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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.
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.
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 . 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 . 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 . Different therapeutic strategies have been intro- duced to improve swallowing impairment . 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 Symptoms 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. Type 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 . 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 . 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  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 . 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 . 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- ment. conditions. 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- . ments, and environmental conditions, e.g., meal situation A high proportion of the patients, between 50% . 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 . 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 . 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 References stroke: a prospective study of quantitative aspects of swallowing in dysphagic patients. Dysphagia 13:32–38, 1998 1. Barer DH: The natural history and functional consequences of 18. Groher M, Bukatman R: The prevalence of swallowing disor- dysphagia after hemispheric stroke. J Neurol 52:236–241, 1989 ders in two teaching hospitals. Dysphagia 1:3–6, 1986 2. Gordon C, Hewer RL, Wade DT: Dysphagia and stroke. BMJ 295:411–414, 1987 19. Kidd D, Lawson J, Nesbitt R, MacMahon J: The natural history 3. Veis S, Logemann J: Swallowing disorders in persons with ce- and clinical consequences of aspiration in acute stroke. QJM rebrovascular accidents. Arch Phys Med Rehabil 66:373–374, 6:409–413, 1995 1985 20. Schmidt J, Holas M, Halvorson K, Reding M: Videofluoro- 4. Teasell R, Bach D, McRae M: Prevalence and recovery of as- scopic evidence of aspiration predicts pneumonia and death but piration poststroke. A retrospective analysis. Dysphagia not dehydration following stroke. Dysphagia 9:7–11, 1994 9:35–39, 1994 21. Elmståhl S, Blabolil V, Fex G, Kuller R, Steen B: Hospital 5. Smithard DG, O’Neill PA, Parks C, Morris J: Complications and nutrition in geriatric long-term care medicine I. Effects of a outcome after acute stroke. Does dysphagia matter? Stroke changed meal environment. Compr Gerontol 1A:29–33, 1987 27:1200–1204, 1996 22. Perlman AL, Luschei ES, Dumond CE: Electrical activity in the 6. Cederholm T: Protein-energy malnutrition in chronic disease. superior pharyngeal constrictor muscle during reflexive and Clinical and immunological studies in elderly subjects with non- non-reflexive tasks. J Speech Hear Res 32:749–754, 1989
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