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Screening for Oropharyngeal Dysphagia in Stroke: Insufficient Evidence for Guidelines

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There is no evaluation of the evidence for the screening of oropharyngeal dysphagia in stroke. We reviewed the literature on clinical screening for oropharyngeal dysphagia in adults with stroke to determine (a) the accuracy of different screening tests used to detect dysphagia defined by abnormal oropharyngeal physiology on videofluoroscopy and (b) the health outcomes reported and whether screening alters those outcomes. Peer-reviewed English-language and human studies were sought through Medline (from 1966 to July 1997) by using the key words cerebrovascular disorders and deglutition disorders, relevant Internet addresses, and extensive hand searching of bibliographies of identified articles. Of the 154 sources identified, 89 articles were original, peer-reviewed, and focused on oropharyngeal dysphagia in stroke patients. To evaluate the evidence, the next selection identified 10 articles on the comparison of screening and videofluoroscopic findings and three articles on screening and health outcomes. Evidence was rated according to the level of study design by using the values of the Canadian Task Force on Periodic Health Examination. From the identified screening tests, most of the screenings were related to laryngeal signs (63%) and most of the outcomes were related to physiology (74%). Evidence for screening accuracy was limited because of poor study design and the predominant use of aspiration as the diagnostic reference. Only two screening tests were identified as accurate: failure on the 50-ml water test (likelihood ratio = 5.7, 95% confidence interval = 2.5–12.9) and impaired pharyngeal sensation (likelihood ratio = 2.5, 95% confidence interval = 1.7–3.7). Limited evidence for screening benefit suggested a reduction in pneumonia, length of hospital stay, personnel costs, and patient charges. In conclusion, screening accuracy needs to be assessed by using both abnormal physiology and aspiration as diagnostic markers for dysphagia. Large well-designed trials are needed for more conclusive evidence of screening benefit.
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Screening for Oropharyngeal Dysphagia in Stroke:
Insufficient Evidence for Guidelines
Rosemary Martino, MA, MSc,
1
Gaylene Pron, PhD,
3
and Nicholas Diamant, MD
1,2
Departments of
1
Speech-Language Pathology and
2
Gastroenterology Medicine, Physiology, and Playfair Neuroscience, University of Toronto,
Toronto Western Hospital, University Health Network, Toronto, Ontario; and
3
Departments of Medical Imaging, Public Health Service, Clinical
Epidemiology, and Health Care Research Program, University of Toronto, Toronto, Ontario, Canada
Abstract. There is no evaluation of the evidence for the
screening of oropharyngeal dysphagia in stroke. We re-
viewed the literature on clinical screening for oropharyn-
geal dysphagia in adults with stroke to determine (a) the
accuracy of different screening tests used to detect dys-
phagia defined by abnormal oropharyngeal physiology
on videofluoroscopy and (b) the health outcomes re-
ported and whether screening alters those outcomes.
Peer-reviewed English-language and human studies were
sought through Medline (from 1966 to July 1997) by
using the key words cerebrovascular disorders and de-
glutition disorders, relevant Internet addresses, and ex-
tensive hand searching of bibliographies of identified
articles. Of the 154 sources identified, 89 articles were
original, peer-reviewed, and focused on oropharyngeal
dysphagia in stroke patients. To evaluate the evidence,
the next selection identified 10 articles on the compari-
son of screening and videofluoroscopic findings and
three articles on screening and health outcomes. Evi-
dence was rated according to the level of study design by
using the values of the Canadian Task Force on Periodic
Health Examination. From the identified screening tests,
most of the screenings were related to laryngeal signs
(63%) and most of the outcomes were related to physi-
ology (74%). Evidence for screening accuracy was lim-
ited because of poor study design and the predominant
use of aspiration as the diagnostic reference. Only two
screening tests were identified as accurate: failure on the
50-ml water test (likelihood ratio 5.7, 95% confidence
interval 2.5–12.9) and impaired pharyngeal sensation
(likelihood ratio 2.5, 95% confidence interval 1.7–
3.7). Limited evidence for screening benefit suggested a
reduction in pneumonia, length of hospital stay, person-
nel costs, and patient charges. In conclusion, screening
accuracy needs to be assessed by using both abnormal
physiology and aspiration as diagnostic markers for dys-
phagia. Large well-designed trials are needed for more
conclusive evidence of screening benefit.
Key words: Cerebrovascular disorders Screening
— Systematic review Evidence Guidelines De-
glutition Deglutition disorders.
Stroke is the third leading cause of death in the United
States and Canada, following heart disease and cancer,
and accounts for 10–12% of all annual deaths in indus-
trialized countries [1]. Among Canadians older than age
65 years, there is an approximate annual incidence of
50,000 new stroke cases each year [2], with the incidence
doubling for each decade after age 55 years [3]. In
Canada, the annual economic burden has been estimated
to be 3 billion dollars in health care costs and lost pro-
ductivity per year [4]. The sources for this economic
burden come directly from the effect of stroke on com-
promised health and indirectly from preventable delays
in the recovery from stroke. At present, the largest single
health care expenditure for stroke patients between the
date of acute hospital admission to the end of 90 days is
rehabilitation, which comprises 32% of the total cost [5].
One method to reduce stroke-related costs is to deter-
mine effective ways to screen or accurately identify pa-
tients at risk for resulting neurologic deficits and then
initiate early referral for diagnosis and treatment.
Oropharyngeal dysphagia is any abnormality in
swallowing physiology of the upper aerodigestive tract.
Correspondence to: Rosemary Martino, M.S., M.Sc., University of
Toronto, Department of Speech-Language Pathology, Tanz Neurosci-
ence Centre, Room 111, 6 Queen’s Park Crescent, Toronto, Ontario,
Canada M5S 3H2
Dysphagia 15:19–30 (2000)
DOI: 10.1007/s004559910006
© Springer-Verlag New York Inc. 2000
This type of dysphagia has been reported to occur in
approximately 30–42% of acute stroke patients requiring
admission to hospital [6,7]. Of those initially affected,
approximately 50% spontaneously recover to a normal
swallow within 7 days after the onset of the stroke event
[6,7]. However, those who remain affected after the first
week show much slower oropharyngeal dysphagia re-
covery rates. The prevalence of clinically diagnosed dys-
phagia in patients at 1 month poststroke has been re-
ported to be 2–21% and can remain as high as 7% at 3
months poststroke [6–8].
In Canada, the annual incidence of oropharyngeal
dysphagia in new stroke patients older than age 65 years
can be predicted to have approximated 15,000–21,000 in
1994. Comparable figures for the United States predict
200,000 new cases. Of these patients, although 50%
would likely have recovered within the first week, the
remainder, or as many as 10,000 in Canada and 100,000
in the United States, would likely continue to suffer oro-
pharyngeal dysphagia for months after the initial stroke
event. The presence of oropharyngeal dysphagia in re-
covering stroke patients has been associated with mal-
nutrition, dehydration, pulmonary compromise, in-
creased length of hospital stay, and institutional care
[6,7,9–12]. Assuming no change with the current health
care intervention and the direction of aging population
demographics [2], the overall economic burden of treat-
ing the consequences of oropharyngeal dysphagia in new
stroke patients can be expected to dramatically increase
over the next few years.
Recently, published guidelines have reported
strong expert consensus among health care professionals
for early detection of oropharyngeal dysphagia after
stroke and for earlier intervention [13]. Earlier detection
and treatment are expected not only to benefit the patient
through shortening the stroke recovery period but also to
reduce the overall rehabilitation costs. However, to date
there has not been any published evidence in the form of
reports or reviews supporting these views. The propor-
tion of the total cost due to swallowing rehabilitation in
particular has not been researched. It is expected that
earlier detection of abnormal swallow physiology and
subsequent earlier intervention will decrease the overall
potential medical complications from pulmonary com-
promise, dehydration, or malnutrition and, as a result,
reduce the overall cost for rehabilitation following
stroke. Early identification of oropharyngeal dysphagia
by members of the health care team is therefore essential
to ensure earlier and appropriate referrals. To this end,
accurate screening procedures are necessary.
Study Objectives
Our aim was to systematically review and evaluate cur-
rent peer-reviewed published literature to determine
whether there is sufficient evidence to recommend bed-
side clinical screening guidelines for oropharyngeal dys-
phagia in adults with stroke. The determination of suffi-
cient evidence was guided by the following three ques-
tions: (a) What clinical screening tests have been used to
detect oropharyngeal dysphagia or abnormal swallow
physiology as defined by objective results on videofluo-
roscopy? (b) What is the accuracy of these screening
tests? and, (c) What outcomes have been reported for
stroke patients with oropharyngeal dysphagia and does
early clinical detection and treatment of abnormal oro-
pharyngeal swallow physiology alter these outcomes?
Materials and Methods
Data Sources
The search of peer-reviewed articles published from 1966 through July
of 1997 comprised the following steps:
1. A structured search through the Medline, HealthSTAR, and
CLINAHL databases limited to English-language articles on hu-
mans by using the medical subject headings deglutition disorders
and cerebrovascular disorders
2. Manual searches of the bibliographies of abstracted references and
recent volumes of the following journals: Dysphagia, Archives of
Physical Medicine and Rehabilitation,andStroke
3. An unstructured search of relevant Internet addresses such as the
Cochrane Collaboration and the National Library of Medicine.
To reduce investigator biases in study inclusion, all relevant
terms were operationally defined a priori. The condition being assessed
was oropharyngeal dysphagia as defined by physiologic swallowing
abnormalities of the upper aerodigestive tract and as detected on vid-
eofluoroscopy. Our premise was that screening guidelines should apply
to all health care team members who are trained in clinical assessment
of poststroke patients, such as speech-language pathologists, nurses,
physicians, physiotherapists, and occupational therapists. For this rea-
son, only those bedside screening tests that were noninvasive and easily
administered to detect the presence or absence of oropharyngeal dys-
phagia were considered. Patient-reported symptoms were excluded.
Articles accepted were original and included adults (i.e., >18 years) in
acute, rehabilitation, or chronic facilities due to stroke. Editorials and
review articles were excluded. Case studies [14], including original
reports that profiled only a single patient, were excluded from evidence
evaluation.
Study Selection
From all retrieved data sources, the first selection focused on original
articles limited to oropharyngeal dysphagia in stroke patients. For the
purpose of evaluating the evidence on health outcome benefit from
screening, the second selection isolated articles dealing with either (a)
20 R. Martino et al.: Evidence for Oropharyngeal Dysphagia Screening
comparison of clinical screening and physiologic results from video-
fluoroscopy or (b) outcome in patients undergoing clinical screening.
Evaluation of the Evidence
Critical Appraisal of Study Methodology
Every selected article was appraised for design strengths and flaws
according to the eight-step criteria adapted from Sackett et al. [15] and
detailed below. Overall, poorly designed trials were considered less
persuasive and were rated lower than well-designed observational stud-
ies and clinical trials.
1. Blinded interpretation of screening tests, videofluorography results,
and outcome status
2. Specified and appropriate patient inclusion and exclusion criteria
3. All subjects eligible and enrolled were accounted for in the results
4. Patient characteristics and treatments were representative and gen-
eralizable to the typical adult stroke patient
5. The screening test was described in sufficient detail to permit rep-
lication
6. Adequate documentation of reliability of diagnostic interpretations
7. Large enough sample size to achieve sufficient power
8. Inclusion of appropriate raw data for calculations of test measures
such as sensitivity, specificity, and likelihood ratios. This criterion
was applied only to studies pertaining to the accuracy of screening.
Evaluation of the Accuracy of Clinical Screening
The articles comparing clinical screening with videofluoroscopic as-
sessment were evaluated for evidence that clinical screening can reli-
ably predict oropharyngeal dysphagia. Screening tests that used the
same technique and targeted the same neurologic area were considered
comparable across studies. When not reported and where possible, the
raw data from study results were used to calculate sensitivity, speci-
ficity, and likelihood ratios for each reported screening test. Sensitivity
was calculated as the proportion of patients with oropharyngeal dys-
phagia who tested positive divided by the total number with oropha-
ryngeal dysphagia, thereby depicting how accurate the screening test is
in detecting those patients with oropharyngeal dysphagia. Specificity
depicts how accurate the screening test is in excluding those patients
without oropharyngeal dysphagia and was calculated as the proportion
of patients without oropharyngeal dysphagia who tested negative di-
vided by the total number without oropharyngeal dysphagia. A good
screening test must have high sensitivity to not miss those with oro-
pharyngeal dysphagia and high specificity to reduce the number of
people with a false positive result [16]. The likelihood ratio (LR) is a
combined estimate of sensitivity and specificity and expresses the odds
that a patient with a positive screening result as opposed to a patient
with a negative screening result will actually have oropharyngeal dys-
phagia. Usefulness of LRs were arbitrarily grouped according to the
categories proposed by Simel et al. [17]: LR <1.5 no prediction, LR
1.5–2.5 indeterminate prediction, LR 2.5–10 intermediate pre-
diction, and LR >10 high prediction. LRs and their 95% confidence
intervals (CIs) were calculated based on reported raw data using SPSS
version 7.0.
Evaluation of the Outcome Benefit of Screening
The articles focusing on health outcomes of screened patients were
graded according to the overall level of evidence for health benefit
following oropharyngeal dysphagia screening in stroke patients. The
criteria implemented to determine the level of evidence was originally
proposed in 1979 by the Canadian Task Force on Periodic Health
Examination and later adopted by the U.S. Preventive Services Task
Force in 1984 [18]. This grading system has five hierarchical levels and
places greater importance on study designs and methodologies that are
less vulnerable to bias and errors of inference. Specifically, the highest
level is derived from at least one properly randomized controlled trial
of sufficient size, followed by well-designed observational studies. The
lowest level of evidence comes from either opinions of experts or
respected authorities (Table 1). The strength, or level, of available
evidence is then interpreted to decide whether the reported screening
tests should be included or excluded from the regular care of stroke
patients. The selected articles were reviewed with respect to their col-
lective level of evidence and ability to recommend inclusion or exclu-
sion of guidelines for oropharyngeal dysphagia screening.
Results
Literature Retrieved
From 1966 to July of 1997, 154 citations addressing
swallowing problems in stroke patients were identified
(Fig. 1). Of these, 124 were derived from computerized
Table 1. Level of evidence
a
I Highest
b
Evidence obtained from at least one properly
randomized controlled trial
II-1 High Evidence obtained from well-designed
controlled trials without randomization
II-2 Moderate Evidence obtained from well-designed cohort
or case control analytic studies, preferable
from more than one centre or research group
II-3 Limited Evidence obtained from comparisons between
times or places with or without the
intervention
III Lowest Opinions of respected authorities, based on
clinical experience, descriptive studies or
reports of expert committees
a
Adapted from the Report of the Canadian Task Force on Periodic
Health Examination, 1984, and by the American Task Force in 1989
[18].
b
Qualitative labels assigned by authors.
Fig. 1. Literature retrieval.
R. Martino et al.: Evidence for Oropharyngeal Dysphagia Screening 21
databases and 30 from manual searches. Of all the cita-
tions, 65 were deleted because they were reviews, edi-
torials, or letters, for a total of 89 [6–12,19–100] original
articles for review. The majority of articles originated
from North America; overall, the greatest contributions
were from the United States, with 46 articles, and the
United Kingdom, with 25. The majority of the articles
were either controlled (41/89, 46%) or descriptive (40/
89, 45%) studies, with only three using the randomized
trial design.
Evidence Supporting Screening Accuracy
From the selection of 89 original articles, 24 addressed
the accuracy of clinical screening tests to detect abnor-
mal swallowing physiology on videofluoroscopy and
were surveyed to determine the type of tests reported. In
these articles, the predominant screening tests pertained
to laryngeal signs, with 38 cites in 15 articles (15/24,
63%). The second most frequent screening tests were
those pertaining to pharyngeal signs, with 15 cites in 12
articles (12/24, 50%), and oral signs, with 18 cites in nine
articles (9/24, 37%). The least common screening meth-
ods, each with only one cite, related to patients’ feeding
postures and signs of respiratory distress during meals.
Interestingly, site of lesion was commonly cited, with 11
cites in 11 articles (11/24, 46%).
The accuracy of reported clinical screening tests
to identify abnormal swallow physiology, as identified
by videofluoroscopy, was assessed with 10 articles from
the original selection of 24. Six [8,20,29,76,77,92] were
excluded because site of brain lesion without a bedside
screening test was compared with videofluoroscopic re-
sults. The lesion site was a dysphagia risk factor derived
from a complex instrumental assessment, such as com-
puted tomography or magnetic resonance imaging, and
therefore did not fit the operational definition of a non-
invasive and simple clinical screening test. An additional
eight articles were excluded: four [52,59,74,90] because
no raw data of individual tests were detailed, one [30]
because neurologic diseases other than stroke were the
cause for dysphagia, one [69] because the screening test
was complex and required instrumental expertise, one
[28] because the article was a case study, and one [26]
because the article was a case series reporting results
Table 2. Critical appraisal of articles assessing screening accuracy
Critical appraisal
Reference
48 68 53 61 33
Blinding
Homogeneous stroke
population
Yes Yes Yes Yes Yes
All subjects
accounted
Yes Yes Yes Yes Yes
Generalizable to
typical stroke
patient
Yes Yes
Reproducible
screening
Yes Yes Yes
Reliability for
outcomes tested
—— ——
Study design Prospective cohort Prospective case
control
Prospective cohort Prospective case
control
Prospective cohort
Stroke patient
selection
n 38 (71%)
a
consecutive
bilateral referred
for VFS
b
n 10 (NR)
cryptogenic
pharyngeal
constrictor
paresis
10 age-&
sex-matched
dysphagics
n 60 (42%)
consecutive acute
admissions
n 8 (0%) left
basal ganglion/
internal capsule
8 age-matched
normals
n 44 (45%)
consecutive
referrals for
swallowing VFS
post failed Burke
Screening
Mean days post
stroke
8 (2–24) ? (30–270) <3 ? (21–28) 35 (14–56)
Statistical power NR
c
NR NR NR NR
a
Percentage of aspirators among total patient sample.
b
Videofluoroscopic assessment.
c
Not reported.
22 R. Martino et al.: Evidence for Oropharyngeal Dysphagia Screening
from different tests for each patient, which prevented
comparisons across patients.
The remaining 10 original articles were critically
appraised for study methodology (Table 2). The majority
consisted of prospective cohort studies containing a ho-
mogeneous stroke population with complete patient fol-
low-up. Five [46–48,61,68] studies restricted subject in-
clusion to subcortical stroke, brainstem stroke, bilateral
stroke, or videofluoroscopically identified pharyngeal
constrictor paresis and thus weakened the generalizabil-
ity of their results to other stroke types. A sixth article
[58] appeared to have studied patients with greater se-
verity of illness as reflected by the high frequency of
aspiration. Of all the articles evaluated, only four
[33,47,48,53] appropriately selected consecutively eli-
gible patients for inclusion. In half the articles
[44,45,47,53,61], sufficient detail to ensure reproducibil-
ity of all screening tests was not reported. All 10 studies
omitted any blinding and reliability testing, which can
potentially increase the likelihood of errors of inference.
Sensitivity, specificity, and LRs were calculated
for the abnormal finding of every clinical screening test
reported in the 10 appraised studies, with the exception
of four. The four values not calculated were Linden et
al.’s [58] test of coughing, Nilsson et al.’s [68] test of
mean drinking time, and Logemann et al.’s [61] tests of
dysarthria and cough. These values could not be com-
puted because the authors omitted raw data on all pa-
tients, reported interval data without declaring abnormal
levels, or included only patients with negative findings.
Overall, most of the screening tests were tested for ac-
curacy by being compared to aspiration (39/49, 80%),
and more than half of all tests (29/49, 59%) were derived
from the same research center.
The screening tests were categorized into groups
according to videofluoroscopic results and were com-
pared for accuracy (i.e., aspiration or any other abnormal
physiology) and the type of neurologic sign the results
represented. From the group using aspiration as the ref-
erence criterion (Table 3A), none of the cited screening
tests provided high prediction value. Five specific tests
ranked as intermediate predictors in at least one article:
abnormal pharyngeal sensation or cranial nerve IX,
failed 50-ml water test, weak voluntary cough, abnormal
motor function of the extremities, and perceptual disor-
der. However, the value of three of these is questionable.
The authors did not specify how they tested for either
perceptual skills or abnormal motor function, thereby
reducing reproducibility of these tests. The criteria to
establish the presence of weak voluntary cough were
provided, but its good predicative value was not repli-
cated in three other studies [44,46,48] from the same
Table 2. Continued
Critical appraisal
Reference
47 46 45 44 58
Blinding
Homogeneous stroke
population
Yes Yes Yes Yes
All subjects
accounted
Yes Yes Yes
Generalizable to
typical stroke
patient
Yes Yes Yes
Reproducible
screening
Yes Yes
Reliability for
outcomes tested
—— ——
Study design Prospective cohort Retrospective
cohort
Prospective cohort Prospective cohort Prospective cohort
Stroke patient
selection
n 23 (65%)
consecutive brain
stem referred for
VFS
n 70 (49%)
bilateral referred
for VFS
n 21 (52%) referred
for VFS
n 47 (51%)
referred for VFS
n 15 (73%)
referred for VFS
Mean days post
stroke
46 (1–575) NR 84 (<30–720) 87 (30–720) ? (30–1380)
Statistical power NR NR NR NR NR
R. Martino et al.: Evidence for Oropharyngeal Dysphagia Screening 23
Table 3. Sensitivities, specificities, and likelihood ratios for detection of abnormal swallow physiology
Signs [reference] Sensitivity % Specificity %
Likelihood ratio
(95% confidence interval)
A: Dysphagia as identified by aspiration on videofluoroscopy
Oral
CN V, motor [47] 40 71 1.4 (0.7–2.0)
Facial weakness [53] 96 31 1.5 (0.9–1.7)
CN V, sensory [47] 27 85 1.9 (0.7–2.2)
Oral sensation [44] 22 53 0.5 (0.2–1.2)
CN VII, motor [47] 100 14 1.2 (0.9–1.6)
CN XII, motor [47] 67 29 0.9 (0.5–1.7)
Impaired tongue movements [53] 64 71 2.2 (1.2–4.4)
Dysarthria
Mild [47] 33 43 0.6 (0.4–1.4)
Moderate [47] 13 57 0.3 (0.2–1.6)
Severe [47] 47 100 1.9 (1.7–3.0)
Oropharyngeal
Abnormal gag [48] 77 57 2.1 (1.1–4.7)
Abnormal gag [47] 87 57 2.0 (0.8–7.7)
Abnormal gag [45] 55 50 1.1 (0.5–2.5)
Abnormal gag [44] 60 48 1.1 (0.6–2.2)
Abnormal gag [46] 47 53 1.0 (0.9–2.3)
CN IX, sensory [47] 47 85 3.1 (0.5–20.1)
Pharyngeal sensation [53] 100 60 2.5 (1.7–3.7)
Laryngeal
Dysphonia [45] 91 40 1.5 (0.6–4.1)
Dysphonia [44] 91 32 1.3 (0.7–9.2)
Dysphonia [46] 85 30 1.2 (0.8–3.7)
Dysphonia [48] 92 9 1.0 (0.8–1.2)
CN X, motor [47] 87 57 2.0 (0.7–7.7)
Water test
50 ml [53] 80 86 5.7 (2.5–12.9)
3 oz. [33] 80 54 1.7 (1.0–6.3)
Weak voluntary cough [45] 55 80 2.7 (0.9–4.3)
Weak voluntary cough [46] 62 61 1.6 (0.9–2.7)
Weak voluntary cough [48] 89 36 1.4 (0.9–2.2)
Weak voluntary cough [44] 68 38 1.1 (0.6–2.4)
Other clinical neurological
Aphasia [53] 60 74 2.3 (1.2–4.1)
Cerebellar signs [47] 20 43 0.3 (0.2–1.3)
Drowsiness [53] 76 66 2.2 (1.4–6.4)
Extremities
Sensory [47] 25 100 1.6 (1.1–2.2)
Motor [47] 73 71 2.6 (0.9–4.1)
Sensory and motor [47] 0 71 Undetermined
Hemianopia [53] 76 63 2.0 (1.3–5.9)
Perceptual disorder (53) 36 88 3.0 (1.9–3.5)
Sensory loss [53] 52 63 1.4 (0.8–2.6)
Unilateral neurologic signs [48] 37 64 1.0 (0.4–2.5)
Bilateral neurologic signs [48] 63 36 1.0 (0.6–1.7)
B: Dysphagia as identified by parameters other than aspiration on videofluoroscopy
Oral
Reduced lingual strength [61]
a
100 100 Undetermined
Oropharyngeal
Abnormal gag [58]
b
100 50 2.0 (0.9–4.5)
Abnormal gag [58]
c
91 50 1.8 (0.5–12.7)
Laryngeal
Dysphonia [58]
c
91 100 3.0 (0.6–14.9)
24 R. Martino et al.: Evidence for Oropharyngeal Dysphagia Screening
research center. Therefore, supportive evidence is pre-
sent for the value of only two tests: abnormal pharyngeal
sensation and the 50-ml water test.
Five other cited tests were replicated in more than
one article to have no to indeterminate predictive value
for aspiration: facial weakness, abnormal cranial nerve V
sensation, impaired tongue movements, abnormal gag
reflex, and dysphonia. Four other tests that rated as in-
determinate predictors were cited without details of how
they were tested or judged to be abnormal: aphasia,
drowsiness, abnormal sensation of the extremities, and
hemianopia. The indeterminate predictive values of se-
vere dysarthria are strengthened by the relatively poorer
predicative values of milder abnormalities. In the case of
the failed 3-oz. water test, the indeterminate predictive
value is strengthened by a good operational definition
that ensures its reproducibility. The remaining screening
tests were found to be of no predictive value for the
presence of aspiration.
Screening tests were also compared with abnor-
mal physiology on videofluoroscopy other than aspira-
tion (Table 3B). From this group, only two tests were
reported by more than one research center: dysphonia
rated with no to intermediate predictive value and abnor-
mal gag reflexes rated with indeterminate predictive
value in both studies. The remaining tests were reported
in the same study and rated as indeterminate predictors
with lower 95% confidence levels in the no-predictive
range.
Evidence Supporting Screening Outcomes
All 89 [6–12,19–100] selected original articles were sur-
veyed to determine the type and distribution of outcomes
reported in their patients. The single most frequently
documented outcome type related to physiological mea-
sures, found in 66 (74%) of the 89 articles. The next most
frequent outcomes pertained to either function (45/89,
51%) or health status (41/89, 46%). The least common
outcome, seldom mentioned, referred to quality of life
(1/89, 1%). Measures of mode of nutritional intake dis-
tinguishing between oral and non-oral feeding methods
and pulmonary compromise, of which pneumonia pre-
dominated, were common. Conversely, measures of mor-
tality, nutrition, and hydration outcomes were relatively
less common.
To complete our second objective and determine
whether early clinical detection and treatment of oropha-
ryngeal dysphagia alter patient outcomes, seven original
articles were identified that included information on both
clinical screening tests and outcomes. Of these seven
articles, four [6,10,12,34] were excluded because they
did not contrast patients screened for oropharyngeal dys-
phagia with those not screened and, therefore, could not
demonstrate the direct effect from screening. The re-
maining three articles, those comparing screened and un-
screened patient populations, were critically appraised
for study design and evaluated for the collective level of
evidence on the benefit of oropharyngeal dysphagia
screening.
Each of the three articles used historical controls,
and two [72,73] were from the same research center in
the United States with the same controls. All articles
were appraised favorably for including only patients with
stroke, following outcomes in all eligible patients, and
representing typical acute [72,73] and rehabilitative [40]
stroke patients. Two articles [40,73] provided sufficient
detail of the screening methods to permit reproducibility.
However, none of the articles included investigator
blinding and reliability testing for cited outcome mea-
sures.
All three articles reported on the health outcome
of pneumonia, two articles [40,72] on the mode of nu-
tritional intake and one [73] on mortality (Table 4). The
absolute risk reduction (ARR) for developing pneumonia
in patients who received screening versus those who did
Table 3. Continued
Signs [reference] Sensitivity % Specificity %
Likelihood ratio
(95% confidence interval
Dysphonia [58]
b
100 25 1.3 (0.8–2.2)
Dysphonia [68]
d
30 80 1.5 (0.5–3.1)
Cerebellar signs [68]
d
20 100 2.2 (1.3–3.8)
General muscle weakness [68]
d
20 100 2.2 (1.3–3.8)
Pyramidal tract disturbance [68]
d
20 90 2.0 (0.2–30.0)
Extrapyramidal tract disturbance [68]
d
10 100 2.1 (1.3–3.4)
CN cranial nerve.
a
Criterion reference was mild swallowing delay.
b
Criterion reference was pooling in pyriform sinuses.
c
Criterion reference was penetration.
d
Criterion reference was pharyngeal constrictor paralysis.
R. Martino et al.: Evidence for Oropharyngeal Dysphagia Screening 25
not ranged from 0.03 to 0.13. Alternately, the relative
risk reduction (RRR) of pneumonia due to screening was
clinically significant in two of three studies, with values
of 81.2–85.1%. Also significant was the RRR for mor-
tality at 70.0% (ARR 0.06). The functional outcome
of non-oral feeding, or percutaneous esophagogastros-
tomy tube insertion, was also reduced after screening but
did not rate as clinically significant. A reduction in cost
outcomes after screening was reported in the areas of
personnel cost, by 34.3 patient days, and total patient
charges, by 14.6%. The effect of screening on the pa-
tients’ length of hospital stay (LOS) was inconsistent,
showing a reduction of 2.5 days in two studies [72,73]
and an increase of 3 days in a third study [40].
Discussion
The main purpose for clinical screening is to identify
patients at risk for oropharyngeal dysphagia and initiate
early referral for diagnosis and treatment to prevent dis-
tressing dysphagia symptoms and to minimize risks to
health. Benefits of screening are documented when pa-
tients who are screened have improved outcomes in con-
trast to patients who are not screened but who are oth-
erwise similar. Direct evidence is the most powerful
level of evidence because it directly connects the appli-
cation of oropharyngeal dysphagia screening with the
occurrence of outcomes (Fig. 2).
For most medical interventions, there is an ab-
sence of published direct evidence, and the benefit of
screening is commonly shown “indirectly” by demon-
strating or proving success with the intervening series of
events, or links, between screening and the final health
outcomes [101]. These intervening steps for oropharyn-
geal dysphagia are summarized in Figure 2 and involve
(a) a positive screening result, (b) a full diagnostic work-
up that detects the presence of oropharyngeal dysphagia,
(c) a change in the choice or timing of oropharyngeal
dysphagia treatment, and (d) a change in outcomes. Evi-
dence supporting individual links is necessary but not
sufficient to determine the overall screening benefit; at
Table 4. Level of evidence for the benefit of dysphagia screening on health outcomes
Evaluation
Reference
40 73 72
Reported influence of screening on
health outcomes (p-value listed if
provided by authors)
Pneumonia
ARR
a
0.13
RRR
b
81.2%
Aspiration pneumonia
ARR 0.07
RRR 85.1%
Mortality
ARR 0.06
RRR 70.0%
Aspiration pneumonia
ARR 0.03
RRR 38.8%, p ns
Reported influence of screening on
function outcomes
PEG tubes inserted
ARR 0.02
RRR 18.0%
PEG tubes inserted
ARR 0.01
RRR 6.7%
Reported influence of screening on cost
outcomes
LOS for all patients
52 ± 20 to 55 ± 29 days
LOS for all patients
9.8 ± 0.9 to 7.2 ± 0.5 days
LOS for all patients
9.8 ± 0.9 to 7.2 ± 0.5 days
Total cost effectiveness
reduced 34.3 patient days
LOS aspiration pneumonia
17.5 ± 6.5 to 12.8 ± 2.2 days
Average charges per patient
reduced by 14.6%
Control comparison Historical
(First 60 to last 60 patients in
a 18 month period)
Historical
(Same center 2 years prior)
Historical
(Same center 1 year prior)
Level of evidence II-3 (Limited) II-3 (Limited) II-3 (Limited)
screening recommendation C
(Poor evidence for definitive
inclusion or exclusion)
C
(Poor evidence for definitive
inclusion or exclusion)
C
(Poor evidence for definitive
inclusion or exclusion)
a
Absolute Risk Reduction Absolute difference in frequency between no screening and with screening.
b
Relative Risk Reduction Percent reduction following screening when RRR >50% almost always, and RRR >25% often, are considered to be
clinically significant [15].
Fig. 2. Evidence chain for the health benefit of screening for oropha-
ryngeal dysphagia in stroke.
26 R. Martino et al.: Evidence for Oropharyngeal Dysphagia Screening
best, it suggests rather than proves the benefits of a
screening program.
Nearly all of the contributions identified for di-
rect and indirect evidence in this review have been pub-
lished recently and from clinical research centers in ei-
ther the United States or the United Kingdom. Of the 89
original studies selected, only 13 were eligible for critical
appraisal and the eventual evaluation of evidence, 10 for
screening accuracy, and three for screening benefit. Most
of the eligible articles assessing screening accuracy were
properly designed with prospective controls, whereas all
eligible articles directly assessing screening benefit used
a weaker study design with historical controls. Regard-
less of design, none of the studies implemented investi-
gator blinding or reliability testing, and few, if any, in-
cluded operational definitions for either screening tests
or outcome values. The only exceptions were the defi-
nitions for the tests that assessed dysphonia (specifically
wet hoarse vocal quality), pharyngeal sensation, gag re-
flexes, and water swallowing. None of the evaluated ar-
ticles reported statistical power calculations, which,
along with small sample sizes, weakens their findings.
These methodologic oversights thereby weaken the
strength of available evidence for both screening accu-
racy and screening benefit.
Although these sources of bias prohibit any de-
finitive conclusions from the evidence, the data provide
valuable preliminary information regarding the current
status of oropharyngeal dysphagia screening along with
suggestions for future research. For example, we learned
that clinicians primarily screen for clinical signs related
to laryngeal, pharyngeal, and oral areas to predict the
presence of dysphagia. Dysphagia was most commonly
defined as aspiration detected on videofluoroscopy. This
is in direct contrast with the view that dysphagia is any
abnormal oropharyngeal swallow physiology detected on
videofluoroscopy and that aspiration is a consequence of
dysphagia rather than its diagnostic marker. According to
this view, dysphagia can be present without aspiration,
but aspiration is dependent on the presence of dysphagia.
One problem with using only aspiration as the diagnostic
marker, as did most of the cited literature, is that mild yet
possibly clinically significant swallowing problems may
inadvertently be missed [49,50]. The value of identifying
either aspiration or abnormal physiology is confirmed by
studies that have shown their ability to predict poor
health [34,43,50]. The current tendency of using only
aspiration to define dysphagia should be expanded to
also include abnormal physiological parameters in future
research assessing intervention benefit. This broader
definition for dysphagia may bring other screening tests
to prominence.
Of the 49 individual tests identified in this re-
view, only two were found to have potential in accurately
predicting dysphagia: the 50-ml water test and reduced
pharyngeal sensation. Although their prediction ability
was assessed only for aspiration, their good predictive
value was supported by good study design including op-
erational definitions on how to administer the tests and
criteria for abnormal findings. Specifically, the water
swallowing test was to be given in 5-ml aliquots, and
positive findings were reported if any coughing or wet
vocal quality ensued immediately after intake [53]. In
contrast, sensation of the pharyngeal area was assessed
by placing the tip of a thin stick on either side of the
pharyngeal wall, and positive findings were reported if
sensation on either side was absent [47,53]. If a patient is
found to have positive findings with either of these two
tests, the possibility of aspiration on videofluoroscopy is
greater, by as much as 5.7 or 2.5 times, respectively, than
in someone with negative findings. Each of these tests is
relatively simple and can be administered by most
trained health care workers, thereby increasing their use-
fulness in frontline screening for dysphagia. The remain-
ing tests identified in this review were not rated as good
predictors because of low LRs, wide 95% CIs, or incon-
sistent results from more than one study.
From this review, it is also apparent that the most
prevalent outcome measures cited pertain to physiologic
parameters. These measures are pertinent to evaluate im-
mediate benefit from behavioral swallowing interven-
tions. Physiological measures are only “surrogate” to
health outcomes [102]. To show absolute benefit from
any intervention including screening, an increase in the
patients’ level of health, function, or life quality must be
demonstrated.
Despite the deluge of data assessing physiologic
measures, this review found limited direct evidence for
the benefit on health outcomes after oropharyngeal dys-
phagia screening programs. The evidence is limited be-
cause these studies have methodologic flaws: the use of
historical comparisons rather than prospective controls,
thereby allowing the possibility of confounding variables
[40,72,73], and two of the three articles presented data
from the same research center, thereby reducing the gen-
eralizability of their results [72,73]. This limited level of
evidence can suggest but not definitively conclude that
oropharyngeal screening benefits outcomes of health,
function, and cost.
This review was conducted in a systematic man-
ner detailing its methodology to ensure a reproducible
and unbiased summary of the available literature on
screening accuracy and screening benefit for patients
with stroke. From our data source selection, none of the
articles, including those eliminated, were randomized
controlled trials or possible level I evidence for screening
benefit. This review did accept one study of screening
accuracy that may have included a relatively small pro-
R. Martino et al.: Evidence for Oropharyngeal Dysphagia Screening 27
portion of nonstroke patients [58] and five other studies
that restricted enrollment to patients with a subtype of
stroke [46–48,61,68]. The original intent of this review
was to assess only articles representative and generaliz-
able to the typical adult stroke patient, regardless of type.
We also required that clinical assessment be combined
with videofluoroscopic assessment of abnormal swallow
physiology as an objective indication of the presence of
dysphagia. Those articles that met this second criterion
but restricted enrollment to only patients with a subtype
of stroke present results that may be generalizable to
other stroke patients with the same subtype but not nec-
essarily to all stroke types. However, we chose to include
these articles in this review for two reasons: (a) they
comprised six of the 10 otherwise eligible articles and (b)
their overall results generally agreed with those from the
remaining studies that included heterogeneous groups of
stroke subjects. Videofluoroscopy was the only instru-
mentation declared in this review to identify abnormal
swallow physiology or dysphagia. Although users of fi-
beroptic endoscopy may argue that videofluoroscopy is
not the only accepted instrumental criterion to measure
dysphagia, it was more frequently cited, and there is
currently no available evidence to suggest that direct-
view instrumentation, such as endoscopy, is a better di-
agnostic standard than indirect instrumentation such as
videofluoroscopy.
In addition to reviewing the literature, a proper
systematic review serves to identify caveats in the cur-
rent literature and suggest future research direction
[103]. It is clear that, for clinical screening for oropha-
ryngeal dysphagia in stroke patients, there is a need for
either trials or better designed studies that include large
enough sample sizes to assess the benefit of health out-
comes between screened and unscreened patients. Fur-
ther studies also need to expand the definition of dys-
phagia beyond only aspiration on videofluoroscopy and
include operational definitions for screening tests and
health outcomes. To achieve its objective, it is likely that
a trial that is multicentered will increase not only the
study power but also the generalizability of results.
In summary, based on the limited available evi-
dence (i.e., level II-3), only a C-level recommendation
could be made for the inclusion of oropharyngeal dys-
phagia screening in stroke patients to benefit outcomes
such as pneumonia, mortality, LOS, and cost (Fig. 3). In
particular, two screening tests are of value in at least
detecting aspiration as the diagnostic marker for dyspha-
gia, the 50-ml water test and pharyngeal sensation. The
direct effect of these tests on health outcomes is not yet
known.
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30 R. Martino et al.: Evidence for Oropharyngeal Dysphagia Screening
... This two-phase study was guided by the concept that 'dysphagia' is the overall category for two types of impairments, namely 'swallowing' and 'feeding'. Swallowing was defined as an impairment in swallowing physiology in the upper aerodigestive tract, from the moment food enters the mouth up until the upper esophageal sphincter [49]. In contrast, 'feeding' was defined as other factors impacting the feeding process including food selectivity, sensory, postural or positioning difficulties and/or need for modified equipment or utensils [3]. ...
... Given the lack of evidence in the pediatric literature on psychometric properties of screening items, we rely on the adult literature to guide our interpretation at this stage. Our findings were in keeping with items identified with high psychometric value in detecting abnormal swallowing physiology following adult stroke [49]. For example, motor function of the seventh cranial nerve [56] and facial weakness [57] were identified with high sensitivity or specificity with aspiration on videofluoroscopy as the gold standard in the adult stroke population. ...
... For example, motor function of the seventh cranial nerve [56] and facial weakness [57] were identified with high sensitivity or specificity with aspiration on videofluoroscopy as the gold standard in the adult stroke population. Drowsiness [57] was identified with relatively high sensitivity [49] and tongue deviation Administration of swallowing trials (n = 57) Content courtesy of Springer Nature, terms of use apply. Rights reserved. ...
Article
Full-text available
Bedside dysphagia assessment protocols are not well developed in acute pediatric stroke unlike adults. The objective of this study was to identify items deemed relevant and feasible by expert consensus to inform the development of a bedside dysphagia screening tool for acute pediatric stroke. A two-phase study was conducted: (1) literature review and expert consultation generated a comprehensive list of dysphagia assessment items; (2) items were formatted in an online survey asking respondents opinion of relevance to acute pediatric stroke and feasibility for bedside administration by a trained health professional. The Dillman Tailored Design approach optimized response rate. Respondents were identified using the snowball method. Speech-language pathologists with > 2 years in pediatric dysphagia were invited to complete the survey. Demographic and practice variables were compared using univariate statistics. Item relevance and feasibility were made using binary or ordinal responses, combined to derive item-content validity indices (I-CVI) to guide item reduction. Items with I-CVI > 0.78 (excellent content validity) were moved forward to tool development. Of the 71 invited respondents, 57(80.3%) responded, of which 34(59.6%) were from North America. Sixty-one items were generated of which 4(6.6%) items were rated ‘to keep’. These were face symmetry (I-CVI:0.89), salivary control (I-CVI:0.95), alertness (I-CVI:0.89) and choking (I-CVI:0.84). Of all respondents, 31(54.4%) endorsed swallowing trials, of which 25(80.6%) endorsed thin liquid by teaspoon (n = 17, 68%) or open cup (n = 20, 80%). We identified candidate items for bedside dysphagia screening with excellent content validity for acute pediatric stroke patients. Next steps include assessment of the psychometric value of each item in identifying dysphagia in children in the acute stage of recovery from stroke.
... Observations of signs (cough, change in vocal quality, etc.) that may be suggestive of dysphagia/aspiration should then be recorded throughout the entire CSE, not just during administration of bolus trials. The more signs present (e.g., abnormal cranial nerve exam, coughing), the higher the predictive value for aspiration, although signs of aspiration are not highly predictive of adverse outcomes in adults (Daniels et al., 2000;Martino et al., 2000). Observation throughout an entire session can allow the clinician to compare data obtained before, during, and after swallow trials. ...
... Observation throughout an entire session can allow the clinician to compare data obtained before, during, and after swallow trials. The reader is referred to previously published reviews about predictive values related to signs predicting dysphagia/aspiration, such as those by Brodsky et al. (2016), Calvo et al. (2016), Daniels et al. (2000), Martino et al. (2000), McCullough et al. (2005), andO'Horo et al. (2015). ...
Article
Purpose This tutorial will provide speech-language pathologists with foundational knowledge about systematic reviews and their importance in everyday practice. It will also assist clinicians in developing critical appraisal skills so that current research can be translated judiciously to clinical environments for patient care. Systematic reviews are often regarded as the highest level of research evidence for implementing best evidence-based practice, because they synthesize research findings from multiple high-quality research studies, identify methodological weaknesses and biases from the studies included, and assist in illuminating areas for future research work based on current gaps in the literature. While systematic reviews can provide comprehensive knowledge to inform clinical practice, few speech-language pathologists receive training on appraising and applying the findings from systematic reviews appropriately within clinical settings. Conclusion Clinicians within the field of speech-language pathology can use the framework provided in this tutorial to evaluate systematic reviews as a preliminary step for determining appropriate assessment and treatment methods for implementing evidence-based practice within clinical settings.
... We decided to include only systematic reviews in which the bedside tools were compared to VFSS, FEES and FEESST because in the literature they were reported to be the reference standard by which to detect patients with dysphagia 13 . As suggested by the JBI 12 , only systematic reviews of randomized controlled trials or cross-sectional studies were included. ...
Article
Introduction. Dysphagia often results in serious, poor health outcomes. Nurses have an important role in assessing dysphagia. Therefore, they need reliable and effective screening tools to detect dysphagia. The purpose of this umbrella review is to locate the most val- id, reliable, and usable bedside screening tools that allow nurses to identify dysphagia in institutionalized patients. Methods. Umbrella Review as suggested by the Joanna Briggs Institute. Inclusion criteria were: systematic reviews of randomized controlled trials or cross-sectional studies. We excluded: pediatric and psychiatric patients. We searched on PubMed, CINAHL, Scopus, Cochrane Library, the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, and the Joanna Briggs Institute Evidence-Based Practice Database. Results. Six re- views were included. Four tools were reported in all the reviews: 3 oz swallowing water test, Mann Assessment of Swallowing Ability, Toronto Bedside Swallowing Screening Test, Gugging Swallowing Screen. They have shown fair to good sensitivity and specificity. The reviews analysed did not allow for a comparative analysis between instruments, which may be hindering the selection of the opti- mal instrument for clinical practice. Conclusions. Almost all reviews have considered stroke patients. The next steps will be to determine if there is a tool applicable in multiple settings with different patients and if this intervention is cost-effective.
... We decided to include only systematic reviews in which the bedside tools were compared to VFSS, FEES and FEEST because in the literature they were reported to be the reference standard by which to detect patients with dysphagia 13 . As suggested by the JBI 12 , only systematic reviews of randomized controlled trials or cross-sectional studies were included. ...
Article
Introduction: Dysphagia often results in serious, poor health outcomes. Nurses have an important role in assessing dysphagia. Therefore, they need reliable and effective screening tools to detect dysphagia. The purpose of this umbrella review is to locate the most valid, reliable, and usable bedside screening tools that allow nurses to identify dysphagia in institutionalized patients. Methods: Umbrella Review as suggested by the Joanna Briggs Institute. Inclusion criteria were: systematic reviews of randomized controlled trials or cross-sectional studies. We excluded: pediatric and psychiatric patients. We searched on PubMed, CINAHL, Scopus, Cochrane Library, the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, and the Joanna Briggs Institute Evidence-Based Practice Database. Results: Six reviews were included. Four tools were reported in all the reviews: 3 oz swallowing water test, Mann Assessment of Swallowing Ability, Toronto Bedside Swallowing Screening Test, Gugging Swallowing Screen. They have shown fair to good sensitivity and specificity. The reviews analysed did not allow for a comparative analysis between instruments, which may be hindering the selection of the optimal instrument for clinical practice. Conclusions: Almost all reviews have considered stroke patients. The next steps will be to determine if there is a tool applicable in multiple settings with different patients and if this intervention is cost-effective.
... 4 Early detection and treatment of dysphagia in stroke patients are crucial to prevent adverse complications, decrease the length of hospital stay, and reduce the health-care costs. 5 Recognizing the current status of dysphagia may have clinical significance in terms of enabling clinicians to provide early treatment of dysphagia after ischemic stroke. ...
Article
Objective To identify the incidence of dysphagia after ischemic stroke and determine factors affecting the presence of dysphagia. Design Retrospective case-control study. This was an interim analysis of a prospective multicenter Korean stroke cohort. Setting Acute care university hospitals. Participants Patients (N=6000) with first-ever acute ischemic stroke. Patients were divided into two groups according to the presence or absence of dysphagia confirmed at 7 days after onset using the American Speech-Language-Hearing Association National Outcomes Measurement System (ASHA-NOMS) scale, which was determined after conducting screening or standardized tests. Interventions Not applicable. Main outcome measures Age at stroke onset, body mass index (BMI), premorbid modified Rankin Scale (mRS), brainstem lesions, National Institutes of Health Stroke Scale (NIHSS), post-stroke mRS, and ASHA-NOMS swallowing level at post-stroke day 7 were evaluated. Results Among ischemic stroke patients, 32.3% (N=1940) had dysphagia at 7 days after stroke onset. At discharge, 80.5% (N=1561) still had dysphagia. The prediction model for the presence of dysphagia identified age at onset, underweight (BMI < 18.5 kg/m²), premorbid mRS, brainstem lesions, and NIHSS as independent predictors. The odds ratio (OR) for the presence of dysphagia significantly increased with underweight (OR [95% confidence interval]: 1.6684 [1.27–2.20]), increased age at onset (1.0318 [1.03-1.04]), premorbid mRS (1.1832 [1.13-1.24]), brainstem lesions (1.6494 [1.39-1.96]), and NIHSS (1.2073 [1.19-1.23]). Conclusions The incidence of dysphagia after ischemic stroke was 32.3%. The prediction model for the presence of dysphagia identified age, low BMI, premorbid disabilities, brainstem lesions, and NIHSS as predictive factors.
... 24 There are emerging pieces of evidence that early detection of dysphagia reduces not only pulmonary complications but also the length of hospital stays and overall healthcare costs for acute post-stroke patients. 25,26 Clinical bedside evaluation can provide clinician data regarding cognition, current medical history, history of dysphagia, nutritional and respiratory status, oral anatomy, labial and lingual control, respiration and its relation to swallow, palatal function, pharyngeal wall contraction, laryngeal control, patients reaction to oral sensory stimulation and patient reaction in an attempt to swallow. 27,28 Though clinical evaluation provides valuable information, sensitivity and specificity for aspiration risk are generally low. ...
Chapter
Stroke is the second‐leading cause of death and a major cause of disability worldwide. The principle underlying all rehabilitation is that the brain has an inherent capacity to recover lost function after stroke. This is based on observations that most survivors regain some or many of the functions initially lost as a result of the stroke. Rehabilitation in stroke is essentially a multidisciplinary activity, which has been described as a problem‐solving educational process focusing on disability and intended to reduce handicap. Rehabilitation has four important components: assessment, planning, intervention, and evaluation. Restoration of motor function is a primary objective of stroke rehabilitation, and there are several pooled data analyses of studies on various strategies for improving motor performance in stroke patients. Evidence suggests that organised care, such as that provided in stroke units, both facilitates neurological recovery and expedites discharges.
Article
Objective To measure the latency of laryngeal adductor reflex (LAR) motion onset at 2 laryngopharyngeal subsites using calibrated aesthesiometers. Study Design Cross-sectional. Setting Academic institution. Methods Twenty-one asymptomatic, healthy subjects (11 male, 10 female) underwent laryngopharyngeal sensory testing with tactile stimuli delivered to the aryepiglottic fold and medial pyriform sinus using 30-mm Cheung-Bearelly monofilaments (4-0 and 5-0 nylon sutures) via channeled flexible laryngoscope. The LAR onset latency, defined as the first visual detection of ipsilateral vocal fold adduction following tactile stimulation, was measured with frame-by-frame analysis of video recordings. Results The overall mean LAR latency across both subsites and stimulation forces was 176.6 (95% CI, 170.3-183.0) ms, without significant difference between subsites or forces. The critical value for LAR response latency prolongation at the .01 significance level was 244 ms. At 30 frames/s video capture resolution, LAR response latency ≥8 frame intervals would indicate abnormal prolongation. Conclusion Aesthesiometer-triggered LAR latency appears to be invariant over an 8.7-dB force range and between the aryepiglottic fold and medial pyriform sinus subsites in controls. Laryngeal adductor reflex latency incongruences between stimulation forces or laryngopharyngeal subsites may serve as pathophysiological features to dissect mechanisms of upper aerodigestive tract disorders. Level of Evidence Level 3B.
Article
Background Early identification of dysphagia aims to mitigate the risk of health consequences in adults poststroke; however, the evidence from experimental trials alone is inconclusive. This meta‐analysis assessed dysphagia screening benefit from both trial and observational data. Methods and Results Seven electronic databases were searched to December 2019. Unique abstracts and full articles were screened for eligibility by 2 independent blinded raters using a priori criteria and discrepancies resolved by consensus. Included studies were summarized descriptively and assessed for methodological quality using Cochrane Risk of Bias Tool. Across studies, pooled estimates of health benefit were derived for homogeneous data using Review Manger 5.3. From the yield of 8860 citations, 30 unique articles were selected: 24 observational and 6 randomized trials. Across studies, comparisons varied: no screening versus screening, late versus earlier screening, informal versus formal screening, pre‐ versus postscreening, and pre‐ versus poststroke guidelines that included screening. Pooled estimates across comparisons favored experimental groups for pneumonia odds ratio (OR), 0.57 (95% CI, 0.45–0.72), mortality OR, 0.52 (95% CI, 0.35–0.77), dependency OR, 0.54 (95% CI, 0.35–0.85), and length of stay standardized mean difference, −0.62 (95% CI, −1.05 to −0.20). Conclusions Combining evidence from experimental and observational studies derived a significant protective health benefit of dysphagia screening following adult acute stroke for pneumonia, mortality, dependency, and length of stay.
Article
Full-text available
This study was designed to quantify the effects of thermal sensitization on the oral and pharyngeal transit times of the swallow following sensitization in a group of 25 neurologically impaired patients exhibiting delayed triggering of the swallowing reflex. Thermal sensitization consists of applying cold (thermal) contact to the base of the anterior faucial arches in order to sensitize the area of the oral cavity where the reflex is triggered. Thermal sensitization improved triggering of the swallowing reflex in 23 of the 25 neurologically impaired patients on swallows of at least one food consistency. Results are discussed in relation to neurologic recovery and carryover of these effects.
Article
The published data on the relationship between dysphagia and both outcome and complications after acute stroke have been inconclusive. We examined the relationship between these, using bedside assessment and videofluoroscopic examination. We prospectively studied 121 consecutive patients admitted with acute stroke. A standardized bedside assessment was performed by a physician. We performed videofluoroscopy blinded to this assessment within 3 days of stroke onset and within a median time of 24 hours of the bedside evaluations. The presence of aspiration was recorded. Mortality, functional outcome, lengthy of stay, place of discharge, occurrence of chest infection, nutritional status, and hydration were the main outcome measures. Patients with an abnormal swallow (dysphagia) on bedside assessment had a higher risk of chest infection (P=.05) and a poor nutritional state (P=.001). The presence of dysphagia was associated with an increased risk of death (P=.001), disability (P=.02), length of hospital stay (P<.001), and institutional care (P<.05). When other factors were taken into account, dysphagia remained as an independent predictor of outcome only with regard to mortality. The use of videofluoroscopy in detecting aspiration did not add to the value of bedside assessment. Bedside assessment of swallowing is of use in identifying patients at risk of developing complications. The value of routine screening with videofluoroscopy to detect aspiration is questioned.
Article
We report differential patterns of swallowing in 40 patients with their first ischemic middle cerebral artery (MCA) stroke and compare these to 20 nonstroke controls. Stroke patients were divided a priori, into groups by right or left and, post hoc, primarily anterior or posterior MCA territory lesions. The left hemisphere subgroup was differentiated from controls by longer pharyngeal transit durations and from the right hemisphere group by shorter pharyngeal response durations. The right hemisphere subgroup was characterized by longer pharyngeal stage durations and higher incidences of laryngeal penetration and aspiration of liquid. Anterior lesion subjects demonstrated significantly longer swallowing durations on most variables compared to both normal and posterior lesion subjects. Changes in the consistency of foods and other modifications for safe nutrition should be considered during the first month of recovery for unilateral stroke patients with swallowing difficulty.
Article
Clinical and videofluoroscopic evaluation of swallowing were correlated to determine their agreement and relationship to feeding recommendations. We reviewed a total of 148 patients with swallowing difficulties, of which 93 (45 women, 48 men; mean age 62 years) were evaluated by both clinical and radiographic examinations. A variety of materials were used for clinical bedside evaluation of oral and pharyngeal function. Radiographic examination was done with variable viscosity materials and videotape recording of the oral cavity and pharynx. The severity of oral and pharyngeal abnormalities was graded and findings of the examinations were compared. The combined results of both evaluations generated an index of swallowing difficulty which was correlated to the type of diet used if oral feeding was recommended or to a nonoral route of nutrition. In the assessment of oral and pharyngeal dysfunction, clinical evaluation and radiographic examination correlated closely in 94% of patients; however, the status of pharyngeal function was not determined in 61 (66%) of the 93 patients by clinical examination alone. The combined swallowing index was calculated in 89 patients and its severity correlated significantly with the type of feeding recommended; 64 patients were placed on one of three types of diets and 25 had enteral feedings. In conclusion, combined clinical and radiographic examinations correlated well, but clinical evaluation alone was limited by failure to evaluate the pharynx in many patients. The swallowing severity correlated well with final feeding recommendations.
Article
One of the foci of Martin Donner's work was the neural control of swallowing. This present investigation continues that work by examining oropharyngeal swallowing in 8 patients identified with a single, small, left-basal ganglion/internal capsule infarction and 8 age-matched normal subjects. Stroke patients were assessed with a bedside clinical and radiographic swallowing assessment, and normal subjects received only the radiographic study. Results revealed disagreement between the bedside and radiographic assessments in one of the 8 stroke patients. Stroke and normal subjects differed significantly on some swallow measures on various bolus viscosities, but behaved the same as normal subjects on a number of measures. Differences in swallowing in the stroke subjects were not enough to prevent them from eating orally. The significant differences seen in the basal ganglia/intemal capsule stroke subjects may result from damage to the sensorimotor pathways between the cortex and brainstem. These differences emphasize the importance of cortical input to the brainstem swallowing center in maintaining the systematic modulations characteristic of normal swallowing physiology.
Article
To demonstrate that sensory nerve transposition may be used to reestablish sensation of the laryngopharynx after central nervous system injury and vagal deficit. Prospective preliminary report of 2 patients following brain-stem stroke with aspiration pneumonia confirmed on chest radiography, severe dysphagia and inability to tolerate oral alimentation, and modified barium swallow that demonstrated cricopharyngeal spasm and impaired laryngeal elevation. Both patients also had severe, bilateral laryngopharyngeal sensory deficits as determined by delivery of air pulse stimuli to the mucosa innervated by the superior laryngeal nerve via a fiberoptic telescope. Each patient underwent surgery as part of management of dysphagia after failure of aggressive nonsurgical treatment. During a cricopharyngeal myotomy and laryngeal suspension, a unilateral microneurorrhaphy between the greater auricular nerve and the superior laryngeal nerve was performed. Ability to tolerate oral diet without development of aspiration pneumonia and postoperative laryngopharyngeal sensory capacity. By 12 months after surgery, both patients had ipsilateral restoration of laryngopharyngeal sensation, with no further episodes of aspiration pneumonia. In select cases of severe dysphagia after central nervous system injury, sensory nerve transposition may be a useful adjunct to the surgical rehabilitation of the patient with dysphagia.