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Dysphagia: Management Approach in Stroke
Marlís González Fernández, MD, PhD Associate Professor Physical Medicine and Rehabilitation April 25, 2017
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Disclosures I have no conflicts of interest to disclose 4/25/2017
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Outline Epidemiology Neural control Screening Evaluation Treatment
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Dysphagia Common after stroke Affects about 50% of stroke patients
Improves within 7-14 days 11-13% still dysphagic at 6 months 4/25/2017
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Consequences Malnutrition Dehydration Pneumonia Higher mortality
Increased length of hospital stay 4/25/2017
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Outcomes Formal dysphagia screen prevents pneumonia1
Aspiration on VFSS associated with lower respiratory tract infection2-3 Clinically unsafe swallow predictive of outcome including lower respiratory tract infection4 4/25/2017 1 Hinchey et al., 2005; 2 Holas et al. 1994; 3 Kidd et al. 1995; 4 Smithard et al., 1998)
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Location Brain stem stroke Bilateral stroke Rostral medulla
Severe dysphagia Less likely to improve Bilateral stroke Pseudobulbar palsy Recurrent strokes 4/25/2017
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Procedure Screen Evaluate Treat Clinical evaluation
Instrumental Examination VFSS FEES Treat 4/25/2017
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Screening goal Detect dysphagia and determine the possibility of aspiration (overt or silent) before developing: Pneumonia Dehydration Malnutrition Airway Obstruction 4/25/2017
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Screening NPO until completed Screen as early as possible
Trained personnel is critical Choose a standardized tool 4/25/2017
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Screening Tools Burke Dysphagia Screening Test (BDST)1
Standardized Swallowing Assessment (SSA)2 Timed tests of Hinds and Wiles3 Bedside swallow assessment (BSA)4 Toronto Bedside Swallowing Screening Test (TOR-BSST)©5 Clinical examination (CE) – any two of a list of clinical features6 4/25/2017 1 DePippo et al. 1994; 2 Ellul et al. 1993; 3 Hinds and Wiles, 1998; 4 Smithard et al., 1996; 5 Martino et al., 2009; Daniels et al., 1997
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Screening Tools They rely on: A few clinical features Swallowing water
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Clinical Examination (Screening)
Positive if any two of the following clinical findings present: Dysphonia Dysarthria Abnormal Gag Abnormal Volitional Cough Cough after swallow Voice changes after swallow 4/25/2017 Daniels et al., 1997
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Screening Tests Summary
Std. Clinical Eval. Sensory Water Se Sp BDST VFSS Yes No 3oz Water swallow 88 22 SSA 5ml X 3 Cup drinking 68 86 Timed Test Symptom Quest. 5-10 ml ml 73 67 BSA VFSS/CE 5 ml X 3 60 ml 70 66 TOR-BSST© 5ml swallow X 10 Cup sip 91.3 66.7 CE N/A 92 MMASA MASA 93
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Formal Clinical Evaluation
Performed by specialist Speech Therapist or SLP Clinical Assessment Determine aspiration risk Unable to detect silent aspiration 4/25/2017
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Silent Aspiration Aspiration without signs of material passage into the respiratory tract. 4/25/2017
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Silent Aspiration Daniels et al. - 13/19 subjects aspirated silently
Holas et al % of patients admitted for rehabilitation after stroke aspirated; 39% of those silently Kidd et al. – 8% of subjects aspirated silently 4/25/2017
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Instrumental Evaluation
Videofluoroscopic swallowing study (VFSS) Fiberoptic endoscopic evaluation of swallowing (FEES) 4/25/2017
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When to obtain instrumental exam?
Silent Aspiration is a concern Effective treatment program needs to be determined Deficit etiology is unclear Oral vs. pharyngeal vs. esophageal dysfunction and diagnoses. 4/25/2017
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VFSS Identify abnormalities of swallowing
Determine the circumstances for safe swallowing Trials of therapeutic and compensatory maneuvers 4/25/2017
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FEES Directly visualize the pharynx and larynx before and after swallowing. Identify aspiration and pharyngeal retention of food before or after swallowing. Cannot visualize during swallowing. Cannot evaluate esophagus or sphincters. 4/25/2017
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Principles of Therapy Therapy is directed at the underlying pathophysiology Use therapeutic exercise to improve range of motion, strength and coordination “Swallowing is the best exercise for swallowing” Recreate the circumstances for safe and efficient swallowing Prevent complications 4/25/2017
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Therapeutic interventions
Swallowing Maneuvers Exercises Diet Modifications 4/25/2017
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Swallowing Maneuvers Neck Flexion Head turn Head tilt
Supraglottic swallow Mendelsohn Maneuver Effortful swallow 4/25/2017
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Diet Modifications Thickened liquids Solids Nectar Honey Chopped
Mechanical soft Pureed 4/25/2017
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Exercises Shaker Exercises Tongue strengthening
Laryngeal elevation and vocal cord adduction exercises 4/25/2017
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Novel Therapies Neuromuscular electrical stimulation (NMES)
Tongue strengthening devices 4/25/2017
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? 4/25/2017
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