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NEW Delivery Of Stroke Rehabilitation to Optimize Functional Recovery
NEW Delivery Of Stroke Rehabilitation to Optimize Functional Recovery

6. Swallowing (Dysphagia), Nutrition and Oral Care

Recommendations and/or Clinical Considerations
6.1 Swallowing (Dysphagia) and Feeding
  1. Screening for swallowing impairment in individuals with stroke is recommended before any oral intake (e.g. medications, food, liquid) by an appropriately trained health professional, using a valid screening tool [Strong recommendation; High quality of evidence]. 
  2. Referral to a trained dysphagia professional is recommended when the initial swallowing screen has failed to prompt further comprehensive assessments and a plan for interventions to address swallowing, feeding, nutrition and hydration [Strong recommendation; High quality of evidence].
    1. An individualized management plan should be developed to address therapy for dysphagia, dietary needs, and specialized nutrition plans [Strong recommendation; Low quality of evidence].
  3. Instrumental swallowing assessments including video fluoroscopic swallow study (VFSS) or fiberoptic endoscopic examination of swallowing (FEES), should be considered for individuals with stroke who have (oro)pharyngeal dysphagia or suspected poor airway protection, identified during the bedside swallowing assessment, to guide therapeutic intervention [Strong recommendation; Low quality of evidence].  
  4. Dysphagia therapy to optimize the efficiency and safety of the oropharyngeal swallow should be implemented with monitoring and reassessment as required [Strong recommendation; Low quality of evidence]. 
    1. Behavioural interventions (such as oropharyngeal exercises) are recommended [Strong recommendation; Moderate quality of evidence]. 
    2. Modified food and/or fluid consistency to address swallowing difficulty and feeding efficiency should be provided [Strong recommendation; Moderate quality of evidence]. 
    3. Electrical stimulation (particularly pharyngeal placement) may be considered as an adjunct to improve dysphagia [Strong recommendation; Low quality of evidence]. 
  5. Enteral nutrition support (i.e., tube feeding) is recommended for individuals with stroke who cannot safely swallow or meet their nutrient and fluid needs orally [Strong recommendation; High quality of evidence]. 
    1. The decision to proceed with enteral nutrition support should be made as early as possible after admission, usually within the first three to seven days after admission in collaboration with the individual with stroke, family (or substitute decision maker), and the interdisciplinary team [Strong recommendation; Low quality of evidence].
    2. A Percutaneous Endoscopic Gastrostomy (PEG) tube is recommended for enteral feeding if the individual with stroke requires a prolonged period of enteral nutrition (i.e. 4 weeks or longer) to reduce the risk of treatment failure and feeding interruption [Strong recommendation; High quality of evidence]. 
  6. Individuals with stroke, their family and caregivers should receive interdisciplinary education on swallowing, prevention of aspiration, and feeding recommendations [Strong recommendation; Moderate quality of evidence].

Section 6.1 Clinical Considerations

  1. To reduce the risk of aspiration pneumonia, individuals with stroke should be permitted and encouraged to contribute to feeding themselves whenever possible (e.g., hand-over-hand assistance).
  2. To reduce the risk of choking and aspiration pneumonia, individuals with stroke should be appropriately positioned while eating or receiving enteral nutrition.
  3. Non-invasive brain stimulation may be considered as an adjunct treatment to train muscles for post-stroke dysphagia. Note these interventions are not yet available/approved for use in Canada.
6.2 Nutrition and Hydration
  1. Individuals with stroke should be screened for malnutrition and dehydration within 24-48 hours of inpatient admission using a valid screening tool [Strong recommendation; Low quality of evidence]. 
    1. Routine and repeated screening for nutritional and hydration status is recommended while supporting individuals with stroke during inpatient admission and after discharge to the community [Strong recommendation; Low quality of evidence]. 
  2. Referral to a dietitian is recommended for individuals with stroke who fail screening or have nutritional concerns, hydration deficits, or other co-morbidities that may require nutritional intervention [Strong recommendation; High quality of evidence].  
    1. Meet nutritional and fluid needs through enteral and/or oral routes while supporting recommendations for food texture and fluid consistency [Strong recommendation, Moderate quality of evidence].
  3. Nutritional supplementation should be considered in individuals with stroke who are experiencing malnutrition [Strong recommendation; Moderate quality of evidence].
6.3 Oral Health
  1. Active oral hygiene interventions (e.g., brushing, oral rinse) are recommended at least twice daily to maintain oral health in individuals with stroke, especially if dysphagia is present [Strong recommendation; Moderate quality of evidence].  
  2. Individuals with stroke, their family and caregivers should receive interdisciplinary education and training in safe and proper oral care [Strong recommendation; Low quality of evidence].
  3. Referrals should be made to appropriate healthcare professionals with expertise in oral health as needed [Strong recommendation; Low quality of evidence].
Rationale +-

Dysphagia is a common complication following a stroke that can significantly impact an individual’s quality of life and nutritional intake. This condition arises due to impaired muscle control in the throat and mouth, leading to difficulties with swallowing food, liquids, or medications. As a result, individuals with dysphagia face an increased risk of aspiration pneumonia, malnutrition, and dehydration. The challenges posed by dysphagia can also lead to social isolation and psychological distress, as mealtime often becomes a stressful experience. The published estimates of the incidence of stroke-related dysphagia vary widely from 19% to 65% in the acute stage of stroke, depending on the lesion location, timing and selection of assessment methods.164

Individuals with stroke emphasize the importance of education and training for individuals with stroke and caregivers relating to the potential risks of dysphagia, such as aspiration, as well as information on dysphagia management. They highlight the importance of screening and assessment for dysphagia following stroke and advocate that screening for dysphagia should occur across the continuum of stroke care. Individuals with stroke also value education on topics such as healthy eating as well as oral health, to support their stroke recovery.

Performance Measures +-

System Indicators

  1. Presence of a dysphagia program for all inpatient stroke rehabilitation units.
  2. Access to dysphagia education programs for staff, individuals with stroke and their families.
  3. Proportion of individuals experiencing dysphagia following an acute stroke.

Process Indicators

  1. Proportion of individuals with acute stroke screened with a standardized screening tool for dysphagia on same day of hospital arrival (Accreditation Canada).
  2. Proportion of individuals with stroke who fail an initial dysphagia screening who then receive a comprehensive assessment by a speech–language pathologist, occupational therapist, dietitian, or other appropriately trained healthcare professional.
  3. Median time in minutes from patient arrival in the emergency department to initial swallowing screening by a trained clinician.
  4. Proportion of individuals with stroke who have their dysphagia status reassessed during stroke rehabilitation.

Patient-Oriented Indicators

  1. Incidence of malnutrition among individuals with stroke admitted to inpatient care for stroke which leads to delays in discharge.
  2. Proportion of individuals with acute stroke and dysphagia who experience post stoke complications such as pneumonia.
  3. Changes in quality of life for individuals with stroke and dysphagia measured at regular intervals during recovery and participation, and reassessed when changes in health status or other life events occur (e.g., at 60, 90- and 180-days following stroke).
Implementation Resources and Knowledge Transfer Tools +-

Resources and tools listed below that are external to Heart & Stroke and the Canadian Stroke Best Practice Recommendations may be useful resources for stroke care. However, their inclusion is not an actual or implied endorsement by the Canadian Stroke Best Practices team or Heart & Stroke. The reader is encouraged to review these resources and tools critically and implement them into practice at their discretion.

Health Care Provider Information

Resources for Individuals with Stroke, Families and Caregivers 

Summary of the Evidence +-

Evidence Table and Reference List 6a

Evidence Table and Reference List 6b

Dysphagia

The implementation of a standardized program for bedside screening is thought to decrease the incidence of dysphagia-related pneumonia. Components may include those related to a patient’s level of consciousness, an evaluation of oral motor function and oral sensation, as well as the presence of a cough. It may also include trials of small sips of water, whereby a “wet” or hoarse voice are suggestive of an abnormal swallow. While a variety of dysphagia screening tools are currently in use, it is unclear which one performs best. To further knowledge in this area, in a Cochrane review, Boaden et al. 165 evaluated the test characteristics of 37 different screening tools of which 24 used only a water test, 6 used a combination of water and other liquid consistencies, and 7 used other methods. When compared against gold standards (which varied across studies), the best performing swallow screening tools were, the combined water swallow tests and Oxygen Saturation Test, Gugging Swallowing Screen (GUSS),166 and Toronto Bedside Swallowing Screening Test (TOR-BSST). 167 Screening tools that used a combination of water and other consistencies as testing materials were more accurate than screening tests that used only water. Nevertheless, the authors concluded that they were unable to identify a single screening tool with high, and precisely estimated sensitivity and specificity due to lack of high-quality studies.

Sherman et al. 168 included the results from 30 studies, of which 6 were RCTs, including patients with swallowing problems following stroke. The outcomes of patients who received no screening vs. screening, were compared. Among the studies in which a previously validated screening tool was used, the Acute Screening of Swallow in Stroke/TIA 169 was used most frequently (n=6), followed by the GUSS166 (n=4), and the Three-Step Swallowing Screen protocol 170,171 and the MetroHealth Dysphagia Screen, 172 which were used in one study each. Overall, dysphagia screening was associated with reduced odds of pneumonia (OR=0.57, 95% CI, 0.45–0.72), mortality (OR=0.52, 95% CI 95% CI, 0.35–0.77), dependency (OR=0.54, 95% CI, 0.35-0.85) and reduced length of hospital length of stay (SMD= −0.62 days, 95% CI, −1.05 to −0.20).

While texture-modified diets, the use of restorative swallowing therapy, and compensatory techniques, are the most commonly used treatments for the management of dysphagia in patients who are still safe to continue oral intake, there is little direct evidence of their benefit. The effectiveness of a variety of treatments for dysphagia and nutritional management was evaluated in a Cochrane review. 173 Dysphagia treatments examined in 41 RCTs included acupuncture, behavioural interventions, drug therapy, neuromuscular electrical stimulation, pharyngeal electrical stimulation, physical stimulation (thermal, tactile), transcranial direct current stimulation, and transcranial magnetic stimulation. Overall, there was no reduction in the odds of death or disability or case fatality at the end of the trial associated with dysphagia therapies. While swallowing therapy significantly reduced the proportion of participants with dysphagia at the end of the trial, reduced the risk of chest infections or pneumonia, and was associated with a mean reduction in hospital length of stay or almost 3 days, the authors cautioned that further high-quality trials are required before clinical decisions can be made about what treatments are effective. Another systematic review including the results of 22 RCTs of patients in acute or critical care settings with dysphagia. 174 Interventions included non-invasive electrical brain stimulation (transcranial electrical stimulation or transcranial magnetic stimulation), pharyngeal electrical stimulation, neuromuscular electrical stimulation, acupuncture, behavioral therapy, chin tuck, respiratory muscle strength training, tongue palate resistance training, and effortful swallow training and traditional swallowing exercises. While swallowing therapy was not associated with a significantly decreased risk of aspiration (RR=0.79, 95% CI 0.44 to 1.45), it was associated with a decreased risk of pneumonia (RR=0.71, 95% CI 0.56 to 0.89).

Surface Neuromuscular electrical stimulation (NMES) using devices such as VitalStim has been used in the rehabilitation of swallowing function in patients with stroke-associated dysphagia.  While this treatment is popular in the United States and other countries, it is not widely used in Canada, and the evidence supporting its use is conflicting. Tarihci Cakmak et al. 175 randomized 34 patients with dysphagia an average of 50 weeks post stroke to receive traditional dysphagia therapy + NMES with the VitalStim device (45 minutes/session x 5 days/week x 3 weeks) or dysphagia therapy only. The stimulation intensity level started at 2 mA, increased by 0.5 mA intervals, and stabilized when the patient felt vibration in the patient’s neck. From baseline to end of follow-up at three months, there were significant improvements within both groups in mean scores for all outcomes (Functional Oral Intake Scale [FOIS], Eating Assessment Tool (EAT-10), the Swallowing Quality of Life Questionnaire (SWAL-QOL), and voice-related quality of life questionnaire, with no between group differences. Carnaby et al.176 recruited 57 patients with post-stroke dysphagia from a stroke rehabilitation unit. Patients were randomized to receive usual care, which included behavioral swallowing therapy for 1 hour/day for 3 weeks, or until hospital discharge, or McNeill Dysphagia Therapy (MDTP) swallowing therapy in addition to active NMES with the VitalStim device or MDTP + sham NMES. Post intervention, there was significantly greater improvement in mean Mann Assessment of Swallowing Ability (MASA) and (FOIS) scores in the MDTP group + sham stimulation compared with the other two groups. At 3 months, in adjusted analysis, compared with usual care, MDTP + sham NMES was associated with a significantly greater likelihood of return to normal diet (hazard ratio [HR]=4.32, 95% CI 1.08-17.2). Park et al. 177 reported significantly greater improvement in swallowing ability following 6 weeks of active treatment with the VitalStim device among 61 stroke rehabilitation patients. At the end of treatment, patients who received active NMES had greater improvement in Videofluoroscopy Dysphagia Scale and Penetration–Aspiration Scale scores, compared with those who received sham treatment. A systematic review authored by Chen et al. 178 included the results for 8 RCTs examining NMES and reported that active treatment was associated with significantly better swallowing function scores at the end of the treatment period (SMD=1.27 (95% CI 0.51-2.02).

For patients who cannot obtain their nutrient and fluid needs orally, enteral nutrition may be required. Results from the largest trial of its kind indicate that there is little difference in outcome between routes of enteral feeding. The Feed or Ordinary Diet (FOOD) trial 179 also addressed the issues of timing of initiation of enteral feeding. The FOOD trial included 1,210 patients admitted within 7 days of stroke from 47 hospitals in 11 countries. In one arm of the trial, patients were randomized to receive either a percutaneous endoscopic gastrostomy (PEG) or nasogastric (NG) feeding tube within 3 days of enrolment into the study. PEG feeding was associated with a non-significant absolute increase in risk of death of 1.0% (–10.0 to 11.9, p=0.9) and a borderline increased risk of death or poor outcome of 7.8% (0.0 to 15.5, p=0.05) at 6 months. In the second part of the trial, patients were randomized to receive enteral feeds as early as possible or to avoid feeding for 7 days. Early tube feeding was associated with non-significant absolute reductions in the risk of death or poor outcome (1.2%, 95% CI -4.2 to 6.6, p=0.7) and death (15.8%, 95% CI -0.8 to 12.5, p=0.09) at 6 months. A Cochrane review 180 comparing NG and PEG feeding tubes also reported few differences between feeding tube types. The review was composed of 11 RCTs including 735 adults with dysphagia, of whom 462 were recovering from stroke. PEG tubes were associated with significantly reduced odds of treatment failures (blocked tubes or disruptions in feeding schedule), but there was no significant difference between groups in mortality, aspiration-related pneumonia or adverse events.

Nutrition

Oral supplementation can be used for patients who are not able to consume sufficient energy and protein to maintain body weight, or for those with premorbid malnutrition. This topic has been explored more extensively in the geriatric population of individuals hospitalized for medical issues. In the Nutrition effect On Unplanned Readmissions and Survival in Hospitalized patients (NOURISH) trial, Deutz et al. 181 randomized 652 malnourished patients, recruited from 78 sites in the United States who were recently hospitalized to receive standard nutritional care + an oral supplement providing an 350 kcal, 20 g protein,  11 g fat, 44 g carbohydrate, and 1.5 g calcium-beta-hydroxy-methylbutyrate (HMB) twice daily or a placebo drink that contained 48 kcal, 12 g carbohydrate, and 10 mg vitamin C during their hospital stay and continuing up to 90 days following discharge. A significantly higher percentage of patients were classified as well-nourished at 90 days (category A, using Subjective Global Assessment) in the oral supplementation group (45.5% vs. 30.0%). For the primary outcome, a composite of death or nonelective readmission within 90 days post discharge, there was no significant difference between the groups (26.8% vs. 31.1%), nor was there a difference in the proportion of patients readmitted after 90 days (25.2% vs. 25.6%); however, mortality was lower in the oral supplementation group (4.8% vs. 9.7%, p=0.018). In a larger RCT, a similar finding was reported. The Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT), recruited 2,088 patients from 8 hospitals in Switzerland with a medical condition, a Nutrition Risk Score-2002 ≥3, who were able to consume food orally, and had an anticipated hospital stay of >4 days. 182 Patients were randomized to receive either individualized nutritional support (intervention group), or standard hospital food (control group). Patients in the intervention group received supplements and enteral feeding, as well as a prescription for oral nutritional supplements at discharge, as required. The primary (composite) outcome was all-cause mortality, admission to the intensive care unit from the medical ward, non-elective hospital readmission after discharge, major complications as a new occurrence or a decline in functional status of ≥ 10% from admission to day 30, measured by the Barthel Index. At 30 days, the risk of primary outcome was significantly lower in the intervention group (23% vs. 27%, adjusted odds ratio [OR]=0.79, 95% CI 0.64 to 0.97). Among the components of the primary outcome, mortality was significantly lower in the intervention group (7% vs. 10%, OR=0.65, 95% CI 0.47 to 0.91) as were the odds of functional decline (4% vs. 6%, OR=0.62, 95% CI 0.40 to 0.96).

The results of trials focused on stroke exclusively are less impressive. In the largest trial of its kind, the FOOD trial, reported that routine supplementation with an additional 540 Kcal/day for all patients, regardless of premorbid nutritional status, did not help to improve global outcomes. 183 In this trial, 4,023 patients were randomized to receive or not receive an oral nutritional supplement in addition to a regular hospital diet, provided for the duration of their entire hospital stay. At 6-month follow-up, there was no significant difference between groups on the primary outcome, death or poor outcome (OR=1.03, 95% CI 0.91 to 1.17), which was comparable with a 1% to 2% absolute benefit or harm from oral supplements. However, in this trial, only 8% of patients were malnourished at baseline, which may have contributed to the null finding. In a recent Cochrane review, 184 the focus was protein and energy supplementation. Although 52 RCTs were included, evaluating a broad range of interventions (protein and energy supplementation, enteral feeding, parenteral supplements, parenteral or enteral supplements, and oral and parenteral supplements) under the umbrella term of nutritional therapies, only data from one to two trials were available for the primary outcomes. Oral supplementation was not associated with a reduction in the odds of disability, defined as an mRS score of 0-2, at 6 months (OR=0.97, 95% CI 0.86 to 1.10; 1 trial [FOOD trial]: GRADE: low), or in the performance of activities of daily living, assessed using the Functional Independence Measure motor subscale, at 3.5 to 8 weeks follow-up (MD= 8.74, 95% CI 5.93 to 11.54, 2 studies; GRADE: very low).

Oral Care

Physical weakness following stroke may prevent patients from independently completing their ADLs, including oral care. Poor oral care, combined with potential side effects of medication (e.g., dry mouth, oral ulcers, stomatitis), may contribute to greater amounts of bacteria in the mouth, leading to an increased risk of pneumonia. Therefore, on admission to hospital, all patients should have an oral/dental assessment to examine mastication, tooth wear, oral disease, and use of appliances following stroke. However, few studies have examined interventions to improve oral hygiene in patients following stroke. A Cochrane review conducted by Campbell et al. 185 included the results of 15 RCTs (n=1,546) that included patients receiving some form of assisted oral healthcare in a healthcare facility following stroke. Trials evaluated interventions designed to improve the cleanliness and health of the mouth, tongue and teeth (e.g., toothbrush, toothpaste, mouth gel, mouthwash, tongue cleaners, lip balm), care protocols led by healthcare staff or informal carers, combinations of education and training, selective decontamination of the digestive tract, and povidone-iodine rinses. Pooling of results was difficult due to the wide variation in treatment contrasts. Oral health care (OHC) interventions were associated with a significant reduction in denture plaque (MD=-1.31, 95% CI -1.96 to -0.66), and improvement in staff/patient OHC knowledge one month after the intervention was delivered (MD=0.70, 95% CI 0.06 to 1.35), when compared with usual care although the results from only a single small trial were included.

Sex & Gender Considerations

No literature was identified that discussed potential sex or gender differences on the topics of screening or treatment for dysphagia, nutrition or oral health, post stroke.

Stroke Resources
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