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Treatment of Dysphagia Improves Nutritional Conditions in Stroke Patients - Dysphagia is a common symptom in stroke patients, and malnutrition is prevalent among these patients. Thus far, nutritional effects of dysphagic treatment have not been evaluated.

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									Dysphagia 14:61–66 (1999)

                                                                                                           © Springer-Verlag New York Inc. 1999

Treatment of Dysphagia Improves Nutritional Conditions in
Stroke Patients

Solve Elmståhl, MD, PhD,1 Margareta Bulow, BSc,1,2 Olle Ekberg, MD, PhD,2 Marie Petersson, MD,1 and
 ¨                                   ¨
Hans Tegner, MD, PhD3
Departments of 1Community Medicine, 2Diagnostic Radiology, and 3Otorhinolaryngology, Malmo University Hospital, Lund University,
Malmo, Sweden

Abstract. Dysphagia is a common symptom in stroke                      is associated with improvements in nutritional param-
patients, and malnutrition is prevalent among these pa-                eters. Subjective complaints is not sufficient to evaluate
tients. Thus far, nutritional effects of dysphagic treat-              the clinical course, and nutritional parameters should be
ment have not been evaluated. The aim of the present                   monitored in patients with oral or pharyngeal dysfunc-
report was to study the effects of swallowing techniques               tion.
on nutritional and anthropometric variables. A survey
                                                                       Key words: Dysphagia — Swallowing — Stroke —
with follow-up was performed at the Departments of
                                                                       Nutrition — Treatment — Swallow maneuvers — De-
Geriatric Medicine and Neurology, Malmo University
Hospital, Sweden. Thirty-eight stroke patients, 53–89                  glutition — Deglutition disorders.
years of age, with subjective complaints of dysphagia
and oral/pharyngeal dysfunction according to videofluo-
roscopic barium swallowing examination (VSBE), were
given swallowing treatment. The treatment included oral                Dysphagia is a common symptom in patients after stroke.
motor exercise, different swallowing techniques, posi-                 Previous studies have shown that about 30–45% of pa-
tioning, and diet modification. Plasma protein levels,                 tients with acute stroke have difficulty with swallowing
body composition, VSBE, and a viso-analogical scale for                a mouthful of water when assessed within 48 hr after the
subjective complaints were repeated before and after                   onset of symptoms [1,2]. However, in most of these pa-
treatment. At baseline, 94% of cases had signs of pen-                 tients with predominantly unilateral cerebral hemisphere
etration and 50–72% had plasma protein levels below                    lesion, symptoms resolved after 1 week. Acute stroke
recommended levels. Treatment reduced the degree of                    and dysphagia have been associated with signs of aspi-
oral dysfunction, (dissociation) and pharyngeal dysfunc-               ration [3,4]. Aspiration verified by a modified videofluo-
tion (penetration and constrictor paresis). Sixty percent              roscopic barium swallow examination (VBSE) was
of cases showed an improved overall VSBE score, and                    noted in more than two-thirds of patients on average 5
improved levels of albumin and total iron-binding capac-               weeks after the onset of stroke [4]. The presence of dys-
ity were restricted to this group. In cases with unchanged             phagia has been associated with an increased risk of
or decreased VSBE score, body weight was reduced and                   chest infection, poor nutritional state, and mortality [5].
a negative correlation to total iron-binding capacity was              Prolonged conditions with protein-energy malnutrition
noted (r    −0.60, p < 0.05). Changes of subjective com-               (PEM) can deprive immune functions and increase mor-
plaints did not correlate with swallowing function or nu-              bidity from infectious diseases and mortality [6–8]. It has
tritional improvements. Swallowing treatment improves                  also been suggested that PEM may alter muscle and
swallowing function, and improved swallowing function                  nerve function and thereby increase swallowing impair-
                                                                       ment [9].
                                                                               Different therapeutic strategies have been intro-
                                                                       duced to improve swallowing impairment [10]. Compen-
Correspondence to: Solve Elmståhl, M.D., Ph.D., Department of Com-
munity Medicine, Malmo University Hospital, S-205 02 Malmo, Swe-
                       ¨                                    ¨          satory techniques include postural adjustment, supraglot-
den                                                                    tic swallowing, the Mendelsohn maneuver, and effortful
62                                                                           S. Elmståhl et al.: Dysphagic Treatment Improves Nutritional Status

swallowing. Other methods attempt to stimulate im-                          Table 1. Descriptive data, in percent, on 38 subjects with dysphagia
paired functions. Orofacial exercises and thermal stimu-                    after stroke
lation of the swallowing reflex are examples of these                       Age (yr)
indirect swallowing therapies. Alterations of the consis-                     <69                                                                24
tency of food and texture are also commonly used for                          70–79                                                              50
treatment of oral and pharyngeal dysfunction.                                 80–89                                                              26
        To our knowledge, no previous study has evalu-                      Gender
                                                                              Female                                                             32
ated the nutritional effects of different swallowing tech-                    Male                                                               68
niques, including direct and indirect methods, in acute                     Social status
stroke patients with dysphagia. The aim of the present                        Married/cohabitant                                                 53
study was to assess the outcome on nutritional and an-                        Noncohabitant                                                      47
thropometric variables of dysphagic stroke patients                         Localization of stroke
                                                                              Left hemisphere                                                    32
treated with a selection of different swallowing tech-                        Right hemisphere                                                   30
niques more than 2 weeks after stroke onset.                                  Bilateral hemispheres                                              11
                                                                              Brainstem                                                          22
                                                                              Others                                                              6
Materials and Methods
                                                                              Dysarthria                                                         61
                                                                              Oral dryness                                                       32
Fifty-two consecutive patients with acute ischemic or hemorrhagic
                                                                            Sensation of obstruction
strokes and dysphagia 2 weeks after stroke onset attending the stroke
                                                                              Yes                                                                26
unit at the Departments of Geriatric Medicine or Neurology in Malmo     ¨
                                                                              No                                                                 56
during 1994–1996 were invited to participate in the study. All patients
                                                                              Unknown                                                             8
were investigated by a speech language pathologist and a physician and
                                                                            Coughing while swallowing
questioned about swallowing complaints. A VBSE was performed be-
                                                                              Yes                                                                50
fore and about 2 months after swallowing therapy was introduced.
                                                                              No                                                                 39
Inclusion criteria were swallowing complaint and oral and/or pharyn-
                                                                              Unknown                                                             1
geal dysfunction according to VBSE. Fourteen patients were excluded;
                                                                            Dental status
six patients did not participate in the second VBSE; five patients in-
                                                                              Own teeth                                                          45
terrupted the therapy, two of whom improved their swallowing; and
                                                                              Denture and own teeth                                              16
three patients were deceased.
                                                                              Dentures only                                                      39
         Thus, the study comprised 38 patients, with a mean age of 74.8
                                                                            Dietary intake
± 8.4 years (range 53–89 years). The median time between stroke onset
                                                                              Oral                                                               89
and the first VBSE was 22 days (lowest quartile 15 days, highest
                                                                              Parenteral                                                         11
quartile 27 days). A computed tomographic (CT) scan was performed
                                                                            Number of drugs
in 35 of the 38 patients, and stroke was confirmed in all but one case.
                                                                              None                                                               71
Localization of cerebral lesions is given in Table 1. Four patients had
                                                                              1–4                                                                13
had a previous stroke.
                                                                              >4                                                                 16
         During a routine upright ingestion of liquid barium for double-
contrast examination, the oral cavity, pharynx, and esophagus were
examined during barium swallowing using fluoroscopy and video in            given to 76% of the patients, included oral motor exercise and thermal
lateral and frontal projections. The patient was asked to take a mouthful   stimulation to enhance the swallowing reflex. The selection of treat-
of liquid barium, hold it in the mouth, and then swallow it on command.     ment by the speech language pathologist was based on the VBSE and
At least three swallows were imaged. The oral, pharyngeal, and pharyn-      clinical examination to facilitate a safe and more efficient oral intake
geoesophagal functions (Table 2) were assessed with a four-grade            [11,12]. Strategies commonly used are changes in body and head pos-
scale, from 0 (normal) to 3 (severe pathology), except for the oral phase   ture or techniques designed to change specific aspects of swallow
(three-grade scales; normal, moderate, to severe pathology) and closure     physiology. Oral motor exercises included different lip and tongue
of the laryngeal vestibule (normal and abnormal). The degree of dis-        exercises if the patient had oral dysfunction according to VBSE. Su-
sociation was categorized as less than 0.5 sec, 0.5–3 sec, 3–10 sec, and    praglottic swallow or chin tuck was chosen for a more effective airway
more than 10 sec. Dysfunction of the pharyngeoesophagal segment was         protection when VBSE showed penetration or retention of contrast
defined as normal, posterior indentation less than 25%, 25–50% and          medium after swallow. When residue in valleculae after swallow was
more than 50%. A score, ranging from 0 to 24, was calculated by             obvious, effortful swallow can increase tongue-base retraction. Ther-
adding the different items together. The median time between the first      mal stimulation was given if there was a delay between oral and pha-
and second VSBE was 52 days.                                                ryngeal swallow (dissociation) to increase sensory awareness in the
                                                                            oral cavity and thereby decrease the degree of dissociation [11,12].
                                                                                    All patients underwent a medical and neurological examination.
Swallowing Therapy                                                          Dental status including whether the patient had teeth and dentures were
                                                                            noted. A visoanalogic scale, with a line ranging from 1 (no complaints)
The following therapeutic strategies, listed in Table 3, were offered and   to 7 (severe complaints), was used to describe the patient’s subjective
given by a speech language pathologist. Direct methods included com-        experience of dysphagia. The patient was asked to draw a line through
pensatory strategies such as head and neck positioning, supraglottic        the scale for his/her swallowing complaints the last week to describe
swallowing, and the Mendelsohn maneuver, and the indirect methods,          the worst and best conditions, respectively.
S. Elmståhl et al.: Dysphagic Treatment Improves Nutritional Status                                                                                   63

Table 2. Barium swallow examination of 38 subjects with stroke and dysphagia, before and after treatment

                                                        Before                                                        After

                                                        n (%)               Mean score             p                  n (%)               Mean score

Oral dysfunction
  Orofacial dysfunction                                 11 (31)             0.44   ±   0.73        <0.10               9 (24)             0.24   ±   0.43
  Leak anterior                                          7 (19)             0.25   ±   0.55                            6 (16)             0.16   ±   0.37
  Leak posterior                                        20 (57)             0.77   ±   0.77        <0.10              17 (45)             0.53   ±   0.65
  Dissociation                                          26 (72)             1.22   ±   1.02        <0.05              24 (63)             0.82   ±   0.77
Pharyngeal dysfunction
  Improper closure of laryngeal vestibule                5 (14)             0.25   ±   0.73                            4 (11)             0.16   ±   0.55
  Defective down tilt of epiglottis                      3 (8)              0.08   ±   0.28                            3 (8)              0.08   ±   0.27
  Penetration                                           34 (94)             2.31   ±   0.98        <0.03              33 (87)             1.79   ±   1.14
  Constrictor paresis                                   20 (56)             0.97   ±   1.06        <0.05              16 (42)             0.71   ±   0.98
Pharyngeoesophagal segment dysfunction                   2 (6)              0.11   ±   0.46                            5 (13)             0.24   ±   0.68

Significant differences between scores before and after treatment are given for the specific swallowing functions; Wilcoxon signed rank test.

Table 3. Type and number of therapeutic methods given to dysphagic             made with the Wilcoxon signed rank test. Spearman correlation coef-
patients                                                                       ficients were calculated for associations between the degree of swallow
                                                                               impairment and laboratory tests. Partial correlation coefficients were
Treatment                                                             %        calculated to adjust for covariates.

  Oral motor exercise                                                 47
  Swallowing strategies                                               74       Results
    Supraglottic swallowing                                           32
    Effortful swallowing                                              11
    Mendelsohn maneuver                                                2       Thirty-four of the patients (89%) had oral feeding and 17
    Thermal stimulation                                               53       (50%) had modified diet with puree. The frequencies and
  Head and neck positioning                                           26
                                                                               type of swallowing impairments according to the swal-
  Diet modification                                                   89
Number                                                                         lowing examination are presented in Table 2. Almost all
  1                                                                   16       patients had signs of penetration (94%), and half of them
  2                                                                   29       had constrictor paresis. The degree of swallowing im-
  3                                                                   34       pairments did not correlate with age, and the impairment
  4                                                                   18
                                                                               did not differ with respect to gender, dental status, or the
  5                                                                    3
                                                                               occurrence of dysarthria. Half of the patients (56%) re-
All swallowing strategies are presented as one treatment except for            ported no subjective signs of obstruction during swal-
thermal stimulation.                                                           lowing.
                                                                                       Swallowing functions improved after treatment;
                                                                               specifically, the degree of constrictor paresis and pen-
        Laboratory variables plasma albumin, transthyretin, orosomu-
coid, retinol-binding protein, transferrin- and total iron-binding capac-
                                                                               etration were reduced, as was dissociation (Table 2). The
ity (TIBC), ceruloplasmin, and c-reactive protein were routinely mea-          overall VSBE score was reduced from 13.5 to 9.9 after
sured by using agaros electrophoresis and immunochemical quantifi-             treatment (p < 0.01). Levels of albumin and TIBC in-
cation of plasma proteins at the Chemical Department, Malmo             ¨      creased significantly after treatment, whereas the mean
University Hospital. Lean body mass and body fat percentage were               body weight decreased by 1.2 kg in the total study popu-
measured with the body composition analyzer system BIA-109 (RJL
systems, Detroit, MI, USA). The previously validated method is based
                                                                               lation (Table 4). The percentage of patients with plasma
on the differences in conductivity between water and fat in the body by        protein levels below present recommendations changed
introducing an alternating current, 800 A at 50 kHz, and detecting the         during treatment from 72% to 42% for albumin (<36 g/l),
voltage drop [13,14]. The electrical conductance is detected as the            from 50% to 19% for TIBC (<46 mol/l), and from 57%
resistance to electrical current by four electrodes placed on the right        to 43% for retinol-binding protein (<50 mg/l).
hand and foot.
                                                                                       Analyses were stratified with respect to verified
                                                                               improvements of swallowing functions by the VSBE.
Statistical Methods                                                            Twenty-three patients (61%) improved their overall
                                                                               VSBE score as opposed to 15 patients with unchanged or
Comparisons between groups of median levels were made with the                 increased score at follow-up (Table 5). The mean age did
Mann-Whitney U-test. Comparison before and after treatment was                 not differ between the two groups (74.8 vs. 74.9 years).
64                                                                         S. Elmståhl et al.: Dysphagic Treatment Improves Nutritional Status

Table 4. Nutritional variables in patients with stroke and dysphagia      and pharyngeal dysfunction [15]. Patients with dyspha-
before and after treatment (Wilcoxon signed rank test)                    gia have also shown a higher risk of poor nutritional
                           Baseline        Follow-up      p          n
                                                                          state, respiratory infections, and death [5]. To improve
                                                                          swallowing functions, different therapy strategies have
Albumin (g/l)              33.7 ± 4.6      36.2 ± 3.2     <0.01      29   been adopted including direct or compensatory tech-
Transthyretin (g/l)         0.27 ± 0.08     0.28 ± 0.09              27
                                                                          niques [16] and indirect techniques including different
RBP (mg/l)                 50.6 ± 16.3     53.1 ± 15.3               25
TIBC ( mol/l)              44.4 ± 13.4     52.0 ± 8.9     <0.01      28   kinds of exercises or stimulation. However, the nutri-
Ceruloplasmin (g/l)         0.35 ± 0.08     0.32 ± 0.06              31   tional consequences have not previously been evaluated.
Orosomucoid (g/l)           1.06 ± 0.36     1.10 ± 0.36              31   It is noteworthy that subjective complaints decreased in
CRP (mg/l)                 15.1 ± 15.0     18.8 ± 39.8               32   patients whose swallowing functions did not improve.
Body weight (kg)           71.2 ± 12.8     70.0 ± 12.9    <0.05      32
Lean body mass (kg)        49.5 ± 1.7      47.3 ± 11.0               25   Therefore, it seems important to continuously evaluate
Body fat percentage (%)    29.5 ± 12.6     30.7 ± 12.5               25   nutritional conditions and swallowing functions in stroke
Dysphagia score (1–7)                                                     patients even if subjective complaints decline.
  Best conditions           2.9 ± 1.5       2.7 ± 1.7                20           A high proportion of the stroke patients with dys-
  Worse conditions          4.4 ± 1.7       2.7 ± 1.8     <0.05      19
                                                                          phagia showed a spontaneous recovery. In a recent fol-
RBP       retinol binding protein; CRP    c-reactive protein; TIBC        low-up study of 100 stroke patients, only two out of 14
total iron binding capacity.                                              dysphagic patients had remaining symptoms after 6
                                                                          months [17]. However, swallowing examination in that
                                                                          study was only performed at the 1-month follow-up, and
The significantly increased levels of albumin and TIBC
                                                                          75% of the dysphagic patients had abnormal examina-
were restricted to the patients who improved their swal-
                                                                          tion. Another study has reported a 2% prevalence of
lowing functions after treatment, and the body weight
                                                                          swallowing dysfunction, defined as coughing or delayed
and body fat percentage were unchanged in this group.
                                                                          swallowing of a mouthful of water, 1 month after stroke,
The patients with unchanged or deteriorating swallowing
functions showed no changes of mean plasma proteins                       which declined to 0.4% 6 months later among the sur-
after treatment, and their body weight was decreased at                   vivors [1]. In that study, no adjustment was made for
follow-up. The VSBE score in the therapy-resistent                        dysphagia among the patients during the follow-up, and
group was negatively correlated to TIBC levels (r                         the functional impairments were not verified by radio-
0.60) at follow-up; thus, the lesser swallowing impair-                   logical assessment. Because all our patients received
ment, the higher the TIBC levels (Fig. 1). A similar                      treatment, the effect of spontaneous recovery has to be
association was noted after adjustment for inflammatory                   considered. We think the present findings were the con-
activity and c-reactive protein (r     −0.52). A significant              sequence of the therapy and not spontaneous recovery
reduction of the proportion of subjects below recom-                      for the following reasons. No correlations were noted
mended level of TIBC (<46 mmol/l) from 50% to 15%                         between time after the onset of stroke and the degree of
(p      0.014) was noted only among patients who im-                      swallowing impairment or improvements after therapy.
proved after therapy. The time from onset of stroke was                   Furthermore, the duration after stroke onset and time
not correlated to either total score of VSBE or changes of                between examinations did not significantly differ be-
the score after therapy when patients were analyzed to-                   tween patients who improved swallowing functions and
gether or the two groups separately. There were no sig-                   those who did not. Left hemisphere lesions were more
nificant differences of proportions of the different types                common among the so-called nonresponders. A higher
of treatment or the number of treatments between the two                  degree of apraxia and communication disturbances could
groups. Left hemisphere lesions were more common in                       be expected in this group, which may explain the less
the group without improvement (40% vs. 23%; p < 0.05).                    favorable effect of therapy. Finally, a major part of spon-
                                                                          taneous recovery occurs within the first 2 weeks after
                                                                          stroke, and most patients with remaining dysphagia in
Discussion                                                                the present study were included after 3 weeks [2,3].
                                                                                  The reduction of subjective complaints of dys-
This study shows an association between dysphagic                         phagia after stroke such as coughing during swallowing
treatment and improved nutritional conditions in stroke                   has been described, but with remaining neuromuscular
patients. Previous studies have shown that swallowing                     dysfunctions [1,4]. In the present study, 60% of patients
impairment is common among stroke patients [1–4].                         without complaints of coughing showed aspiration dur-
High prevalence of malnutrition (47%) among stroke pa-                    ing the VSBE, and the detection of this condition seems
tients on admission to rehabilitation has been reported                   important to prevent respiratory infections [18,19]. As-
and associated with dysphagia, most probably due to oral                  piration found by VSBE has been associated with in-
S. Elmståhl et al.: Dysphagic Treatment Improves Nutritional Status                                                                              65

Table 5. Changes of nutritional variables in dysphagic patients who improved after treatment (n       23) or were unchanged (n      15) according to
barium swallow examination

                               Improved after therapy                                           Unchanged after therapy

                               Baseline           Follow-up           p               n         Baseline          Follow-up         p            n

Albumin (g/l)                  33.8 ± 4.6         36.2 ± 3.4          <0.05           19        33.5 ± 4.9        36.2 ± 3.0                     10
Transthyretin (g/l)            0.27 ± 0.08        0.28 ± 0.09                         18        0.27 ± 0.09       0.29 ± 0.11                     9
Orosomucoid (g/l)              1.06 ± 0.30        1.12 ± 0.29                         19        1.06 ± 0.45       1.07 ± 0.46                    12
RBP (mg/l)                     53.0 ± 18.2        54.1 ± 13.8                         15        46.8 ± 12.8       51.6 ± 17.9                    10
TIBC ( mol/l)                  45.0 ± 15.8        53.8 ± 10.0         <0.05           17        43.5 ± 9.0        49.3 ± 6.2                     11
Ceruloplasmin (g/l)            0.33 ± 0.06        0.32 ± 0.07                         19        0.37 ± 0.09       0.33 ± 0.05                    12
CRP (mg/l)                     15.1 ± 13.9         9.5 ± 2.3                          19        14.8 ± 17.3       16.9 ± 16.1                    13
Body weight (kg)               68.4 ± 12.0        68.4 ± 13.7                         19        75.5 ± 13.3       72.2 ± 11.8       <0.05        13
Lean body mass (kg)            45.1 ± 10.8        44.8 ± 11.4                         16        57.2 ± 13.1       51.2 ± 9.2                      9
Body fat percentage (%)        33.1 ± 12.1        32.5 ± 13.2                         16        23.2 ± 11.4       27.7 ± 11.5                     9
Dysphagia score (1–7)
  Best conditions               2.6 ± 1.3          2.7 ± 1.7                          11         3.3 ± 1.8         2.7 ± 1.8                         9
  Worse conditions              3.7 ± 1.8          2.9 ± 2.0                          10         5.2 ± 1.1         2.6 ± 1.8        <0.05            9
Overall score of barium
  swallow examination          16.1 ± 8.0          8.3 ± 5.9          <0.001          23         9.6 ± 5.0        12.2 ± 5.3        <0.01        15

RBP   retinol binding protein; CRP        c-reactive protein; TIBC        total iron binding capacity. Differences between groups were tested by the
Mann-Whitney U-test.

                                                                               in the group with improved VBSE. The TIBC increased
                                                                               from low levels, indicating either an inflammatory con-
                                                                               dition or malnutrition. It seems most unlikely that these
                                                                               changes could be explained by reduced inflammatory
                                                                               activity because levels of orosomucoid and c-reactive
                                                                               protein were unchanged. None of the patients had any
                                                                               acute illness prior to the stroke. Stable body weight
                                                                               among the so-called responders also indicated a condi-
                                                                               tion of energy balance, which was in accordance with the
                                                                               laboratory findings, in contrast to the patients without
                                                                               improvement according to the VSBE. Only one of the
                                                                               patients had a TIBC level above 70 mol/l, indicating
Fig. 1. Relationship between total iron-binding capacity (TIBC) and            iron deficiency. Therefore, the changes of the plasma
swallowing function (barium swallowing score) in stroke patients with          proteins are in accordance with improved nutritional
improved or unchanged swallowing function after swallowing treat-
                                                                                        The etiology of malnutrition is often multifacto-
                                                                               rial, including swallowing difficulties but also cognitive,
creased risk of pneumonia and death following stroke                           conative, and emotional disturbances, motor impair-
[20].                                                                          ments, and environmental conditions, e.g., meal situation
        A high proportion of the patients, between 50%                         [21]. This study was not designed to evaluate the effect
to 72%, had plasma protein levels below present recom-                         of these possible covariates or the effect of specific treat-
mended levels, which may indicate a condition of mal-                          ment strategies because one of the purposes was to
nutrition. These data are similar to findings in a previous                    evaluate the overall effect of swallowing therapy in
study of stroke patients on rehabilitation service [15].                       stroke patients. A study population that could benefit
The dysphagic condition will most likely cause insuffi-                        from a specific treatment is not easily selected because
cient food intake. Therefore, the malnutrition that fol-                       the effect depends on the kind of neuromuscular defect
lows is not only restricted to protein but also to energy                      and localization of the cerebral lesion. Furthermore, pa-
and other micronutrients. This was also illustrated by the                     tients with a specific lesion may also benefit from several
fact that patients not responding to therapy significantly                     kinds of different swallowing treatments. Treatment ap-
decreased their body weight and lean body mass as an                           plied to one structure may facilitate improvement in
indicator of too low protein and energy intake. After                          other area. An example is the propulsive mechanism of
therapy, albumin and TIBC levels increased significantly                       the tongue. The main goal is improved strength and
66                                                                        S. Elmståhl et al.: Dysphagic Treatment Improves Nutritional Status

range of the tongue for more efficient bolus transport.                        malignant disorders. Dissertation, Karolinska Institute, Stock-
The improved strength may also affect pharyngeal clear-                        holm, 1994
                                                                          7.   Chandra RK, Joshi P, Au B, Woodford G, Chandra S: Nutrition
ance by the increased tongue-base retraction and may
                                                                               and immunocompetence of the elderly: effect of short-term nu-
also enhance speech production [22]. A case study de-                          tritional supplementation on cellmediated immunity and lym-
sign was chosen instead of a traditional case control                          phocyte subsets. Nutr Res 2:223–232, 1982
study from an ethical standpoint of not withholding treat-                8.                                  ´
                                                                               Elmståhl S, Persson M, Andren M, Blabolil V: Malnutrition in
ment to dysphagic stroke patients. The scoring system                          geriatric patients—a neglected problem? J Adv Nurs 26:851–
used for the VSBE was chosen arbitrarily and founded                           855, 1997
                                                                          9.   Veldee MSS, Peth LD: Can protein-calorie malnutrition cause
on our clinical experience. We believe that it reflects
                                                                               dysphagia? Dysphagia 2:86–101, 1992
fundamental aspects of transportation through the phar-                  10.   Logemann J: Treatment of aspiration related to dysphagia: an
ynx. An unchanged or worse score may have a negative                           overview. Dysphagia 1:34–38, 1986
prognostic bearing.                                                      11.   Logemann J: Evaluation and Treatment of Swallowing Disor-
        In conclusion, swallowing therapy given to stroke                      ders. San Diego: College-Hill Press, 1983
patients showed that about 60% responded with better                     12.   Logemann J: Dysphagia: evaluation and treatment. Folia Pho-
swallowing function and that this group also had a better                      niatr Logop 47:140–64, 1995
                                                                         13.   Steen B, Boseaus I, Elmståhl S, Galvard H, Isaksson B, Rob-
nutritional status at follow-up, thereby reducing the risk
                                                                               ertsson E: Body composition in the elderly estimated with an
for developing a condition of malnutrition. Nutritional                        electrical impedance method. Compr Gerontol 1A:102–105,
parameters should be monitored in patients with oral or                        1987
pharyngeal dysfunction to evaluate the clinical condi-                   14.                                             ´
                                                                               Elmståhl S, Petersson M, Lilja B, Rosen I, Samuelsson S-M,
tions or treatment. As shown previously, assessment of                               ¨
                                                                               Bjuno L: Body composition in patients with Alzheimer’s disease
subjective complaints is not sufficient to evaluate the                        and healthy controls. J Clin Exp Gerontol 14:17–31, 1992
                                                                         15.   Finestone HM, Greene-Finestone LS, Wilson ES, Teasell RW:
clinical course.
                                                                               Malnutrition in stroke patients on the rehabilitation service and
Acknowledgments. This study was supported by the Swedish National              at follow-up: prevalence and predictors. Arch Phys Med Rehabil
Board of Health and Welfare and the Medical Faculty of Lund Uni-               76:310–316, 1995
versity.                                                                 16.   Logemann J, Kahrilas P: Relearning to swallow after stroke—
                                                                               application of maneuvers and indirect biofeedback: a case study.
                                                                               Neurology 40:1136–1138, 1990
                                                                         17.   Nilsson H, Ekberg O, Olsson R, Hindfelt B: Dysphagia in
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