Swallowing

031 Electrical pharyngeal stimulation for post stroke dysphagia: A meta-analysis of individual patient data from randomised controlled trials

Hamdy S¹, Bath P², Scutt P²

¹Neuroscience Research Institute, University of Manchester, Manchester, UK

²Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK

Introduction: Dysphagia is common (∼50%) in patients with acute stroke and is associated with a poor outcome. Current treatment options are limited. Electrical Pharyngeal Stimulation (EPS) is a novel treatment for post-stroke dysphagia.

Method: We searched for randomised controlled trials of EPS in dysphagic patients within 3 months of stroke in the Cochrane Stroke Group trials register (January 2014), citation databases, and reference lists of published trials and review articles. Individual patient data were analysed using binary or ordinal logistic regression, or multiple regression, with adjustment for trial, age, severity and baseline score. Data are number (%), median [interquartile range] or mean (standard deviation).

Results: 3 completed trials of EPS were identified, these including 66 patients: age 72 (12) years, male 61%, severity National Institute for Health Stroke Scale (NIHSS) 10 (6), dysphagia severity rating scale (DSRS) 7.1 (4.3), penetration aspiration scale (PAS, using videofluroscopy) cumulative score 27 [12]. At baseline, patients randomised to EPS had more severe dysphagia and dependency. In comparison with no EPS, EPS was associated, at 2 weeks, with a lower PAS: 20.0 (10.2) vs 24.8 (10.1); DSRS >3: 10 (33%) vs 15 (58%); modified Rankin Scale: 3.5 [2] vs 3.5 [2]; and length of stay in hospital: 47.4 (22.8) vs 72.0 (62.1) days.

Discussion: Across 3 small trials, EPS was associated with less clinical and radiological evidence of dysphagia, less dependency, and a shorter of length of stay in hospital.

032 Cochrane systematic review of interventions for dysphagia in acute stroke

Lee H, Bath P

Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK

Introduction: Dysphagia is common (∼50%) after stroke and is associated with a poor outcome. However, the treatment of dysphagia remains unclear.

Method: We updated our Cochrane systematic review that assesses the effectiveness of interventions in stroke patients with dysphagia. Searches were carried out on the Cochrane Stroke Group trials register, databases, review articles and reference lists (January 2014). Randomised controlled trials in dysphagic patients within 3 months of stroke were included. Odds Ratios (OR, 95% confidence intervals) and mean differences (MD) were calculated using random effects models in view of heterogeneity. Results are reported where there is more than 1 trial with relevant data.

Results: Dysphagia was reduced with acupuncture (OR 0.24, 95% CI 0.13–0.45) and behavioural interventions (BH: OR 0.52, 95% CI 0.0.30–0.88). Trends to reduced length of stay in hospital were present for BH (MD –2.7, 95% CI –5.7, 0.28) and electrical pharyngeal stimulation (EPS: MD –12.6, 95% CI –26.6, 1.3). On videofluoroscopy, EPS was associated with a reduced penetration aspirations score (MD –4.3, 95% CI –8.3, –0.3). Treatment failure was less common with Percutaneous Endoscopic Gastronomy (PEG) than nasogastric tube feeding (OR 0.08, 95% CI 0.01–0.49). Nutritional supplementation was associated with less pressure sores (OR 0.56, 95% CI 0.32–0.96) and higher energy and protein intake.

Discussion: The numbers of management strategies for post-stroke dysphagia, trials and recruited patients, are increasing. Although several strategies have potentially useful effects, none yet have definitive evidence across multiple outcome domains to support their widespread routine use.

033 Pilot RCT evaluating a new approach to neuromuscular stimulation to treat dysphagia post stroke

Sproson L¹, Pownall S¹, Enderby P², Freeman J³

¹Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK

²School of Health & Related Research, Sheffield, Leeds, UK

³University of Leeds, Leeds, UK

Introduction: Dysphagia is a common problem with negative impact post-stroke, affecting up to 70% of patients. Post-stroke pneumonia causes 30% of stroke-related deaths, longer hospital stay, and increased rates of institutionalization. Dysphagia care post stroke currently focusses on management of symptoms via modified oral intake textures, oral motor exercises and adaptation of patients' posture, rather than direct treatment to rehabilitate functional swallowing. Previous research findings on efficacy of transcutaneous electrical stimulation have been conflicting. This study therefore meets the call for robust clinical trials to clarify evidence and guide clinical practice.

Method: This 30 patient pilot randomised control trial evaluates a new device (AMPCARE ESP) using new parameters, electrode design and placement. Stimulation is combined with specialised laryngeal exercises, performed against the resistance of a new, specially designed postural device. Patients in the treatment arm receive treatment 5 days a week for 4 weeks. Patients in the control arm receive usual care as described above. Outcome measures include: Functional oral Intake Scale, (blinded) videofluoroscopy Rosenbek Penetration-Aspiration Scale ratings and qualitative data.

Results: The study is in progress. So far 21 participants have completed their respective arms and data shows very positive trends in favour of the stimulation. By December we will present full findings.

Discussion: Implications for clinical practice, including patient selection, treatment intensity and economic implications will be considered.

034 Increasing team competency in fibreoptic endoscopic evaluation of swallowing (FEES): Evaluating the impact on service delivery and management decisions for acute stroke patients

Wood D, McFarlane M

Stroke Unit, North West London Hospitals NHS Trust, London, UK

Introduction: Dysphagia and aspiration are common post stroke and can contribute to extended hospital admission, increased morbidity and mortality. Early identification of dysphagia is critical in the post-stroke population. FEES has repeatedly proven itself to be a valid, easily accessible, cost effective and highly repeatable tool for identifying aspiration. FEES is a safe procedure with low incidence of complications. FEES has received increasing support for its use in acute dysphagia assessment, specifically in the acute stroke population. Our stroke unit provides an Speech and Language (SLT)-led FEES service and availability of competent SLTs was identified as a major limitation in carrying out regular FEES as required. The aim was to investigate the impact on service delivery and management decisions following all SLTs working on the acute stroke unit with post-basic dysphagia training receiving training and undertaking FEES competency in line with trust FEES policy.

Method: Retrospective data were collected from SLT assessment log records, 6 months prior to the introduction of team FEES training and 6 months post. Data were collated regarding referral rates for instrumental dysphagia assessment, including videofluoroscopy, reason for referral, waiting times and management decisions following FEES.

Results: Results will be presented at the conference.

Discussion: The results of this study are intended to inform clinical practice, improve service planning and delivery with regards to post-stroke dysphagia management.