Ribeiro PW, Cola PC, Gatto AR, da Silva RG, Luvizutto GJ, Braga GP, Schelp AO, de Arruda Henry MA, Bazan R.
J Stroke Cerebrovasc Dis. 2015 Jul 14. pii: S1052-3057(15)00254-2. doi: 10.1016/j.jstrokecerebrovasdis.2015.05.009. [Epub ahead of print]
The present study aimed to evaluate the relation between the National Institutes of Health Stroke Scale (NIHSS) score and the presence of laryngeal penetration and/or laryngotracheal aspiration in ischemic stroke patients and to verify what factors are predictors of the occurrence of pneumonia in the evaluated patients.
This was an observational study of ischemic stroke in the acute or subacute phases. Neurologic examination included anamnesis, Bamford classification, and application of the NIHSS. Speech therapy evaluation was carried out after clinical stabilization of the patient, and all individuals who were considered dysphagic were sent for examination by means of videofluoroscopic recordings. The parameters observed in the objective examination were the presence of laryngeal penetration and/or laryngotracheal aspiration. The pneumonia data were obtained in accordance with local protocols, which were based on international guidelines. The relation of laryngeal penetration and laryngotracheal aspiration with the NIHSS score was assessed by the Mann–Whitney U test, and predictors for the occurrence of pneumonia were analyzed by multiple logistic regression using semiautomatic backward selection. Significance was set at P less than .05.
The relations between laryngeal penetration and the NIHSS score and between laryngotracheal aspiration and the NIHSS score were not statistically significant. The predictors for pneumonia occurrence in the ischemic stroke patients with a clinical diagnosis of dysphagia were age (P = .002; odds ratio [OR], 1.12) and NIHSS score (P = .04; OR, 1.17), whereas laryngeal penetration of liquid (P = .065; OR, 3.70) tended to correlate with pneumonia but not significantly.
There was no relation between the NIHSS score and laryngeal penetration or laryngotracheal aspiration, and the principal predictors of pneumonia in dysphagic patients after ischemic stroke were advanced age and neurologic severity.
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Early identification of dysphagia is associated with lower rates of pneumonia after acute stroke. The Barnes-Jewish Hospital-Stroke Dysphagia Screen (BJH-SDS) was previously developed as a simple bedside screen performed by nurses for sensitive detection of dysphagia and was previously validated against the speech pathologist’s clinical assessment for dysphagia. In this study, acute stroke patients were prospectively enrolled to assess the accuracy of the BJH-SDS when tested against the gold-standard test for dysphagia, the video-fluoroscopic swallow study (VFSS).
Acute stroke patients were prospectively enrolled at a large tertiary care inpatient stroke unit. The nurse performed the BJH-SDS at the bedside. After providing consent, patients then underwent VFSS for determination of dysphagia and aspiration. The VFSS was performed by a speech pathologist who was blinded to the results of the BJH-SDS. Sensitivity and specificity were calculated. Pneumonia rates were assessed across the five year period over which the BJH-SDS was introduced into the Stroke Unit.
A total of 225 acute stroke patients were enrolled. Sensitivity and specificity of the screen to detect dysphagia were 94% and 66%, respectively. Sensitivity and specificity of the screen to detect aspiration were 95% and 50%, respectively. No increase in pneumonia was identified during implementation of the screen (p=0.33).
The BJH-SDS, validated against video-fluoroscopy, is a simple bedside screen for sensitive identification of dysphagia and aspiration in the stroke population.
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Pisegna JM, Kaneoka A, Pearson WG Jr, Kumar S, Langmore SE.
Clin Neurophysiol. 2015 May 9. pii: S1388-2457(15)00309-0. doi: 10.1016/j.clinph.2015.04.069.
The primary aim of this review is to evaluate the effects of non-invasive brain stimulation on post-stroke dysphagia.
Thirteen databases were systematically searched through July 2014. Studies had to meet pre-specified inclusion and exclusion criteria. Each study’s methodological quality was examined. Effect sizes were calculated from extracted data and combined for an overall summary statistic.
Eight randomized controlled trials were included. These trials revealed a significant, moderate pooled effect size (0.55; 95% CI=0.17, 0.93; p=0.004). Studies stimulating the affected hemisphere had a combined effect size of 0.33 (95% CI=-0.52, 1.18; p=0.44), while studies stimulating the unaffected had a much larger, significant pooled effect size (0.70; 95% CI=0.25, 1.15; p=0.002). At long-term follow up, three studies demonstrated a large but non-significant pooled effect size (0.81, p=0.11).
This review found evidence for the efficacy of non-invasive brain stimulation on post-stroke dysphagia. A greater effect size resulted when stimulating the unaffected rather than the affected hemisphere. This finding is in agreement with previous studies implicating the plasticity of cortical neurons in the unaffected hemisphere.
Non-invasive brain stimulation appears to assist cortical reorganization in post-stroke dysphagia but emerging factors highlight the need for more data.
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Drozdz D, Mancopes R, Silva AM, Reppold C.
Int Arch Otorhinolaryngol. 2014 Apr;18(2):172-7. doi: 10.1055/s-0033-1364169.
The rehabilitation in oropharyngeal dysphagia evidence-based implies the relationship between the interventions and their results.
Analyze level of dysphagia, oral ingestion, anxiety levels and nutritional status of patients with stroke diagnosis, before and after speech therapy.
Clinical assessment of dysphagia partially using the Protocol of Risk Assessment for Dysphagia (PARD), applying the scale Functional Oral Intake Scale for Dysphagia in Stroke Patients (FOIS), Beck Anxiety Inventory (BAI) and the Mini Nutritional Assessment MNA(®). The sample consisted of 12 patients, mean age of 64.6 years, with a medical diagnosis of hemorrhagic and ischemic stroke and without cognitive disorders. All tests were applied before and after speech therapy (15 sessions). Statistical analysis was performed using the chi-square test or Fisher’s exact test, McNemar’s test, Bowker’s symmetry test and Wilcoxon’s test.
During the pre-speech therapy assessments, 33.3% of patients had mild to moderate dysphagia, 88.2% did not receive food orally, 47.1% of the patients showed malnutrition and 35.3% of patients had mild anxiety level. After the therapy sessions, it was found that 33.3% of patients had mild dysphagia, 16.7% were malnourished and 50% of patients had minimal level of anxiety.
There were statistically significant evolution of the level of dysphagia (p = 0.017) and oral intake (p = 0.003) post-speech therapy. Although not statistically significant, there was considerable progress in relation to the level of anxiety and nutritional status.
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O Scottish Intercollegiate Guidelines Network desenvolveu um guia para manejo da disfagia pós-AVC. É um texto muito interessante para os que trabalham na área e para os interessados em prover aos seus pacientes um atendimento fonoaudiológico baseado em evidências científicas. Além de compilar o que há de mais novo em avaliação e tratamento das disfagias no AVE, este guia traz o grau de recomendação de cada ferramenta a partir da força da evidência que cada estudo provê. Além de recomendar, o disfagiabrasil traz o link com o arquivo na íntegra para compartilhar com todos:
GUIDELINE DISFAGIA AVC
Yang SN, Pyun SB, Kim HJ, Ahn HS, Rhyu BJ.
Dysphagia. 2015 Apr 28
The objective of this study is to assess the efficacy and safety of non-invasive brain stimulation (NIBS) in patients with dysphagia subsequent to stroke. A systematic search of the literature published by Medline (January 1, 1976 through June 21, 2013), EMBASE (January 1, 1985 through June 21, 2013), and the Cochrane Library (January 1, 1987 through June 21, 2013) was conducted for all relevant articles related to NIBS, dysphagia, and cerebrovascular disorders (CVD). Two reviewers (S.N.Y and S.B.P) independently evaluated the eligibility of retrieved data according to the selection criteria and assessed methodological quality of the studies using the ‘assessing risk of bias’ table recommended in the Cochrane Handbook for Systematic Reviews of Interventions (version 5.0.2). Six randomized controlled trials (59 intervention groups and 55 placebo groups) were identified as addressing the use of NIBS for dysphagia after CVD and were included in the meta-analysis. The function scale score improvement of dysphagia in patients treated with NIBS was statistically significant compared with that of patients who underwent sham stimulation (standardized mean difference = 1.08, 95 % confidence intervals = 0.29–1.88, p = 0.008; I2 = 72 %). A subgroup analysis based on the type of intervention (three repetitive transcranial magnetic stimulation (rTMS) studies and three transcranial direct current stimulation (tDCS) studies) revealed a statistically significant beneficial effect of NIBS compared with sham stimulation in the rTMS group, but not in the tDCS group. When the results were examined based on intervention site (ipsilesional vs. contralesional site stimulation), no statistically significant difference was noted between two groups. No complications of NIBS were reported in this analysis.
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Momosaki R, Abo M, Watanabe S, Kakuda W, Yamada N, Kinoshita S.
Neuromodulation. 2015 May 6.
The purpose of this pilot study was to determine the safety and feasibility of a six-day protocol of in-hospital repetitive peripheral magnetic stimulation combined with intensive swallowing rehabilitation (rPMS-ISR) for poststroke dysphagia.
The subjects were eight patients with dysphagia caused by bilateral cerebral infarction (age: 62-70; time from onset of stroke: 27-39 months). rPMS was applied to the suprahyoid muscles, at strength set at 90% of the minimal intensity that elicited pain with a parabolic coil. One train of stimuli comprised 20 Hz for 3 sec followed by 27-sec rest. A single session included delivery of repetitive 20 trains of stimuli over 10 min, followed by 20 min of swallowing rehabilitation. Each patient received this combination treatment twice daily, morning and afternoon, over six consecutive days. Swallowing function was evaluated before and after intervention.
rPMS-ISR induced significant improvement in swallowing ability, laryngeal elevation delay time, penetration aspiration scale, and swallowing quality of life (p < 0.01), but had no significant effect on the functional oral intake scale.
The six-day in-hospital RPMS-ISR protocol seems safe and feasible for poststroke patients with dysphagia. The combination protocol improved swallowing function. Further larger studies are needed to confirm its efficacy.
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CoDAS vol.25 no.2 São Paulo 2013
Ana Rita GattoI; Paula Cristina ColaII; Roberta Gonçalves da SilvaIII; André Augusto SpadottoIV; Priscila Watson RibeiroV; Arthur Oscar SchelpV; Lidia Raquel de CarvalhoVI; Maria Aparecida Coelho de Arruda HenryII
OBJETIVO: Verificar o efeito do sabor azedo e da temperatura fria no tempo de trânsito oral da deglutição.
MÉTODOS: Participaram deste estudo 52 indivíduos (28 do gênero masculino e 24 do gênero feminino) após acidente vascular encefálico isquêmico, com lesão à direita ou à esquerda e disfagia orofaríngea de grau leve a moderado, com idades variando de 50 a 80 anos (mediana=66 anos). Foi realizada a videofluoroscopia da deglutição para a análise dos tempos de deglutição. Cada indivíduo foi avaliado durante a deglutição de bolo na consistência pastosa, oferecido em colher com 5 ml, com quatro estímulos diferentes (natural, frio, azedo e azedo-frio). Após o exame foram realizadas as medidas de tempo de trânsito oral utilizando software específico. Foram mensurados o tempo de trânsito oral (a partir do início do movimento do bolo alimentar na boca) e o tempo de trânsito oral total (a partir do momento em que o bolo é colocado na boca).
RESULTADOS: A associação entre o estímulo azedo e a temperatura fria provocou mudanças significavas no tempo de trânsito oral total e no tempo de trânsito oral, com redução nestes tempos.
CONCLUSÃO: O sabor azedo e a temperatura fria associados apresentaram redução do tempo de trânsito oral em pacientes pós acidente vascular encefálico.
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John JS, Berger L.
J Contin Educ Nurs. 2015 Mar;46(3):103-4.
Aspiration pneumonia from dysphagia following stroke presents significant morbidity and mortality in that population. Dysphagia screening before oral intake has been a standard of care for years, but there is a lack of consensus on the best screening tool. The Gugging Swallowing Screen (GUSS) is presented as a potentially better alternative to other dysphagia screens due to its safer progression of oral intake, more thorough evaluation of swallowing, and ability to enable earlier nutrition.
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