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National Clinical Guideline Centre (UK). Stroke Rehabilitation: Long Term Rehabilitation After Stroke [Internet]. London: Royal College of Physicians (UK); 2013 May 23. (NICE Clinical Guidelines, No. 162.)
Dysphagia (difficulty swallowing) is common following stroke, occurring in up to 67% of stroke patients. Stroke patients with dysphagia have higher rates of chest infection, aspiration pneumonia, dehydration and malnutrition than stroke patients without dysphagia. The presence of dysphagia is also associated with a significantly increased risk of death, disability, length of hospital stay, and institutional care.
Symptoms and signs which may indicate the presence of dysphagia include:
- A feeling that food or liquid is sticking in the throat;
- A sensation of a foreign body or “lump” in the throat;
- A need to modify or restrict certain food types
- Drooling;
- Difficulty initiating a swallow
- Nasal regurgitation of food or drink during swallowing
- Coughing or choking during eating and drinking
- Gurgly or wet voice after swallowing
- Unexplained weight loss
- Respiratory symptoms including increasing respiratory rate and shortness of breath.
Dysphagia rehabilitation programmes use a combination of approaches aimed at either improving or compensating for the underlying disorder. Programmes may focus on strengthening muscles or on using different groups of muscles to assume the function of the damaged muscles. General dysphagia management programmes that incorporate early identification of swallowing difficulties through screening or assessment and modification of oral intake have been associated with a reduced risk of pneumonia in the acute stage of stroke.
11.1.1. Evidence review: In people after stroke what is the clinical and cost-effectiveness of interventions for swallowing versus alternative interventions/usual care to improve difficulty swallowing (dysphagia)?
| Clinical Methodological Introduction | |
|---|---|
| Population: | Adults and young people 16 or older who have had a stroke |
| Intervention: |
|
| Comparison: |
|
| Outcomes: |
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11.1.1.1. Clinical evidence
Searches were conducted for systematic reviews and RCTs comparing interventions to improve swallowing for reducing dysphagia in patients with stroke. Only studies with a minimum sample size of 20 participants (10 in each arm) and including at least 50% of participants with stroke were selected. Three (3) RCTs were identified.
Table 57
Summary of studies included in the clinical evidence review. For full details of the extraction please see Appendix H.
Comparison of behavioural interventions for dysphagia versus usual care
Table 58
Standard low intensity swallowing therapy for dysphagia versus usual care - Clinical study characteristics and clinical summary of findings.
Table 59
Standard high intensity swallowing therapy for dysphagia versus usual care - Clinical study characteristics and clinical summary of findings.
Table 60
Reinforcement of swallowing postures versus usual care- Clinical study characteristics and clinical summary of findings.
Comparison of unlimited oral intake of water in addition to thickened liquids versus thickened liquids only
Table 61
Unlimited oral intake of water in addition to thickened liquids versus thickened liquids only - Clinical study characteristics and clinical summary of findings.
11.1.2. Economic Literature review
One study was included that included the relevant comparison.169 This is summarised in the economic evidence profile below (Table 62 and Table 63). See also the full study evidence tables in Appendix I.
Table 62
Standard ‘low intensity’ swallowing therapy versus usual care – Economic study characteristics.
Table 63
Standard ‘low intensity’ swallowing therapy versus usual care – Economic summary of findings.
11.1.3. Evidence statements
Clinical evidence statement(s)
Standard low intensity swallowing therapy for dysphagia versus usual care
One study (Carnaby 200636) comprising 204 people who have had a stroke showed that people who received a standard low intensity swallowing therapy were no more likely to return to their pre-stroke diet after 6 months than those who received usual care (moderate confidence in the effect).
One study (Carnaby 200636) comprising 204 people who have had a stroke showed that there were significantly fewer people of those who received a standard low intensity swallowing therapy experiencing chest infections compared to those who received usual care (moderate confidence in the effect).
Standard high intensity swallowing therapy for dysphagia versus usual care
One study (Carnaby 200636) comprising 204 people who have had a stroke showed that people who received a standard high intensity swallowing therapy were significantly more likely to return to their pre-stroke diet after 6 months than those who received usual care (moderate confidence in the effect).
One study (Carnaby 200636) comprising 204 people who have had a stroke showed that there were significantly fewer people of those who received a standard high intensity swallowing therapy experiencing chest infections compared to those who received usual care (moderate confidence in the effect).
Reinforcement of swallowing postures versus usual care
One study (DePippo 199463) comprising 77 people who have had a stroke showed that people who received reinforcement of swallowing postures did not have higher rates of pneumonia compared to those who received usual care (very low confidence in the effect).
Unlimited oral intake of water in addition to thickened liquids versus thickened liquids only
One study (Garon 199789) comprising 20 people who have had a stroke showed no case of aspiration pneumonia in either the group who received unlimited oral intake of water in addition to thickened liquids or the thickened liquids only group (very low confidence in the effect)
Health economic evidence statement(s)
- One directly applicable study with minor limitations showed that low intensity SLT saves around £213 per patient compared to usual care when initial costs and cost of treating chest infections are included.
11.1.4. Recommendations and link to evidence
| |
|---|---|
| Relative values of different outcomes | The outcomes reported in the studies included: return to normal diet, occurrence of chest infection and aspiration pneumonia. In the short-term the prevention of aspiration pneumonia is a critical outcome, but in the long term a return to a normal diet has a significant impact on quality of life for both patients and carers. Dysphagia may result in percutaneous endoscopic gastrostomy (PEG) feeding, which may have a significant negative impact on quality of life as well as significantly increased costs. |
| Trade-off between clinical benefits and harms | Untreated dysphagia could lead to serious complications including: aspiration pneumonia, dehydration and death. Normal swallowing allows people to enjoy meal times and related social interactions, and is therefore considered to be linked to an improvement in quality of life. People who are having thickened food may need assistance with oral hygiene and this should be monitored. The GDG agreed that good oral hygiene has been linked with a reduction in aspiration pneumonia and should be incorporated into any dysphagia management plan. The group noted that people with dysphagia have a higher risk of aspiration pneumonia. |
| Economic considerations | One directly applicable study with minor limitations showed that low intensity swallowing therapy saves around £213 per patient compared to usual care when initial costs and cost of treating chest infections are included. The GDG agreed that the cost of providing swallowing therapy for dysphagia compared to usual care could potentially be offset by cost savings due to reductions in chest infections and improved outcomes for patients including reduced mortality and improvement in quality of life. |
| Quality of evidence | The GDG considered the Carnaby study36 to be a well conducted single centred study, which examined the effects of high and low intensity swallowing on return to pre-stroke diet at 6 months and aspiration pneumonia compared to a control group. The control group was not typical of current UK practice, where physicians only referred their patients to the speech and language therapists if they considered it to be appropriate was not typical of current UK practice. Treatment, if offered, consisted mainly of supervision for feeding and precautions for safe swallowing (for example, positioning, slowed rate of feeding). Appraisal of this study graded the results for the outcomes reported as moderate. The evidence showed that a significantly lower proportion of participants who received the swallowing therapy experienced chest infections compared to usual care group. In addition a significantly higher proportion of participants receiving the high intensity swallowing therapy returned to pre stroke diet at 6 months compared to usual care. The study was not powered to compare low against high intensity therapy, but there was consensus amongst the group that the benefit of swallowing therapy employing a full range of techniques clearly outweighed the harms and should be offered at least three times a week to patients with dysphagia. It is not possible to recommend the high intensity intervention from the evidence reviewed, but the GDG agreed that the range of swallowing therapies should be specified and that the minimum should be the low intensity therapy of at least 3 times per week, but in some circumstances the high intensity may be more appropriate for those patients who are medically stable, able to tolerate an hour of therapy each day and follow instructions/information provided. One small study by Garon89 examined the effects of thickened fluids and free access to water on the occurrence of pneumonia but there were no episodes of pneumonia in either group. On the basis of this study, the authors reported that they allow free access to water. However, members of the GDG were aware of other studies investigating free access to water but no other RCT data was available at present. The GDG did not consider the results from this study were sufficient to recommend free access to water. There was uncertainty amongst the GDG about whether there may be potential harms but it was agreed this was an important area which requires further research. |
| Other considerations | The group were aware of a growing evidence base of the benefits of post-operative patients are fully hydrated in reducing length of stay in hospital. The GDG noted that patients should be weighed regularly and any weight loss needs to be explained and agreed that the problem of weight loss may be due to dysphagia, but could also be attributed to other causes such as difficulties feeding due to neglect, or upper limb weakness or depression. |
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