severe chronic dysphagia.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21498591.

Combined conventional speech therapy and functional electrical stimulation in acute stroke patients with dyphagia: a randomized controlled trial

BACKGROUND

Stroke is the main cause of oropharyngeal neurogenic dysphagia. Electrostimulation has been used as a therapeutic tool in these cases. However, there are few studies that prove its effectiveness. We evaluated the effect of functional electrostimulation as a complement to conventional speech therapy in patients with dysphagia after a stroke in a stroke unit.

METHODS

We performed a clinical, randomized, and controlled trial divided into intervention group (IG) (n = 16) and control group (CG) (n = 17). All patients were treated with conventional speech therapy, and the IG also was submitted to the functional electrotherapy. Primary outcomes were Functional Oral Ingestion Scale (FOIS) and Swallowing videoendoscopy (FEES). The degree of dysphagia was scored in functional, mild, moderate and severe dysphagia according to FEES procedure. Dysphagia Risk Evaluation Protocol (DREP) was considered a secondary outcome.

RESULTS

There was a significant difference regarding FOIS scores after 5 days of intervention in groups. Both groups also showed a tendency to improve dysphagia levels measured by FEES, although not statistically significant. Improvements on oral feeding was seen in both groups. No significant differences between groups before and after the intervention were detected by DREP scores. Electrical stimulation did not show additional benefits beyond conventional therapy when comparing outcomes between groups.

CONCLUSION

Conventional speech therapy improved oral ingestion even regardless the use of electrostimulation in a stroke unit.

TRIAL REGISTRATION

This research was registered in ClinicalTrials.gov (Identifier: NCT03649295 ) in 28/08/2018 and in the Brazilian Registry of Clinical Trials (ReBEC) (Register Number: RBR-56QK5J), approval date: 18/12/2018. HGF Ethics Committee Approval Number: N. 2.388.931.

Economic evaluations of health care interventions in oropharyngeal dysphagia after stroke: protocol for a systematic review

BACKGROUND AND PURPOSE

Oropharyngeal dysphagia (OD) affects 40-81% of patients after stroke. A recent systematic review on the costs of OD and its main complications showed higher acute and long-term costs for those patients who developed OD, malnutrition and pneumonia after stroke. These results suggest that appropriate management of post-stroke OD could reduce clinical complications and costs. The purpose of this systematic review is to assess the available literature for healthcare interventions that are efficient or cost-effective in the management of OD.

METHODS

A systematic review on economic evaluations of health care interventions will be performed on post-stroke patients with OD following PRISMA recommendations. Four bibliographic databases will be searched and a subsequent reference check will be done. English and Spanish literature will be included without date restrictions. Studies will be included if they refer to economic evaluations or in which cost savings were reported in post-stroke patients suffering OD. Studies will be excluded if they are partial economic evaluation studies, if they refer to esophageal dysphagia, or if OD is caused by causes different from stroke. Evidence will be presented and synthetised with a narrative method and using tables. Quality evaluation will be done using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement.

DISCUSSION

The protocol for this systematic review is the first step to assess the cost-effectiveness of the healthcare interventions that have been described as potential treatments for post-stroke OD. This systematic review will summarise the current evidence on the relation between cost and benefits associated with the appropriate management of OD in post-stroke patients.

TRIAL REGISTRATION

PROSPERO CRD42020136245.

A Systematic and a Scoping Review on the Psychometrics and Clinical Utility of the Volume-Viscosity Swallow Test (V-VST) in the Clinical Screening and Assessment of Oropharyngeal Dysphagia

(1) Background: The volume-viscosity swallow test (V-VST) is a clinical tool for screening and diagnosis of oropharyngeal dysphagia (OD). Our aims were to examine the clinical utility of the V-VST against videofluoroscopy (VFS) or fiberoptic endoscopic evaluation of swallow (FEES) and to map the V-VST usage with patients at risk of OD across the years since it was described for the first time, carrying a systematic and a scoping review. (2) Methods: We performed both a systematic review (SR) including studies that look at the diagnostic test accuracy, and a scoping review (ScR) with articles published from September 2008 to May 2020. Searches were done in different databases, including PubMed and EMBASE from September 2008 until May 2020, and no language restrictions were applied. A meta-analysis was done in the SR to assess the psychometric properties of the V-VST. Quality of studies was assessed by Dutch Cochrane, QUADAS, GRADE (SR), and STROBE (ScR) criteria. The SR protocol was registered on PROSPERO (registration: CRD42020136252). (3) Results: For the diagnostic accuracy SR: four studies were included. V-VST had a diagnostic sensitivity for OD of 93.17%, 81.39% specificity, and an inter-rater reliability Kappa = 0.77. Likelihood ratios (LHR) for OD were 0.08 (LHR-) and 5.01 (LHR+), and the diagnostic odds ratio for OD was 51.18. Quality of studies in SR was graded as high with low risk of bias. In the ScR: 34 studies were retrieved. They indicated that V-VST has been used internationally to assess OD's prevalence and complications. (4) Conclusions: The V-VST has strong psychometric properties and valid endpoints for OD in different phenotypes of patients. Our results support its utility in the screening and clinical diagnosis and management of OD.

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.

Effect of a gum-based thickener on the safety of swallowing in patients with poststroke oropharyngeal dysphagia

BACKGROUND

Increasing viscosity with thickening agents is a valid therapeutic strategy for oropharyngeal dysphagia (OD). To assess the therapeutic effect of a xanthan gum-based thickener (Nutilis Clear^® ) at six viscosities compared with thin liquid in poststroke OD (PSOD) patients.

METHODS

A total of 120 patients with PSOD were studied in this controlled, multiple-dose, fixed-order, and single-blind study using videofluoroscopy (VFSS). A series of boluses of 10 mL thin liquid and 2000, 1400, 800, 450, 250, and 150 mPa s viscosities were given in duplicate, interrupted in case of aspiration. We assessed the safety and efficacy of swallow and the kinematics of the swallow response.

KEY RESULTS

A total of 41.2% patients had safe swallow at thin liquid which significantly increased for all viscosities from 71.9% at 150 mPa s to 95.6% at 1400 mPa s (P < .001). PAS score (3.7 ± 2.3) at thin liquid was also reduced by increasing bolus viscosity (P < .001). The prevalence of patients with aspiration at thin liquid was 17.5% and decreased at all viscosities (P < .01), except at 150 mPa s. Increasing viscosity shortened time to laryngeal vestibule closure (LVC) at all viscosities (P < .01) and reduced bolus velocity at ≥450 mPa s (P < .05). The prevalence of patients with pharyngeal residue at each viscosity 37.7%-44.7% was similar to that at thin liquid (41.2%).

CONCLUSIONS AND INFERENCES

The prevalence of unsafe swallow with thin liquids is very high in PSOD. Increasing shear bolus viscosity with this xanthan gum-based thickener significantly increased the safety of swallow in patients with PSOD in a viscosity-dependent manner without increasing the prevalence of pharyngeal residue.