Interventions for dysphagia and nutritional support in acute and subacute stroke

Clinical Pharmacology and Pharmacy, Faculty of Medicine, University of Colombo, Kynsey Road, Colombo, Sri Lanka, 8.
Cochrane database of systematic reviews (Online) (Impact Factor: 6.03). 10/2012; 10(10):CD000323. DOI: 10.1002/14651858.CD000323.pub2
Source: PubMed


Stroke is often complicated by problems with swallowing (dysphagia) and poor nutrition. Normal oral feeding in those with swallowing problems may lead to pneumonia and an increased risk of death. Therapies to improve swallowing are designed to accelerate recovery of swallowing function and reduce the risk of developing pneumonia. We reviewed 33 studies involving 6779 patients (the average age of patients across the studies was 71 years). There was some evidence that acupuncture and behavioural interventions may reduce dysphagia but the roles of drug therapy, neuromuscular electrical stimulation, pharyngeal electrical stimulation, physical stimulation, transcranial direct current stimulation, and transcranial magnetic stimulation remain unclear. Liquid food may be given directly into the stomach through feeding tubes, either via the gullet, using a nasogastric tube (NGT), or directly into the stomach via a percutaneous endoscopic gastrostomy (PEG) tube. Starting tube feeding (with either NGT or PEG) early after stroke may reduce death although the information available remains inconclusive. If longer-term feeding is required PEG feeding provides better nutrition and is more secure than a NG tube. The available trial evidence does not support the routine use of protein and energy supplements in acute stroke patients who are able to take food by mouth; supplements may show benefit in those who have signs of malnutrition, for example through reducing pressure sores.

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    • "Gastrostomy (percutaneous endoscopic gastrostomy [PEG]) placement has become a preferred method for long-term feeding in patients with dysphagia incurred from stroke. Compared with nasogastric tube (NGT) feeding, PEG reduced intervention failures (e.g., feeding interruption, blocking or leakage of the tube, non-adherence to treatment and gastrointestinal bleeding), and had higher feed delivery and albumin concentration [7,8]. "
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    ABSTRACT: Objective To determine predictors of early recovery of functional swallow in patients who had gastrostomy (percutaneous endoscopic gastrostomy [PEG]) placement for dysphagia and were discharged to inpatient rehabilitation (IPR) after stroke. Methods A retrospective study of prospectively identified patients with acute ischemic and hemorrhagic stroke from July 2008 to August 2012 was conducted. Patients who had PEG during stroke admission and were discharged to IPR, were studied. We compared demographics, stroke characteristics, severity of dysphagia, stroke admission events and medications in patients who remained PEG-dependent after IPR with those who recovered functional swallow. Results Patients who remained PEG dependent were significantly older (73 vs. 54 years, p=0.009). Recovery of swallow was more frequent for hemorrhagic stroke patients (80% vs. 47%, p=0.079). Age, adjusting for side of stroke (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.82-0.98; p=0.016) and left-sided strokes, adjusting for age (OR, 15.15; 95% CI, 1.32-173.34; p=0.028) were significant predictors of swallow recovery. Patients who recovered swallowing by discharge from IPR were more likely to be discharged home compared to those who remained PEG-dependent (90% vs. 42%, p=0.009). Conclusion Younger age and left-sided stroke may be predictive factors of early recovery of functional swallow in patients who received PEG. Prospective validation is important as avoidance of unnecessary procedures could reduce morbidity and healthcare costs.
    Annals of Rehabilitation Medicine 08/2014; 38(4):467-75. DOI:10.5535/arm.2014.38.4.467
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    ABSTRACT: Oropharyngeal Dysphagia (OD) is both underestimated and underdiagnosed as a cause of malnutrition and respiratory complications following stroke. OD occurs in more than 50% of stroke patients. Aspiration pneumonia (AP) occurs in up to 20% of acute stroke patients and is a major cause of mortality after discharge. Systematic screening for OD should be performed on every patient with stroke before starting oral feeding, followed, if appropriate by clinical and instrumental (videofluroscopy and/or fiberoptic endoscopy) assessment. Bolus modification with adaptation of texture and viscosity of solids and fluids and postural adjustments should be part of the minimal treatment protocol, but they do not change the impaired swallow physiology nor promote recovery of damaged neural swallow networks in stroke patients. To this purpose, two new neurostimulation approaches are being developed to stimulate cortical neuroplasticity to recover swallowing function: (i) those aimed at stimulating the peripheral oropharyngeal sensory system by chemical, physical or electrical stimulus; and (ii) those aimed at directly stimulating the pharyngeal motor cortex, such as repetitive transcranial magnetic stimulation (rTMS). The study of Park et al. in this issue of Neurogastroenterology and Motility evaluated the effect of rTMS in dysphagic stroke patients and showed a marked improvement in swallow physiology. Other studies also using rTMS showed plastic changes in pharyngeal motor cortical areas relevant to swallowing function. If further randomized controlled trials confirm these initial results, the neurorehabilitation strategies will be introduced to clinical practice sooner rather than later, improving the recovery of dysphagic stroke patients. Progress at last.
    Neurogastroenterology and Motility 03/2013; 25(4). DOI:10.1111/nmo.12112 · 3.59 Impact Factor
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    ABSTRACT: Dysphagia is common after stroke. Neuromuscular electrical stimulation (NMES) and fiberoptic endoscopic evaluation of swallowing (FEES) for the treatment of dysphagia have gained in popularity, but the combined application of these promising modalities has rarely been studied. We aimed to evaluate whether combined NMES, FEES, and traditional swallowing rehabilitation can improve swallowing functions in stroke patients with moderate to severe dysphagia. Thirty-two patients with moderate to severe dysphagia poststroke (≥3 weeks) were recruited. Patients received 12 sessions of NMES for 1 h/day, 5 days/week within a period of 2-3 weeks. FEES was done before and after NMES for evaluation and to guide dysphagic therapy. All patients subsequently received 12 sessions of traditional swallowing rehabilitation (50 min/day, 3 days/week) for 4 weeks. Primary outcome measure was the Functional Oral Intake Scale (FOIS). Secondary outcome measures included clinical degree of dysphagia, the patient's self-perception of swallowing ability, and the patient's global satisfaction with therapy. Patients were assessed at baseline, after NMES, at 6-month follow-up, and at 2-year follow-up. Twenty-nine patients completed the study. FOIS, degree of dysphagia, and patient's self-perception of swallowing improved significantly after NMES, at the 6-month follow-up, and at the 2-year follow-up (p < 0.001, each compared with baseline). Most patients reported considerable satisfaction with no serious adverse events. Twenty-three of the 29 (79.3 %) patients maintained oral diet with no pulmonary complications at 2-year follow-up. This preliminary case series demonstrated that combined NMES, FEES, and traditional swallowing rehabilitation showed promise for improving swallowing functions in stroke patients with moderate-to-severe dysphagia. The benefits were maintained for up to 2 years. The results are promising enough to justify further studies.
    Dysphagia 04/2013; 28(4). DOI:10.1007/s00455-013-9466-9 · 2.03 Impact Factor
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