Dysphagia after stroke - Incidence, diagnosis, and pulmonary complications
ABSTRACT To determine the incidence of dysphagia and associated pulmonary compromise in stroke patients through a systematic review of the published literature.
Databases were searched (1966 through May 2005) using terms "cerebrovascular disorders," "deglutition disorders," and limited to "humans" for original articles addressing the frequency of dysphagia or pneumonia. Data sources included Medline, Embase, Pascal, relevant Internet addresses, and extensive hand searching of bibliographies of identified articles. Selected articles were reviewed for quality, diagnostic methods, and patient characteristics. Comparisons were made of reported dysphagia and pneumonia frequencies. The relative risks (RRs) of developing pneumonia were calculated in patients with dysphagia and confirmed aspiration.
Of the 277 sources identified, 104 were original, peer-reviewed articles that focused on adult stroke patients with dysphagia. Of these, 24 articles met inclusion criteria and were evaluated. The reported incidence of dysphagia was lowest using cursory screening techniques (37% to 45%), higher using clinical testing (51% to 55%), and highest using instrumental testing (64% to 78%). Dysphagia tends to be lower after hemispheric stroke and remains prominent in the rehabilitation brain stem stroke. There is increased risk for pneumonia in patients with dysphagia (RR, 3.17; 95% CI, 2.07, 4.87) and an even greater risk in patients with aspiration (RR, 11.56; 95% CI, 3.36, 39.77).
The high incidence for dysphagia and pneumonia is a consistent finding with stroke patients. The pneumonia risk is greatest in stroke patients with aspiration. These findings will be valuable in the design of future dysphagia research.
[Show abstract] [Hide abstract]
ABSTRACT: There is growing evidence of potential benefits of repetitive transcranial magnetic stimulation (rTMS) in the rehabilitation of dysphagia. However, the site and frequency of stimulation for optimal effects are not clear. The aim of this pilot study is to investigate the short-term effects of high-frequency 5 Hz rTMS applied to the tongue region of the motor cortex on swallowing functions and the quality of life of post-stroke individuals with dysphagia. Two male and two female participants were assigned randomly to active and sham groups. The participants in the active group received 10 sessions of active rTMS for 2 weeks, whereas the sham participants received 10 sessions of sham rTMS for 2 weeks. Each participant received a total of 3000 pulses of 5 Hz active or sham rTMS per day for 10 days. Outcome measures were taken at baseline, 1 week and 1 month post-rTMS. Participants who received active rTMS had improved swallowing functions and swallowing-related quality of life at 1 week and 1 month post-stimulation. The study showed that excitatory rTMS applied over the tongue motor cortex is a feasible approach in individuals with chronic post-stroke dysphagia. Further investigation with larger sample population is warranted to support the benefit of this stimulation protocol. © 2015 Royal College of Speech and Language Therapists.International Journal of Language & Communication Disorders 01/2015; DOI:10.1111/1460-6984.12144 · 1.44 Impact Factor
[Show abstract] [Hide abstract]
ABSTRACT: This descriptive review of the literature outlines the current evidence-base underpinning the potential of transcranial brain stimulation techniques to modulate swallowing function in healthy individuals and in treating post-stroke dysphagia. Published research was identified by review of scientific databases (Scopus, Medline Ovid, Science Direct, AMED and Google Scholar) using relevant keywords. In addition, the reference lists of identified articles were scrutinized to identify further potentially relevant papers. Studies employing variants of transcranial magnetic or direct current stimulation for the purpose of modulating swallowing motor cortical excitability in healthy participants or dysphagia following stroke were included. Due to a significant heterogeneity in stimulation paradigms, all included studies were summarised and descriptively analysed in relation to the participants tested, cortical representations targeted by brain stimulation and outcome measures used. Seventeen studies met inclusion criteria (seven evaluating healthy participants, 10 evaluating participants presenting with post-stroke dysphagia). Cortical stimulation most commonly targeted pharyngeal motor representations (13/17 studies). In the 10 clinical studies, stimulation was applied contralesionally (5/10 studies), ipsilesionally (3/10 studies) or bilaterally (2/10 studies). A range of behavioural and neurophysiological outcome measures demonstrated positive effects on swallowing function across studies. There is promising proof of concept that non-invasive brain stimulation may provide a useful adjunct to post-stroke swallowing rehabilitation practice. Eventual transition of optimal paradigms into routine clinical practice will be accompanied by practical considerations in relation to local and national frameworks, e.g. the prescription and provision of treatment. Copyright © 2015. Published by Elsevier Inc.Physiology & Behavior 02/2015; 143. DOI:10.1016/j.physbeh.2015.02.025 · 3.03 Impact Factor
[Show abstract] [Hide abstract]
ABSTRACT: The Quality in Acute Stroke Care (QASC) trial evaluated systematic implementation of clinical treatment protocols to manage fever, sugar, and swallow (FeSS protocols) in acute stroke care. This cluster-randomised controlled trial was conducted in 19 stroke units in Australia. To describe perceived barriers and enablers preimplementation to the introduction of the FeSS protocols and, postimplementation, to determine which of these barriers eventuated as actual barriers. Preimplementation: Workshops were held at the intervention stroke units (n = 10). The first workshop involved senior clinicians who identified perceived barriers and enablers to implementation of the protocols, the second workshop involved bedside clinicians. Postimplementation, an online survey with stroke champions from intervention sites was conducted. A total of 111 clinicians attended the preimplementation workshops, identifying 22 barriers covering four main themes: (a) need for new policies, (b) limited workforce (capacity), (c) lack of equipment, and (d) education and logistics of training staff. Preimplementation enablers identified were: support by clinical champions, medical staff, nursing management and allied health staff; easy adaptation of current protocols, care-plans, and local policies; and presence of specialist stroke unit staff. Postimplementation, only five of the 22 barriers identified preimplementation were reported as actual barriers to adoption of the FeSS protocols, namely, no previous use of insulin infusions; hyperglycaemic protocols could not be commenced without written orders; medical staff reluctance to use the ASSIST swallowing screening tool; poor level of engagement of medical staff; and doctors' unawareness of the trial. The process of identifying barriers and enablers preimplementation allowed staff to take ownership and to address barriers and plan for change. As only five of the 22 barriers identified preimplementation were reported to be actual barriers at completion of the trial, this suggests that barriers are often overcome whilst some are only ever perceived rather than actual barriers. © 2015 Sigma Theta Tau International.Worldviews on Evidence-Based Nursing 01/2015; DOI:10.1111/wvn.12078 · 1.35 Impact Factor