|Year : 2015 | Volume
| Issue : 2 | Page : 44-48
Functional oral intake measures after behavioral management in oropharyngeal dysphagia post cerebrovascular stroke
Mohamed Farahat Ibrahim
Consultant, Associate Professor of Phoniatrics Communication and Swallowing Disorders Unit (CSDU), ORL Department, King Abdulaziz University Hospital, King Saud University, Riyadh, Saudi Arabia
|Date of Web Publication||2-Jan-2020|
MD Mohamed Farahat Ibrahim
P. O Box 245, Riyadh, 11411 ORL Department, Communication and Swallowing Disorders Unit (CSDU) King Abdulaziz University Hospital Riyadh
Source of Support: None, Conflict of Interest: None
Background/objective: Dysphagia is a common complaint in patients who developed cerebrovascular stroke. Those patients show different degrees of compliance on swallowing therapy and functional swallowing outcomes. The aim of this work was to evaluate compliance and functional outcome measures after receiving swallowing therapy in patients with oropharyngeal dysphagia post cerebrovascular stroke.
Materials and Methods: In this study, behavioral swallowing therapy was applied to 22 patients with oropharyngeal dysphagia post cerebrovascular stroke and the compliance to therapy was evaluated together with the functional swallowing outcome measures.
Results: There was significant statistical difference in the compliance to swallowing therapy through different follow up sessions. Also, there was significant improvement of the functional swallowing outcome measures from the bedside initial assessment through the follow up sessions.
Conclusion: The results of this study proved the compliance and effectiveness of behavioral swallowing therapy in improving the functional swallowing outcome measures in patients with oropharyngeal post cerebrovascular stroke.
Keywords: Dysphagia, functional oral intake, behavioral therapy, videofluorsocopy
|How to cite this article:|
Ibrahim MF. Functional oral intake measures after behavioral management in oropharyngeal dysphagia post cerebrovascular stroke. Saudi J Otorhinolaryngol Head Neck Surg 2015;17:44-8
|How to cite this URL:|
Ibrahim MF. Functional oral intake measures after behavioral management in oropharyngeal dysphagia post cerebrovascular stroke. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2015 [cited 2022 Dec 8];17:44-8. Available from: https://www.sjohns.org/text.asp?2015/17/2/44/274656
| Introduction|| |
Dysphagia is highly prevalent among stroke patients. Some estimates suggest that nearly 65% of stroke survivors suffer some degree of impairment in the ability to swallow . This limitation in the ability to safely ingest adequate amounts of food and liquid places the patient with stroke at risk for poor nutrition and hydration and/or for complications such as aspiration related pneumonia ,. Moreover, dysphagia and related complications increase length of acute stay and are associated with increased mortality, comorbidity, and increased health care costs . Furthermore, studies report that dysphagia persists and perhaps worsens during the first month after stroke .
One persistent problem in studies of dysphagia is the variability in documenting dysphagia symptoms and their functional impact. Typically, to identify the presence of dysphagia symptoms, clinical investigators use subjective measures such as observations of coughing after liquid ingestion . Although a standard clinical examination of dysphagia in stroke patients has recently been published, few appropriate tools are available to document the functional impact of dysphagia symptoms on the oral intake of food and liquid in post strokepatients.
Functional level of oral intake of food and liquid in dysphagic patients is typically established after clinical or instrumental (fluoroscopic or endoscopic) examination. To document change in oral feeding function, clinical investigators often use global indicators such as time to return to oral feeding or feeding in the absence of complications. A variety of outcome scales are available that consider oral intake of food and liquid; however, these scales typically cover many aspects of impairment and often are disease specific ,. Other scales may have a focus other than documenting change in eating or may suffer from poor psychometric characteristics (ie, no established reliability or validity characteristics) ,. and others were tested for validity and reliability . The aim of these scales is to document the clinical changes and functional outcomes in patients with oropharyngeal dysphagia.
Dysphagia characteristics tend to show significant improvement by 1-month post stroke . These changes may be related to overall improvement in health and functional status or after receiving different modalities of behavioral swallowing therapy. So, the aim of this study was to evaluate compliance and functional outcome measures after receiving swallowing therapy in patients with oropharyngeal dysphagia post cerebrovascular stroke.
| Subjects and Methods|| |
This prospective study was conducted on 30 consented Saudi subjects with oropharyngeal dysphagia due to neurological origin who were referred to the swallowing disorders clinics, Communication and Swallowing Disorders Unit, ENT Department, King Khalid University Hospital in the period between January 2012 to May 2013. All the patients were subjected to a comprehensive swallowing assessment protocol, and underwent Modified Barium Swallow (MBS) studies in the fluoroscopy room of Radiology Department, King Khalid University Hospital. At the same session of the MBS, findings were continuously monitored, by experienced phoniatrician and 3 Speech Language Pathologists, for the different volumes and consistencies that were presented to the patients.
Once the abnormalities in the patient’s anatomy and/ or swallow physiology have been identified, treatment strategies were introduced during the radiographic study in order to facilitate safe and more efficient oral intake. Such strategies included changes in head or body posture, heightening sensory input prior to the swallow, and, when possible, swallow therapy techniques to change specific aspects of swallow physiology, such as swallow maneuvers. After finishing the procedure, a counseling session was given to the patient’s caregivers or their relatives (using the recorded exam as an educational tool) about using the selected treatment strategy that was tailored to the patient to overcome his/ her problem and trained them on it when needed.
The initial assessment presented the baseline data for the patient. The follow up evaluations were done after 1 week and after 4 weeks, by answering certain questions, to examine the effect of the selected treatment strategy according to a specially designed scoring protocol  where each subject served as his or her own control (within-subject strategy). The scoring system included (1) Compliance of the patient to treatment strategy with sub items included: (a) degree of success of the therapy to control the swallowing problem and (b) ability of generalization and carry-on over daily life, The sub items were rated according to a four-point score with lower rating towards normal compliance. (2) Functional outcome measures (FOM): with sub items included:
- intake method with lower rating towards oral feeding,
- type of diet with lower rating towards regular diet,
- meal duration with lower rating towards normal premorbid meal duration. All sub items were rated according to a four-point score.
The collected data were analysed using SPSS (Statistical Package for Social Science program, version 15, Chicago, Illinois). Wilcoxon signed rank test was used to compare the amount of progress from pre-treatment to post-treatment in all patients.
| Results|| |
Thirty Saudi patients with oropharyngeal dysphagia post cerebrovascular stroke were included in this study. They were 16 males (53%) with ages ranging from 20 to 76 years with a mean age of 48.5±15.23 years and 14 females (47%) with ages ranging from 18 to 70 years with a mean age of 44.5±20.87 years [Table 1]. Eight patients were excluded from the study due to severe affection of their cognitive abilities with inability to follow commands. The remaining 22 patients received different modalities of swallowing behavioral therapy [Table 2].
|Table 2: Distribution of patients according to the received modalities of behavioral swallowing therapy|
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There was a significant difference between the first follow up and the second follow up visit regarding the success of the treatment strategy to control the swallowing problem [Table 3]. Moreover, all the patients had the ability to use the selected treatment strategy frequently at the time of the second follow up [Table 4].
|Table 3: Comparison between the degree of success of the selected treatment strategy to control the swallowing problem through the firs and second follow up sessions (n=22)|
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|Table 4: Comparison between the ability of generalisation of the treatment strategy through the first and second follow up sessions (n=22)|
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At the initial assessment, 19 (87%) patients were on total oral feeding and only 3 (13%) patients were on both oral and tube feeding. At the second follow up session, all the patients was shifted to total oral feeding. The subjects showed improvement of their difficult to swallow consistency throughout the first and second follow up sessions [Table 5]. Meal duration for the patients showed significant improvement from the initial assessment through both follow up sessions [Table 6].
|Table 5: Comparison between the type of difficult food through the initial assessment and both follow up sessions (n=22).|
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|Table 6: Degree of changes in meal duration through the initial assessment and both follow up sessions (n=22).|
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| Discussion|| |
Behavioral therapy for oropharyngeal dysphagia begins with definition of the patient’s anatomic and physiologic swallowing disorder(s) . In the current study, this was done using videofluoroscopic study (Modified Barium Swallow “MBS”). Radiographic findings of oropharyngeal dysphagia in the subjects included residue (food remaining in the mouth, valleculae, pyriform sinuses, or on the pharyngeal walls), penetration (food or liquid entering the airway entrance), and aspiration (food or liquid entering the airway to the level of the trachea). Each of these findings points toward specific impairment in the normal anatomical or physiologic process of swallowing; for example, residue in the valleculae indicates reduces tongue base movement or reduced pharyngeal wall contraction.
After defining the patient’s swallowing problem, MBS session included the introduction of selected treatment strategies to improve the swallow, i.e., to eliminate aspiration or inefficient swallowing. These treatment strategies were selected on the basis of the patient’s anatomic or physiologic swallow impairments. Also, they depended on the patient’s general physical condition, mental status, cognitive ability, and speech/language ability . Swallowing therapy techniques often allow for a safe and efficient swallow in neurologically impaired patients ,,. In the current study, different positions, sensory enhancement techniques, swallow maneuvers, and sometimes combined therapy were used to eliminate the patient’s swallowing problem. This was followed by a counselling session for the patients and/or their caregivers on how to use the selected treatment strategy in an attempt for better success and generalization.
Outcome measures in healthcare are becoming increasingly functional, focusing on social and psychological aspects of impairment . It is extremely difficult to randomise a study with stroke patients who also, in many cases, have a spontaneous recovery and then compare treated with untreated patients . Therefore, the follow up sessions in the current study were 3 weeks spaced to minimise the effect of spontaneous recovery.
Most patients succeeded to use the described therapy through the day time and there was significant difference in the degree of success of the selected treatment strategy to control swallowing. Six patients (27%) ended with regular oral diet on the second follow up session. Moreover, there was significant difference in the meal duration of the patients from the initial assessment through the follow up sessions. These findings were similar to Zhen et al . and Svensson et al . who found that patients with swallowing therapy had more confidence in their swallowing ability and had less problems with food preparation and eating. In contrary, Drulia et al . concluded that traditional dysphagia therapy had small to moderate effect sizes (between 0.3 and 0.6), and to improve the effect sizes, adaptive research designs are needed to develop the optimal methods and dosages of therapy before future clinical trials.
| Conclusion|| |
The current study proved that behavioral swallowing therapy in patients with oropharyngeal dysphagia post cerebrovascular stroke is compliant by the patients and it improved the functional swallowing outcomes from the initial assessment through the follow up sessions. However, more randomized control studies are suggested to better study the long-term effect of swallowing therapy.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]