Arquivo da tag: Acute stroke

The Effect of Early Neuromuscular Electrical Stimulation Therapy in Acute/Subacute Ischemic Stroke Patients With Dysphagia

Kyeong Woo Lee, MD, PhD, Sang Beom Kim, MD, PhD, Jong Hwa Lee, MD, PhD, Sook Joung Lee, MD, PhD, Jae Won Ri, MD,corresponding author and Jin Gee Park, MD

Ann Rehabil Med. Apr 2014; 38(2): 153–159.
Published online Apr 29, 2014.

Abstract:

Objective

To compare the outcome of an early application of neuromuscular electrical stimulation (NMES) combined with traditional dysphagia therapy (TDT) versus traditional dysphagia therapy only in acute/subacute ischemic stroke patients with moderate to severe dysphagia by videofluoroscopic swallowing study (VFSS).

Methods

Fifty-seven dysphagic stroke patients were enrolled in a VFSS within 10 days after stroke onset. Patients were randomly assigned into two treatment groups. Thirty-one patients received NMES combined with TDT (NMES/TDT group) and 26 patients received TDT only (TDT group). Electrical stimulation with a maximal tolerable intensity was applied on both suprahyoid muscles for 30 minutes, 5 days per week during 3 weeks. The swallowing function was evaluated at baseline and 3, 6, and 12 weeks after baseline. Outcomes of the VFSS were assessed using the Functional Oral Intake Scale (FOIS).

Results

The mean ages were 63.5±11.4 years in the NMES/TDT group and 66.7±9.5 years in the TDT group. Both groups showed a significant improvement on the FOIS after treatment. The FOIS score was significantly more improved at 3 and 6 weeks after baseline in the NMES/TDT group than in the TDT group (p<0.05).

Conclusion

An early application of NMES combined with TDT showed a positive effect in acute/subacute ischemic stroke patients with dysphagia. These results indicated that the early application of NMES could be used as a supplementary treatment of TDT to help rehabilitate acute/subacute dysphagic stroke patients by improving their swallowing coordination.

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Neuromuscular Electrical Stimulation Efficacy in Acute Stroke Feeding Tube-Dependent Dysphagia During Inpatient Rehabilitation

Kushner DS, Peters K, Eroglu ST, Perless-Carroll M, Johnson-Greene D.

Am J Phys Med Rehabil. 2013 Mar 8.

Abstract

OBJECTIVE:

The aim of this study was to compare the efficacy of neuromuscular electrical stimulation (NMES) in addition to traditional dysphagia therapy (TDT) including progressive resistance training (PRT) with that of TDT/PRT alone during inpatient rehabilitation for treatment of feeding tube-dependent dysphagia in patients who have had an acute stroke.

DESIGN:

This study is an inpatient rehabilitation case-control study involving 92 patients who have had an acute stroke with initial Functional Oral Intake Scale (FOIS) scores of 3 or lower and profound to severe feeding tube-dependent dysphagia. Sixty-five patients, the NMES group, received NMES with TDT/PRT, and 27 patients, the case-control group, received only TDT/PRT. Treatment occurred in hourly sessions daily for a mean ± SD of 18 ± 3 days. χ Analyses/t tests revealed no significant statistical differences between the groups for age (t = -0.85; P = 0.40), sex (χ = 0.05; P = 0.94), and stroke location (χ = 4.2; P = 0.24). A Mann-Whitney U test revealed a statistically significant difference between the groups for the initial FOIS score (z = -2.4; P = 0.015), with the NMES group having worse initial scores with a mean rank of 42.64 and the case-control TDT/PRT group having a mean rank of 55.8. The main outcome measure was the comparison of the FOIS scores after treatment.

RESULTS:

The mean ± SD FOIS score after NMES with TDT/PRT treatment was 5.1 ± 1.8 compared with 3.3 ± 2.2 in the case-control TDT/PRT group. The mean gain for the NMES group was 4.4 points; and for the case-control group, 2.4 points. Significant improvement in swallowing performance was found for the NMES group compared with the TDT/PRT group (z = 3.64; P < 0.001). Within the NMES group, 46% (30 of 65) of the patients had minimal or no swallowing restrictions (FOIS score of 5-7) after treatment, whereas 26% (7 of 27) of those in the case-control group improved to FOIS scores of 5-7, a statistically significant difference (χ = 6.0; P = 0.01).

CONCLUSIONS:

This study suggests that NMES with TDT/PRT is significantly more effective than TDT/PRT alone during inpatient rehabilitation in reducing feeding tube-dependent dysphagia in patients who have had an acute stroke.

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The cost of pneumonia after acute stroke

I. L. Katzan, N. V. Dawson, C. L. Thomas, M. E. Votruba, R. D. Cebul

Neurology May 29, 2007 vol. 68 no. 22 1938-1943

Abstract

Objective: To determine the incremental costs of pneumonia occurring during hospitalization for stroke.

Methods: We reviewed hospital records of all Medicare patients admitted for ischemic or hemorrhagic stroke to 29 hospitals in a large metropolitan area, 1991 through 1997, excluding those who died or had do not resuscitate orders written within 3 days of admission. Hospital costs of patients with stroke were determined using Medicare Provider Analysis and Review data after adjustment for baseline factors affecting cost and propensity for pneumonia. Secondary analyses examined the risk-adjusted relationship of pneumonia to discharge disposition.

Results: Pneumonia occurred in 5.6% (635/11,286) of patients with stroke, and was more common among patients admitted from nursing homes and those with greater severity of illness (p < 0.001). Mean adjusted costs of hospitalization for patients with stroke with pneumonia were $21,043 (95% CI $19,698 to 22,387) and were $6,206 (95% CI $6,150 to 6,262) for patients without pneumonia, resulting in an incremental cost of $14,836 (95% CI $14,436 to 15,236). Patients with pneumonia were over 70% more likely to be discharged with requirements for extended care (adjusted OR 1.73, 95% CI 1.32 to 2.26).

Conclusion: Extrapolated to the over 500,000 similar patients hospitalized for stroke in the United States, the annual cost of pneumonia as a complication after acute stroke is approximately $459 million.

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Assessments in Australian stroke rehabilitation units: a systematic review of the post-stroke validity of the most frequently used

Kitsos G; Harris D; Pollack M; Hubbard IJ

Disabil Rehabil;33(25-26):2620-32, 2011.

PURPOSE: In Australia, stroke is the leading cause of adult disability. For most stroke survivors, the recovery process is challenging, and in the first few weeks their recovery is supported with stroke rehabilitation services. Stroke clinicians are expected to apply an evidence-based approach to stroke rehabilitation and, in turn, use standardised and validated assessments to monitor stroke recovery. In 2008, the National Stroke Foundation conducted the first national audit of Australia’s post acute stroke rehabilitation services and findings identified a vast array of assessments being used by clinicians. This study undertook a sub-analysis of the audit’s assessment tools data with the aim of making clinically relevant recommendations concerning the validity of the most frequently selected assessments. METHOD: Data reduction ranked the most frequently selected assessments across a series of sub-categories. A serial systematic review of relevant literature using Medline and the Cumulative Index to Nursing and Allied Health Literature identified post-stroke validity ranking. RESULTS: The study found that standardised and non-standardised assessments are currently in use in stroke rehabilitation. It recommends further research in the sub-categories of strength, visual acuity, dysphagia, continence and nutrition and found strengths in the sub-categories of balance and mobility, upper limb function and mood. CONCLUSIONS: This is the first study to map national usage of post-stroke assessments and review that usage against the evidence. It generates new knowledge concerning what assessments we currently use post stroke, what we should be using and makes some practical post stroke clinical recommendations.

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Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial

Middleton S; McElduff P; Ward J; Grimshaw JM; Dale S; D’Este C; Drury P; Griffiths R; Cheung NW; Quinn C; Evans M; Cadilhac D; Levi C; QASC Trialists Group

Lancet;378(9804):1699-706, 2011 Nov 12.

BACKGROUND: We assessed patient outcomes 90 days after hospital admission for stroke following a multidisciplinary intervention targeting evidence-based management of fever, hyperglycaemia, and swallowing dysfunction in acute stroke units (ASUs). METHODS: In the Quality in Acute Stroke Care (QASC) study, a single-blind cluster randomised controlled trial, we randomised ASUs (clusters) in New South Wales, Australia, with immediate access to CT and on-site high dependency units, to intervention or control group. Patients were eligible if they spoke English, were aged 18 years or older, had had an ischaemic stroke or intracerebral haemorrhage, and presented within 48 h of onset of symptoms. Intervention ASUs received treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction with multidisciplinary team building workshops to address implementation barriers. Control ASUs received only an abridged version of existing guidelines. We recruited pre-intervention and post-intervention patient cohorts to compare 90-day death or dependency (modified Rankin scale [mRS] ≥2), functional dependency (Barthel index), and SF-36 physical and mental component summary scores. Research assistants, the statistician, and patients were masked to trial groups. All analyses were done by intention to treat. This trial is registered at the Australia New Zealand Clinical Trial Registry (ANZCTR), number ACTRN12608000563369. FINDINGS: 19 ASUs were randomly assigned to intervention (n=10) or control (n=9). Of 6564 assessed for eligibility, 1696 patients’ data were obtained (687 pre-intervention; 1009 post-intervention). Results showed that, irrespective of stroke severity, intervention ASU patients were significantly less likely to be dead or dependent (mRS ≥2) at 90 days than control ASU patients (236 [42%] of 558 patients in the intervention group vs 259 [58%] of 449 in the control group, p=0·002; number needed to treat 6·4; adjusted absolute difference 15·7% [95% CI 5·8-25·4]). They also had a better SF-36 mean physical component summary score (45·6 [SD 10·2] in the intervention group vs 42·5 [10·5] in the control group, p=0·002; adjusted absolute difference 3·4 [95% CI 1·2-5·5]) but no improvement was recorded in mortality (21 [4%] of 558 in intervention group and 24 [5%] of 451 in the control group, p=0·36), SF-36 mean mental component summary score (49·5 [10·9] in the intervention group vs 49·4 [10·6] in the control group, p=0·69) or functional dependency (Barthel Index ≥60: 487 [92%] of 532 patients vs 380 [90%] of 423 patients; p=0·44). INTERPRETATION: Implementation of multidisciplinary supported evidence-based protocols initiated by nurses for the management of fever, hyperglycaemia, and swallowing dysfunction delivers better patient outcomes after discharge from stroke units. Our findings show the possibility to augment stroke unit care. FUNDING: National Health & Medical Research Council ID 353803, St Vincent’s Clinic Foundation, the Curran Foundation, Australian Diabetes Society-Servier, the College of Nursing, and Australian Catholic University.

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Do nasogastric tubes worsen dysphagia in patients with acute stroke?

Autor(es): Dziewas R; Warnecke T; Hamacher C; Oelenberg S; Teismann I; Kraemer C; Ritter M; Ringelstein EB; Schaebitz WR
Fonte: BMC Neurol; 8: 28, 2008.
BACKGROUND: Early feeding via a nasogastric tube (NGT) is recommended as safe way of supplying nutrition in patients with acute dysphagic stroke. However, preliminary evidence suggests that NGTs themselves may interfere with swallowing physiology. In the present study we therefore investigated the impact of NGTs on swallowing function in acute stroke patients.
METHODS: In the first part of the study the incidence and consequences of pharyngeal misplacement of NGTs were examined in 100 stroke patients by fiberoptic endoscopic evaluation of swallowing (FEES). In the second part, the effect of correctly placed NGTs on swallowing function was evaluated by serially examining 25 individual patients with and without a NGT in place.
RESULTS: A correctly placed NGT did not cause a worsening of stroke-related dysphagia. Except for two cases, in which swallowing material got stuck to the NGT and penetrated into the laryngeal vestibule after the swallow, no changes of the amount of penetration and aspiration were noted with the NGT in place as compared to the no-tube condition. Pharyngeal misplacement of the NGT was identified in 5 of 100 patients. All these patients showed worsening of dysphagia caused by the malpositioned NGT with an increase of pre-, intra-, and postdeglutitive penetration.
CONCLUSION: Based on these findings, there are no principle obstacles to start limited and supervised oral feeding in stroke patients with a NGT in place.

Functional lesions in dysphagia due to acute stroke: discordance between abnormal findings of bedside swallowing assessment and aspiration on videofluorography

Osawa A, Maeshima S, Matsuda H, Tanahashi N.

Neuroradiology. 2012 Nov 18. [Epub ahead of print]

Abstract

INTRODUCTION:

Bedside swallowing assessments are often used to assess dysphagia. However, in some patients, aspiration pneumonia occurs without any problems on bedside swallowing assessments and some patients do not suffer aspiration pneumonia despite abnormal results of bedside swallowing assessments in acute stroke. To detect the differences of lesions related to bedside swallowing assessment abnormality and aspiration, we investigated swallowing-related functional lesions in terms of cerebral blood flow in patients with dysphagia after stroke.

METHODS:

The study included 50 acute stroke patients who underwent bedside swallowing assessments and videofluorography as well as single-photon emission computed tomography (CT) at approximately the same time. Bedside swallowing assessments included repetitive saliva swallowing test and modified water swallowing test as dry and wet swallowing tasks. The presence or absence of aspiration was assessed using videofluorography. We divided patients into three subgroups based on the outcomes of the bedside swallowing assessments and presence or absence of aspiration. Statistical image analysis was performed using single-photon emission CT to determine their relationship with bedside swallowing assessments and videofluorography results.

RESULTS:

Twenty-seven (54.0 %) and 28 (56.0 %) patients had abnormal repetitive saliva swallowing test and modified water swallowing test results. Videofluorography indicated aspiration in 35 (70.0 %) patients. In comparing patients with and without abnormal results on each test, the groups with abnormal repetitive saliva swallowing test, abnormal modified water swallowing test, and aspiration demonstrated lower cerebral blood flow in the left precuneus, left insula, and anterior cingulate gyrus, respectively.

CONCLUSIONS:

Based on the analysis of cerebral blood flow, functional lesions differed across abnormal repetitive saliva swallowing test and abnormal modified water swallowing test findings and aspiration on videofluorography, and each test may assess different functions among the many processes involved in swallowing.

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