Dysphagia Outcomes in Patients with Brain Tumors Undergoing Inpatient Rehabilitation

The purpose of this retrospective study was to compare functional dysphagia outcomes following inpatient rehabilitation for patients with brain tumors with that of patients following a stroke. Group 1 (n = 24) consisted of consecutive admissions to the brain injury program with the diagnosis of brain tumor and dysphagia. Group 2 (n = 24) consisted of matched, consecutive admissions, with the diagnosis of acute stroke and dysphagia. Group 2 was matched for age, site of lesion, and initial composite cognitive FIM score. The main outcome measures for this study included the American Speech-Language-Hearing Association (ASHA) National Outcome Measurement System (NOMS) swallowing scale, length of stay, hospital charges, and medical complications. Results showed that swallowing gains made by both groups as evaluated by the admission and discharge ASHA NOMS levels were considered to be statistically significant. The differences for length of stay, total hospital charges, and speech charges between the two groups were not considered to be statistically significant. Three patients in the brain tumor group (12.5%) demonstrated dysphagia complications of either dehydration or pneumonia during their treatment course as compared to 0% in the stroke group. This study confirms that functional dysphagia gains can be achieved for patients with brain tumors undergoing inpatient rehabilitation and that they should be afforded the same type and intensity of rehabilitation for their swallowing that is provided to patients following a stroke. The Dr. Ralph and Marian Falk Medical Research Foundation supported this work. Work completed at Marianjoy Rehabilitation Hospital, Wheaton, Illinois     

Dysphagia following strokes: Clinical observations of swallowing rehabilitation employing Palatal Training Appliances

A retrospective study was undertaken to evaluate the progress of a group of dysphagic stroke patients for whom a dental prosthesis the Palatal Training Appliance (PTA), was used in the active rehabilitation of the swallowing mechanism. Patients selected were those who had sustained a stroke uncomplicated by other neurological illness, during one 12-month period, and whose dysphagia caused anxiety to the medical staff in the hospital ward. Thirty severely dysphagic stroke patients satisfied these criteria. The study recorded the duration and type of supplementary feeding required during hospitalization. Thirteen patients had evidence of aspiration before the PTA was fitted and 5 afterwards. Seven patients died, but only 1 was recorded as having a febrile illness which may have contributed to the death. At discharge, which averaged 10 weeks after admission, 22 of the 23 survivors were taking an adequate oral diet. It was also noted that almost half of the patients who wore dentures before the cerebrovascular event were unable to control them afterwards, adding to their neurological swallowing difficulties. The fitting of a PTA and correction of unstable dentures appeared to help both motivation and function. The results show an improvement in the rehabilitation of oral feeding compared with previous reports by other authors, who did not use the dental appliance. There did not appear to be any medical contraindication to its use.     

Effectiveness of Computer-Based Dysphagia Training for Direct Patient Care Staff

Speech–language pathologists (SLPs) in medical settings are responsible for evaluating patients’ feeding and swallowing. Once an evaluation is completed, nursing staff typically provides hands-on care and supervision of meals. SLPs seek to improve outcomes for individuals with dysphagia by educating direct-care staff. This project sought to determine whether a computer-based swallowing safety module could produce changes in knowledge levels of nursing staff. This module was designed to replace inservices conducted by staff SLPs. Nursing staff would be required to complete the training when hired and as an annual assessment. The training module was designed and pilot-tested along with a pre- and posttest to assess changes in knowledge. Participants in the experimental group took the pretest, completed the computer training module, and then took the posttest. Participants in the control group took the pre- and posttest with no intervening training. Statistically significant differences were found between the two groups on posttest scores. Participants in the experimental group demonstrated increased test scores, while the scores of the control group did not change significantly. This study indicates that computer-based training for nursing staff related to swallowing safety and dysphagia is effective.     

Awareness of Dysphagia by Patients Following Stroke Predicts Swallowing Performance

Patients awareness of their disability after stroke represents an important aspect of functional recovery. Our study aimed to assess whether patient awareness of the clinical indicators of dysphagia, used routinely in clinical assessment, related to an appreciation of a swallowing problem and how this awareness influenced swallowing performance and outcome in dysphagic stroke patients. Seventy patients were studied 72 h post hemispheric stroke. Patients were screened for dysphagia by clinical assessment, followed by a timed water swallow test to examine swallowing performance. Patient awareness of dysphagia and its significance were determined by detailed question-based assessment. Medical records were examined at three months. Dysphagia was identified in 27 patients, 16 of whom had poor awareness of their dysphagic symptoms. Dysphagic patients with poor awareness drank water more quickly (5 ml/s vs. <1 ml/s, p = 0.03) and took larger volumes per swallow (10 ml vs. 6 ml, p = 0.04) than patients with good awareness. By comparison, neither patients with good awareness or poor awareness perceived they had a swallowing problem. Patients with poor awareness experienced numerically more complications at three months. Stroke patients with good awareness of the clinical indicators of dysphagia modify the way they drink by taking smaller volumes per swallow and drink more slowly than those with poor awareness. Dysphagic stroke patients, regardless of good or poor awareness of the clinical indicators of dysphagia, rarely perceive they have a swallowing problem. These findings may have implications for longer-term outcome, patient compliance, and treatment of dysphagia after stroke. This work was presented in abstract form at the Dysphagia Research Society meeting, Burlington, Vermont, 1999     

Oral sensorimotor function for feeding in patients with tetanus

Tetanus still remains a significant health problem in developing countries; it is a serious disease with a high mortality rate. The purpose of this study was to characterize the oral sensorimotor function for feeding in patients with tetanus. Thirteen patients clinically diagnosed with tetanus and admitted to an intensive care unit between December of 2005 and May of 2007 underwent a screening tool for dysphagia, involving the assessment of clinical features and 2 swallowing tests. Results indicate that the oral sensorimotor function for feeding in these patients is severely compromised, with the exception for the clinical feature of palate elevation and performance in the saliva swallowing test. The factor analysis indicated that the evaluation of tongue movement change in the oromotor examination is important in predicting alterations of cough/voice in the water swallowing test, thus suggesting that oral feeding might be unsafe. When looking at developing countries, the prolonged intensive medical and nursing care required by many patients with tetanus places extra demands on an already stretched healthcare budget. Intervention by a speech pathologist could mean that time in the ICU would be reduced as well as the number of re-admissions due to complications.     

Findings of Videofluoroscopic Swallowing Studies AreAssociated with Tube Feeding Dependency at Discharge in StrokePatients with Dysphagia

The factors associated with tube feeding dependency in stroke patients with dysphagia have received little attention. This study aimed to identify factors independently associated with tube feeding dependency at discharge in stroke patients with dysphagia using videofluoroscopic swallowing studies (VSS) and clinical findings. One hundred eighty-one consecutive tube-fed inpatients with stroke-related dysphagia referred for VSS were enrolled in the study. Of them, 47 patients continued to require tube feeding at discharge. In the final logistic regression analysis model, advanced age, recurrent stroke, confinement to a wheelchair at discharge, long duration from stroke onset to VSS, and stasis in valleculae or pyriform sinuses and aspiration on VSS were independently associated with tube feeding dependency at discharge. This study confirms the association between findings of VSS and tube feeding dependency at discharge in stroke patients with dysphagia. Based on the final regression model, a preliminary equation was proposed to help clinicians better predict the tube feeding dependency at discharge in stroke patients with dysphagia. An erratum to this article is available at .     

Dietary management of swallowing disorders

Two major concerns in the dietary management of the dysphagic patient are to maintain adequate nutrition and to ensure safety during oral feeding. Dysphagic patients require modifications of standard hospital diets. Kitchen or nursing staff must remove from standard diet trays solid foods and liquids that pose swallowing hazards. Training kitchen and nursing staff and removing food are time consuming. It is also hazardous if certain foods are served to dysphagic patients through error or lack of knowledge. In addition, there is risk of inadequate nutrition when food is removed from trays. This paper proposes a four-level diet plan for patients who have difficulty swallowing solids and liquids. These diets gradually advance for patients undergoing treatment to improve swallowing function. The proposed diets save time for kitchen and nursing staff, reduce the risk of aspiration among patients, and serve as models for families as they prepare for discharge and meal planning at home. Diet guidelines are based on recommendations of the American Dietetic Association.     

Is the Gag Reflex Useful in the Management of Swallowing Problems in Acute Stroke?

The goal of this study was to compare the diagnostic value of an absent gag reflex in acute stroke patients with the bedside swallowing assessment (BSA) and assess its relationship to outcomes. Two hundred forty-two acute stroke patients had their gag reflex tested and a BSA performed. Numbers needing nasogastric or gastrostomy tube insertion were noted, also their discharge destination, discharge Barthel Index, and mortality. The mean age of the subjects was 76.5 ± 10.2 years; 37.6% were male; 41.7% of the patients were dysphagic on BSA; 18.2% had an absent gag. Dysphagia was present in 88.6% of the patients with an absent gag and in 31.3% of those with an intact gag. The gag reflex was absent in 38.6% of dysphagic and 3.5% of nondysphagic patients. Comparing an absent gag against the criterion of the BSA, its specificity was 0.96, sensitivity 0.39, positive predictive value 0.89, and negative predictive value 0.69. Regression analyses found that an intact gag gave an Odds Ratio [CI] of 0.23 [0.06–0.91] for gastrostomy feeding but did not predict other outcomes. We conclude that the gag reflex is as specific as but less sensitive than the BSA in detecting dysphagia in acute stroke patients. An intact gag may be protective against longer-term swallowing problems and the need for enteral feeding.Deborah Ramsey’s post has been funded by Action Research.     

Dysphagia in Stroke: A Prospective Study of Quantitative Aspects of Swallowing in Dysphagic Patients

This is a prospective study of 100 consecutive stroke patients. Within 24 h after stroke onset they were asked specifically about swallowing complaints and subjected to a clinical examination including neurologic examination, Mini-Mental test, and Barthel score. Dysphagic patients were examined with the repetitive oral suction swallow test (the ROSS test) for quantitative evaluation of oral and pharyngeal function at 24 h, after 1 week, and after 1 month. At 6 months, the patients were interviewed about persistent dysphagia. Seventy-two patients could respond reliably at 24 h after the stroke onset and 14 of these complained of dysphagia. Non-evaluable patients were either unconscious, aphasic, or demented. The presence of dysphagia was not influenced by age or other risk factors for stroke. Facial paresis, but no other clinical findings, were associated with dysphagia. Dysphagia 24 h after stroke increased the risk of pneumonia but did not influence the length of hospital stay, the manner of discharge from hospital, or the mortality. The initial ROSS test, during which the seated patient ingests water through a straw, was abnormal in all dysphagic stroke patients. One-third of the patients were unable to perform the test completely. Above all, dysfunction was disclosed during forced, repetitive swallow. All phases of the ingestion cycle were prolonged whereas the suction pressures, bolus volumes, and swallowing capacities were low. Abnormalities of quantitative swallowing variables decreased with time whereas the prevalences of swallowing incoordination and abnormal feeding-respiratory pattern became more frequent. After 6 months, 7 patients had persistent dysphagia. Five of these were initially non-evaluable because of unconsciousness, aphasia, or dementia.     

Effects of a multidisciplinary management program on neurologically impaired patients with dysphagia

Dysphagia is a major problem in patients with neurologic disorders. Aspiration pneumonia and impaired nutritional status are consequences of dysphagia that result in high morbidity and mortality rates [1, 2]. Assessment and treatment of the dysphagic patient by a multidisciplinary team have been advocated but to date the effects of such an approach have not been demonstrated quantitatively. This prospective study was conducted to determine if a dysphagia program would improve patients' caloric intake and body weight, decrease the instances of aspiration pneumonia, or improve patients' feeding ability. Patients were referred from a 26 bed neurology/neurosurgery unit. A time series design was utilized. The control group consisted of 15 patients (mean age=46.1 years), managed according to the existing ward routine. Subsequently, nursing staff attended a dysphagia training program. Following this, the treated group of 16 patients, (mean age=49.3 years) was assessed by the dysphagia team, using bedside and videofluoroscopic examinations to determine the specific swallowing disorder. An individualized treatment program was designed for each patient. The groups were compared on the basis of deviation from their baseline weight, deviation from ideal energy intake, and the incidence of aspiration pneumonia. Statistical analysis revealed that the groups were comparable in age, number of days on the study, and Glasgow Coma Scale score; and that a significant weight gain and increase in caloric intake occurred in the treated group. No incidence of aspiration pneumonia was reported in either group. We speculate that this may have been influenced by the meticulousness of the care delivered in an acute unit as well as greater attention to prevention given in both groups. We conclude that the institution of a multidisciplinary team to manage dysphagia resulted in improvement in patients' weight and caloric intake.     

Cervical Spinal Cord Injury and Deglutition Disorders

The association of cervical spinal cord injury and swallowing disorders is clinically well recognized. This study was performed to determine the clinical significance and the outcome of deglutition disorders observed in the initial treatment of cervical spinal cord injury in our tertiary care spinal cord injury unit. All patients with cervical spinal cord injury admitted to our facility for initial care between January 1997 and December 2000 were included in our study. Prevalence of dysphagia and frequency of pneumonia were determined. An assessment of deglutition at discharge was performed. Dysphagia was diagnosed in 26 of the 73 patients with cervical spinal cord injury. Tracheostomy and duration of orotracheal intubation are associated with dysphagia. The disorder necessitated dietary restrictions in 18 patients. Six of these patients had to be discharged with a percutaneous enterogastric feeding tube; seven had persistent problems not resulting in dietary restrictions. The incidence of late pneumonia was significantly increased with two associated deaths. Dysphagia is a serious complication associated with prolonged requirement for ventilatory support. Patients have to be monitored closely because the incidence of pneumonia is increased. While the situation improves for most patients, a significant number of patients need a percutaneous enterogastric feeding tube as a permanent solution.     

A direct intervention program for chronic neurogenic dysphagia secondary to brainstem stroke

Little objective documentation is available regarding the efficacy of therapies for oropharyngeal dysphagia. Information specifying efficacy of treatment for chronic dysphagic conditions is almost nonexistent. This report describes a direct therapy program for chronic neurogenic dysphagia resulting from brainstem stroke, and provides information on immediate and long-term clinical outcome. Changes in swallowing physiology reflect goals of therapy. Long-term follow-up shows that functional benefits are long lasting without related health complications.     

Improving care for patients with dysphagia

BACKGROUND: Early diagnosis and effective management of dysphagia reduce the incidence of pneumonia and improve quality of care and outcome. Dysphagic stroke patients rarely perceive that they have a swallowing problem, and thus carers have to take responsibility for following the safe swallow recommendations made by the Speech and Language Therapist (SLT). Published work and observations in our own Trust indicated that patients with dysphagia may be fed in a manner which places them at significant risk of aspiration, despite SLT advice for safe swallowing. OBJECTIVE: To determine compliance with swallowing recommendations in patients with dysphagia and to investigate the effectiveness of changes in practice in improving compliance. DESIGN: Sequential observational study before and after targeted intervention. SETTING: An acute general and teaching hospital in an inner city area. SUBJECTS: All patients with dysphagia on the caseload of the speech and language therapy department at the time of the study. METHODS: Observations were made on compliance with the recommendations of SLTs regarding consistency of fluids, dietary modifications, amount to be given at a single meal/drink, swallowing strategies, general safe swallow recommendations and whether supervision was required. A dysphagia link nurse programme was established, together with modification of an in-house training scheme, use of pre-thickened drinks and modification of swallowing advice sheets. The same observations were repeated after this intervention. RESULTS: Thirty-one patients were observed before and 54 after the intervention. There was improvement in compliance with the recommendations on consistency of fluids (48-64%, P<0.05), amount given (35-69%, P<0.05), adherence to safe swallow guidelines (51-90%, P<0.01) and use of supervision (35-67%, P<0.01). There were no significant differences in compliance with dietary modifications or swallowing strategies. Improvement in compliance was demonstrated in medical and geriatric wards and the stroke unit, but not in the surgical wards. Compliance with 'nil by mouth' instructions was 100% throughout. CONCLUSIONS: Relatively simple and low-cost measures, including an educational programme tailored to the needs of individual disciplines, proved effective in improving the compliance with advice on swallowing in patients with dysphagia. It is suggested that this approach may produce widespread benefit to patients across the NHS.     

Functional Benefits of Dysphagia Therapy Using Adjunctive sEMG Biofeedback

This article describes a retrospective analysis of functional outcome, time in therapy, and cost per unit of functional change in patients who received therapy for pharyngeal dysphagia. Twenty-five patients presenting dysphagia following stroke and 20 patients with dysphagia following treatment for head/neck cancer completed a systematic therapy program supplemented with surface electromyographic (sEMG) biofeedback. Eighty-seven percent (39/45) of all patients increased their functional oral intake of food/liquid including 92% of stroke patients and 80% of head/neck cancer patients. Patients with dysphagia following stroke demonstrated greater improvement than those in the head/neck cancer group. Patients in the stroke group completed more therapy sessions thus increasing the total cost of therapy, but they made more functional progress resulting in lower costs per unit of functional change than patients in the head/neck cancer group. Limitations of this study are described in reference to implications for future clinical research on the efficacy of this therapy approach.     

Outcomes of Swallowing Rehabilitation in Chronic Brainstem Dysphagia: A Retrospective Evaluation

This study examines the functional and physiologic outcomes of treatment in a group of 10 patients with chronic dysphagia subsequent to a single brainstem injury. All patients participated in a structured swallowing treatment program at a metropolitan teaching hospital. This program differs from more traditional swallowing treatment by the inclusion of surface electromyography biofeedback as a treatment modality and the completion of 10 hr of direct treatment in the first week of intervention. A retrospective analysis of medical records and patient questionnaires was used to gain information regarding medical history, site of lesion, prior interventions, and patient perception of swallowing recovery. Physiologic change in swallowing treatment, as measured by severity ratings of videofluoroscopic swallowing studies, was demonstrated in nine of 10 patients after 1 week or 10 sessions of treatment. Functional change was measured by diet level tolerance after 1 week of treatment, at 6 months, and again at 1 year posttreatment. Eight of the 10 patients were able to return to full oral intake with termination of gastrostomy tube feedings, whereas two demonstrated no long-term change in functional swallowing. Of the eight who returned to full oral intake, the average duration of tube feedings following treatment until discontinuation was 5.3 months, with a range of 1–12 months. Six patients who returned to oral intake maintained gains in swallowing function, and two patients returned to nonoral nutrition as the result of a new unrelated medical condition.     

Percutaneous Endoscopic Gastrostomy (PEG) for Enteral Nutrition in Patients with Stroke

Background: The use of percutaneous endoscopic gastrostomy (PEG) for enteral nutrition in patients admitted for stroke is difficult, varying and needs specific consideration. There is therefore need for more data on this patient group. We examined the indications, survival, tube removal and time with PEG in stroke patients and in other patients with PEG with the aim of providing guidance for the management of enteral nutrition via PEG in stroke patients. Methods: Retrospective assessment of data from all stroke patients and patients with other diseases (control group) who had received PEG for enteral nutrition during a period of 8.5 years. Results: Eighty-three stroke patients with dysphagia received PEG after unsuccessful use of nasogastric tubes or long-term tube feeding. Early mortality rate was 19% in the stroke group, 26% in the older group (>74 years) and 12% in the younger group (60-74 years). The PEG tubes were later removed due to swallowing recovery in 20% of the older group and in 31% of the younger group. At 90 days, 50%-60% still needed PEG. The stroke patients were older compared to the control group ( n &#114 = &#114 115); 30-day mortality was similar but more patients recovered the ability to swallow. Conclusions: Stroke patients are older than other patients who receive PEG; 27% have swallowing recovery and more than 75% have long-term need for PEG. Nasogastric tubes often fail, and the need for early PEG placement (within 2 weeks) must be assessed in appropriate patients. The patient's prognosis, the objective of nutritional treatment, duration of dysphagia, age and comorbidity should all be taken into consideration.     

Percutaneous endoscopic gastrostomy (PEG) for enteral nutrition in patients with stroke

BACKGROUND: The use of percutaneous endoscopic gastrostomy (PEG) for enteral nutrition in patients admitted for stroke is difficult, varying and needs specific consideration. There is therefore need for more data on this patient group. We examined the indications, survival, tube removal and time with PEG in stroke patients and in other patients with PEG with the aim of providing guidance for the management of enteral nutrition via PEG in stroke patients. METHODS: Retrospective assessment of data from all stroke patients and patients with other diseases (control group) who had received PEG for enteral nutrition during a period of 8.5 years. RESULTS: Eighty-three stroke patients with dysphagia received PEG after unsuccessful use of nasogastric tubes or long-term tube feeding. Early mortality rate was 19% in the stroke group, 26% in the older group (>74 years) and 12% in the younger group (60-74 years). The PEG tubes were later removed due to swallowing recovery in 20% of the older group and in 31% of the younger group. At 90 days, 50%-60% still needed PEG. The stroke patients were older compared to the control group (n = 115); 30-day mortality was similar but more patients recovered the ability to swallow. CONCLUSIONS: Stroke patients are older than other patients who receive PEG; 27% have swallowing recovery and more than 75% have long-term need for PEG. Nasogastric tubes often fail, and the need for early PEG placement (within 2 weeks) must be assessed in appropriate patients. The patient's prognosis, the objective of nutritional treatment, duration of dysphagia, age and comorbidity should all be taken into consideration.     

The Incidence, Management, and Complications of Dysphagia in Patients with Medullary Strokes Admitted to a Rehabilitation Unit

The objective of this study was to examine the frequency of dysphagia symptoms and related consequences in medullary stroke patients admitted to a stroke rehabilitation unit. A chart review of a cohort of 563 stroke patients admitted to a rehabilitation unit was used to identify patients with evidence of predominantly medullary lesions. The results of both initial and followup videofluoroscopic modified barium swallowing (VMBS) studies were also reviewed for evidence of aspiration and residuum in patients with dysphagia. Twenty of the 563 patients (3.6%) were diagnosed with a medullary stroke. Eleven of the 20 (55%) patients were identified clinically with dysphagia and nine had at least one (VMBS) study. All dysphagic patients demonstrated some degree of either aspiration or residuum on both initial and final swallowing studies and received some form of dietary modification. Comparisons between patients with and without dysphagia demonstrated significant differences with regard to length of hospital stay and the development of pneumonia (p < 0.05). More than half of the patients with medullary strokes presented with clinical indications of dysphagia, were more likely to develop aspiration pneumonia, and experienced longer hospital stays. Aspiration pneumonia appeared to be an early complication of stroke and dietary modifications did not prevent its development.     

Clinical and Scintigraphic Assessment of Swallowing of Older Patients Admitted to a Tertiary Care Geriatric Ward

This study aimed to verify if older patients admitted to a tertiary care geriatric ward with no spontaneous complaints of dysphagia have impaired swallowing function as detected by a specialized clinical assessment and a scintigraphic study of swallowing. Thirty patients (mean age = 76.2 years, 17 women), consecutively admitted for the treatment of acute or chronic diseases, were studied. Two control groups were also studied, one consisting of 10 healthy older persons (mean age = 69.6 years, 5 women) and the other consisting of 20 young volunteers (mean age = 25.4 years, 11 women). A complete clinical assessment of swallowing was performed by a speech pathologist. Each subject was also submitted to scintigraphic studies of oropharyngeal transit after swallowing liquid and syrup boluses labeled with ^99mtechnetium phytate. Transit time, clearance time, and residuals were measured. Five patients had impairments in swallowing function detected by clinical assessment, three of them in the absence of complaints even after specific questioning. Scintigraphic transit times did not differ between the groups studied; however, residuals after syrup swallows were greater in the patient group compared with the healthy older volunteers. These findings suggest an increased risk for aspiration and the usefulness of a brief assessment of swallowing function in all patients admitted to tertiary care geriatric wards.     

Rehabilitative Management of Oropharyngeal Dysphagia in Acute Care Settings: Data from a Large Italian Teaching Hospital

A high incidence of oropharyngeal dysphagia (OD) in acute-care settings has been reported; however, no data on its management are found in the literature. Here we report the experience with rehabilitative management of OD in a large Italian hospital. The characteristics of inpatients with OD during 2004 have been studied prospectively. For each patient, demographic data, the department referring the patient, the disease causing OD, and the presence of a communication disorder were registered. The swallowing level at the beginning and at the end of rehabilitation were recorded. Of the 35,590 inpatients admitted to San Giovanni Battista Hospital of Turin during 2004, 222 of them were referred for the assessment and rehabilitation of OD. The inpatients with OD came from different departments and mainly had a neurologic disease. In 110 patients a communication disorder was present. The swallowing impairment was moderate to severe at the moment of referral, while on average patients were able to eat by mouth after swallowing therapy. Dysphagia rehabilitation in an acute care setting is requested from different departments because of its prevalence and severity; skilled specialists are needed for early assessment and the best management.