Clinical Decision Making in Patients with Stroke-Related Dysphagia

Abstract

This article aims to highlight stroke considerations in the evaluation and management of dysphagia. Although dysphagia was previously thought to occur only following brainstem or bilateral cortical strokes, the development of brain imaging and dynamic swallowing studies has revealed small, unilateral supratentorial strokes can produce dysphagia. In this article, screening, evaluation, and management of dysphagia are outlined, as well as the clinical decision making that occurs when taking into account cognitive and communication deficits that may be present. For the clinical swallow examination, chart review, interview, informal evaluation of cognition and communication, observation of posture, oral cavity inspection, cranial nerve examination, and the direct swallowing assessment are reviewed along with tailoring of each according to the deficits observed. Specific compensation and rehabilitation strategies are discussed along with how cognitive and communication deficits can guide the clinician's decision-making process to select an appropriate plan of care. A case study is provided to synthesize the process into a real-world scenario.

Keywords

dysphagia - stroke - rehabilitation - assessment/evaluation

Financial Disclosures

C.C.F. receives salary support from Memorial Hermann Health System.

M.E.J. receives salary support from the University of Houston and Memorial Hermann Health System.

S.K.D. receives salary support from the University of Houston, and royalties from Plural Publishing and MedBridge.

• References

• 1 Daniels SK, Huckabee ML, Gozdzikowska K. Dysphagia Following Stroke, 3rd ed. San Diego, CA: Plural Publishing; 2019
• 2 Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke 2005; 36 (12) 2756-2763
• 3 Mann G, Hankey GJ, Cameron D. Swallowing function after stroke: prognosis and prognostic factors at 6 months. Stroke 1999; 30 (04) 744-748
• 4 Daniels SK, Foundas AL. Lesion localization in acute stroke patients with risk of aspiration. J Neuroimaging 1999; 9 (02) 91-98
• 5 Robbins J, Levine RL, Maser A, Rosenbek JC, Kempster GB. Swallowing after unilateral stroke of the cerebral cortex. Arch Phys Med Rehabil 1993; 74 (12) 1295-1300
• 6 Cola MG, Daniels SK, Corey DM, Lemen LC, Romero M, Foundas AL. Relevance of subcortical stroke in dysphagia. Stroke 2010; 41 (03) 482-486
• 7 Daniels SK, Pathak S, Mukhi SV, Stach CB, Morgan RO, Anderson JA. The relationship between lesion localization and dysphagia in acute stroke. Dysphagia 2017; 32 (06) 777-784
• 8 Joundi RA, Martino R, Saposnik G, Giannakeas V, Fang J, Kapral MK. Predictors and outcomes of dysphagia screening after acute ischemic stroke. Stroke 2017; 48 (04) 900-906
• 9 Steinhagen V, Grossmann A, Benecke R, Walter U. Swallowing disturbance pattern relates to brain lesion location in acute stroke patients. Stroke 2009; 40 (05) 1903-1906
• 10 Jauch EC, Saver JL, Adams Jr HP. , et al; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44 (03) 870-947
• 11 Edmiaston J, Connor LT, Loehr L, Nassief A. Validation of a dysphagia screening tool in acute stroke patients. Am J Crit Care 2010; 19 (04) 357-364
• 12 Anderson JA, Pathak S, Rosenbek JC, Morgan RO, Daniels SK. Rapid aspiration screening for suspected stroke: Part 2: Initial and sustained nurse accuracy and reliability. Arch Phys Med Rehabil 2016; 97 (09) 1449-1455
• 13 Martino R, Silver F, Teasell R. , et al. The Toronto Bedside Swallowing Screening Test (TOR-BSST): development and validation of a dysphagia screening tool for patients with stroke. Stroke 2009; 40 (02) 555-561
• 14 Freeland TR, Pathak S, Garrett RR, Anderson JA, Daniels SK. Using medical mannequins to train nurses in stroke swallowing screening. Dysphagia 2016; 31 (01) 104-110
• 15 Edmiaston J, Connor LT, Steger-May K, Ford AL. A simple bedside stroke dysphagia screen, validated against videofluoroscopy, detects dysphagia and aspiration with high sensitivity. J Stroke Cerebrovasc Dis 2014; 23 (04) 712-716
• 16 Trapl M, Enderle P, Nowotny M. , et al. Dysphagia bedside screening for acute-stroke patients: the Gugging Swallowing Screen. Stroke 2007; 38 (11) 2948-2952
• 17 Daniels SK, Pathak S, Rosenbek JC, Morgan RO, Anderson JA. Rapid aspiration screening for suspected stroke: part 1: development and validation. Arch Phys Med Rehabil 2016; 97 (09) 1440-1448
• 18 Suiter DM, Leder SB. Clinical utility of the 3-ounce water swallow test. Dysphagia 2008; 23 (03) 244-250
• 19 Warner HL, Suiter DM, Nystrom KV, Poskus K, Leder SB. Comparing accuracy of the Yale swallow protocol when administered by registered nurses and speech-language pathologists. J Clin Nurs 2014; 23 (13-14): 1908-1915
• 20 Suiter DM, Sloggy J, Leder SB. Validation of the Yale Swallow Protocol: a prospective double-blinded videofluoroscopic study. Dysphagia 2014; 29 (02) 199-203
• 21 American Speech-Language-Hearing Association Steering Committee of Special Interest Division 13. Frequently asked questions (FAQ) on swallowing screening: special emphasis on patients with acute stroke. 2009 . Available at: http://www.asha.org/uploadedFiles/FAQs-on-Swallowing-Screening.pdf . Accessed April 24, 2019
• 22 Ebrahimian Dehaghani S, Yadegari F, Asgari A, Bagheri Z. The mediator effect of cognition on the relationship between brain lesion location and dysphagia in patients with stroke: applying a structural equation model. J Oral Rehabil 2019; 46 (01) 33-39
• 23 Parker C, Power M, Hamdy S, Bowen A, Tyrrell P, Thompson DG. Awareness of dysphagia by patients following stroke predicts swallowing performance. Dysphagia 2004; 19 (01) 28-35
• 24 Schroeder MF, Daniels SK, McClain M, Corey DM, Foundas AL. Clinical and cognitive predictors of swallowing recovery in stroke. J Rehabil Res Dev 2006; 43 (03) 301-310
• 25 Langmore SE, Terpenning MS, Schork A. , et al. Predictors of aspiration pneumonia: how important is dysphagia?. Dysphagia 1998; 13 (02) 69-81
• 26 McCullough GH, Rosenbek JC, Wertz RT, McCoy S, Mann G, McCullough K. Utility of clinical swallowing examination measures for detecting aspiration post-stroke. J Speech Lang Hear Res 2005; 48 (06) 1280-1293
• 27 Vanderwegen J, Guns C, Van Nuffelen G, Elen R, De Bodt M. The influence of age, sex, bulb position, visual feedback, and the order of testing on maximum anterior and posterior tongue strength and endurance in healthy Belgian adults. Dysphagia 2013; 28 (02) 159-166
• 28 Smith Hammond CA, Goldstein LB, Horner RD. , et al. Predicting aspiration in patients with ischemic stroke: comparison of clinical signs and aerodynamic measures of voluntary cough. Chest 2009; 135 (03) 769-777
• 29 Murray J. Manual of Dysphagia Assessment in Adults. San Diego, CA: Singular; 1999
• 30 Logemann JA. Evaluation and Treatment of Swallowing Disorders. 2nd ed. Austin, TX: Pro-Ed; 1998
• 31 Mann G. MASA: The Mann Assessment of Swallowing Ability. Clifton Park, NY: Thomson Delmar Learning; 2002
• 32 Martin-Harris B, Brodsky MB, Michel Y. , et al. MBS measurement tool for swallow impairment--MBSImp: establishing a standard. Dysphagia 2008; 23 (04) 392-405
• 33 Leonard R, Kendall KA. Dysphagia Assessment and Treatment Planning. 4th ed. San Diego, CA: Plural Publishing; 2019
• 34 Huckabee ML, Macrae P, Lamvik K. Expanding instrumental options for dysphagia diagnosis and research: ultrasound and manometry. Folia Phoniatr Logop 2015; 67 (06) 269-284
• 35 Molfenter SM, Steele CM. Physiological variability in the deglutition literature: hyoid and laryngeal kinematics. Dysphagia 2011; 26 (01) 67-74
• 36 Daniels SK, Schroeder MF, DeGeorge PC, Corey DM, Rosenbek JC. Effects of verbal cue on bolus flow during swallowing. Am J Speech Lang Pathol 2007; 16 (02) 140-147
• 37 Garcia JM, Hakel M, Lazarus C. Unexpected consequence of effortful swallowing: case study report. J Med Speech-Lang Pathol 2004; 12 (02) 59-67
• 38 Molfenter SM, Hsu CY, Lu Y, Lazarus CL. Alterations to swallowing physiology as the result of effortful swallowing in healthy seniors. Dysphagia 2018; 33 (03) 380-388
• 39 Rangarathnam B, McCullough GH. Utility of the clinical swallowing exam for understanding swallowing physiology. Dysphagia 2016; 31 (04) 491-497
• 40 Baylow HE, Goldfarb R, Taveira CH, Steinberg RS. Accuracy of clinical judgment of the chin-down posture for dysphagia during the clinical/bedside assessment as corroborated by videofluoroscopy in adults with acute stroke. Dysphagia 2009; 24 (04) 423-433
• 41 Fraser S, Steele CM. The effect of chin down position on penetration-aspiration in adults with dysphagia. Can J Speech-Lang Pathol Audiol 2012; 36 (02) 142-148
• 42 Miles A, McFarlane M, Scott S, Hunting A. Cough response to aspiration in thin and thick fluids during FEES in hospitalized inpatients. Int J Lang Commun Disord 2018; 53 (05) 909-918
• 43 Bülow M, Olsson R, Ekberg O. Videomanometric analysis of supraglottic swallow, effortful swallow, and chin tuck in patients with pharyngeal dysfunction. Dysphagia 2001; 16 (03) 190-195
• 44 Macrae P, Anderson C, Humbert I. Mechanisms of airway protection during chin-down swallowing. J Speech Lang Hear Res 2014; 57 (04) 1251-1258
• 45 Shanahan TK, Logemann JA, Rademaker AW, Pauloski BR, Kahrilas PJ. Chin-down posture effect on aspiration in dysphagic patients. Arch Phys Med Rehabil 1993; 74 (07) 736-739
• 46 Huckabee ML, Steele CM. An analysis of lingual contribution to submental surface electromyographic measures and pharyngeal pressure during effortful swallow. Arch Phys Med Rehabil 2006; 87 (08) 1067-1072
• 47 Steele CM, Huckabee ML. The influence of orolingual pressure on the timing of pharyngeal pressure events. Dysphagia 2007; 22 (01) 30-36
• 48 Knigge MA, Thibeault S. Relationship between tongue base region pressures and vallecular clearance. Dysphagia 2016; 31 (03) 391-397
• 49 Turkington LG, Ward EC, Farrell AM. Carbonation as a sensory enhancement strategy: a narrative synthesis of existing evidence. Disabil Rehabil 2017; 39 (19) 1958-1967
• 50 Troche MS, Okun MS, Rosenbek JC. , et al. Aspiration and swallowing in Parkinson disease and rehabilitation with EMST: a randomized trial. Neurology 2010; 75 (21) 1912-1919
• 51 Shaker R, Easterling C, Kern M. , et al. Rehabilitation of swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening. Gastroenterology 2002; 122 (05) 1314-1321
• 52 Rogus-Pulia N, Rusche N, Hind JA. , et al. Effects of device-facilitated isometric progressive resistance oropharyngeal therapy on swallowing and health-related outcomes in older adults with dysphagia. J Am Geriatr Soc 2016; 64 (02) 417-424
• 53 Rosenbek JC, Robbins J, Willford WO. , et al. Comparing treatment intensities of tactile-thermal application. Dysphagia 1998; 13 (01) 1-9
• 54 Fujiu M, Logemann JA. Effect of a tongue-holding maneuver on posterior pharyngeal wall movement during deglutition. Am J Speech Lang Pathol 1996; 5 (01) 23-30
• 55 Felix VN, Corrêa SM, Soares RJ. A therapeutic maneuver for oropharyngeal dysphagia in patients with Parkinson's disease. Clinics (São Paulo) 2008; 63 (05) 661-666
• 56 McCullough GH, Kamarunas E, Mann GC, Schmidley JW, Robbins JA, Crary MA. Effects of Mendelsohn maneuver on measures of swallowing duration post stroke. Top Stroke Rehabil 2012; 19 (03) 234-243
• 57 Yoon WL, Khoo JK, Rickard Liow SJ. Chin tuck against resistance (CTAR): new method for enhancing suprahyoid muscle activity using a Shaker-type exercise. Dysphagia 2014; 29 (02) 243-248
• 58 Mishra A, Rajappa A, Tipton E, Malandraki GA. The recline exercise: comparisons with the head lift exercise in healthy adults. Dysphagia 2015; 30 (06) 730-737
• 59 Robbins J, Kays SA, Gangnon RE. , et al. The effects of lingual exercise in stroke patients with dysphagia. Arch Phys Med Rehabil 2007; 88 (02) 150-158
• 60 Hegland KW, Davenport PW, Brandimore AE, Singletary FF, Troche MS. Rehabilitation of swallowing and cough functions following stroke: an expiratory muscle strength training trial. Arch Phys Med Rehabil 2016; 97 (08) 1345-1351
• 61 Sjögren P, Nilsson E, Forsell M, Johansson O, Hoogstraate J. A systematic review of the preventive effect of oral hygiene on pneumonia and respiratory tract infection in elderly people in hospitals and nursing homes: effect estimates and methodological quality of randomized controlled trials. J Am Geriatr Soc 2008; 56 (11) 2124-2130
• 62 van der Maarel-Wierink CD, Vanobbergen JN, Bronkhorst EM, Schols JM, de Baat C. Oral health care and aspiration pneumonia in frail older people: a systematic literature review. Gerodontology 2013; 30 (01) 3-9
• 63 Powers WJ, Rabinstein AA, Ackerson T. , et al; American Heart Association Stroke Council. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2018; 49 (03) e46-e110
• 64 Chaudhuri G, Hildner CD, Brady S, Hutchins B, Aliga N, Abadilla E. Cardiovascular effects of the supraglottic and super-supraglottic swallowing maneuvers in stroke patients with dysphagia. Dysphagia 2002; 17 (01) 19-23