Benfield, Jacqueline
(2021)
The assessment and rehabilitation of post stroke dysphagia.
PhD thesis, University of Nottingham.
Abstract
Comprehensive Screening Tests
Post stroke dysphagia is common and requires accurate screening to identify patients that need further assessment and management. Nurses and other non-specialists in dysphagia are often trained to screen swallowing post-stroke. In addition to screening for dysphagia more comprehensive screening tests allow non-specialists to recommend modified oral intake. Little is known about the accuracy, clinical utility and cost effectiveness of these tests.
A systematic review and meta-analysis were conducted to describe the comprehensive swallow screening tests that are available for use in acute stroke by nurses or other non-specialists. The review also evaluated the accuracy, clinical utility and cost effectiveness of these tools. In a prospective study, one of these comprehensive screening tests, the Dysphagia Trained Nurse Assessment (DTNAx) was validated against usual SLT assessment and videofluoroscopy with 47 acute stroke patients. This thesis also aimed to find out the experiences of Dysphagia Trained Nurses (DTNs) by carrying out semi-structured interviews with nine nurses.
Five comprehensive screening tests for dysphagia were identified, but validation studies were mostly low or very low quality. Three studies validating the Gugging Swallow Screen provided sufficient data for meta-analysis, demonstrating high sensitivity; 96% (95%CI 0.90-0.99) but lower specificity, 65% (95%CI 0.47-0.79). The DTNAx was superior to the other tests in its safety and content validity. In its subsequent validation, compared to the SLTAx in the identification of dysphagia, the DTNAx had a sensitivity of 96.9% (95% confidence intervals CIs 83.8%-99.9%) and specificity 89.5% (95% CIs 75.2%-97.1%). Compared to the VFS in the identification of aspiration, the DTNAx had a sensitivity of 77.8% (CIs 40.0%-97.2%) and specificity 81.6% (CIs 65.7% to 92.3%). Over 81% of the diet and fluid recommendations made by the DTNs were in absolute agreement with the SLTAx. Dysphagia Trained Nurses reported high regard for the role and gave useful insights into the challenges that arise in the busy acute stroke unit.
Biofeedback in dysphagia rehabilitation
Ongoing dysphagia can have detrimental effects on physical and mental health post stroke. SLTs conduct more detailed assessments and provide rehabilitation to patients with persistent dysphagia. The use of biofeedback is beneficial in stroke rehabilitation and is gaining ground as an adjunct in the field of dysphagia rehabilitation but there are no robust studies of its effectiveness or feasibility in the acute stroke setting.
A second systematic review and meta-analysis investigated the evidence on the effects of swallow therapy augmented by biofeedback in adults with dysphagia. Finally, a randomised controlled feasibility study into swallow strength and skill training with surface electromyography (sEMG) biofeedback in 27 acute stroke patients with dysphagia was performed.
Only 23 studies were identified that investigated biofeedback as a dysphagia intervention, of which three main types were reported: surface electromyography, accelerometry and tongue manometry. Five controlled studies were included in the meta-analyses. Compared to the control, biofeedback augmented dysphagia therapy enhanced hyoid displacement significantly (three studies, MD=0.22cm; 95% CI [0.04, 0.40], p=0.02) but there was no significant difference in functional oral intake. Risk of bias was high and there was significant statistical heterogeneity.
The RCT demonstrated feasibility and acceptability in participants recruited; 11 out of the 13 participants in the intervention group completed the treatment (>80% of sessions). The planned recruitment target was not met and would need to be mitigated for in future studies. Most participants found the intervention challenging but comfortable and the right duration, frequency and time post stroke. There were no related serious adverse events. There were no significant differences between groups in Functional Oral Intake Scale (FOIS), Dysphagia Severity Rating Scale (DSRS) and Penetration Aspiration Scale (PAS) at 2-weeks or at 90 days.
Conclusions
Using the DTNAx, trained nurses can screen acute stroke patients for dysphagia accurately and make early swallowing recommendations in line with SLTs. Further research is needed to investigate the clinical utility and cost effectiveness of this versus other swallow assessment pathways in acute stroke. Swallow strength and skill training with sEMG biofeedback is feasible and acceptable to acute stroke patients with dysphagia. It is safe and it may improve post stroke dysphagia. Further research investigating approaches to intervention delivery, treatment dose and effectiveness is indicated.
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