Effectiveness of swallow therapy on swallowing ability among patients with cerebrovascular accident

Parimala, Kalpana V, Maheshwari R. Effectiveness of Swallow Therapy on Swallowing Ability among Patients with Cerebrovascular Accident. Cardiometry; Issue 23; August 2022; p. 148153; DOI: 10.18137/cardiometry.2022.23.148153; Available from:

The central nervous system consisting of brain and spinal cord is a highly specialized system responsible for the control and integration of the body’s entire activities. Brain controls most of the voluntary and involuntary activities of the human body. The major problem of cerebrovascular accident is the paralysis of swallowing muscles leading to swallowing difficulty which is known as dysphagia[1]. Approximately 90% of CVAs were attributed to 10 risk factors that are preventable (hypertension, regular physical inactivity, high apolipoprotein B/A1 ratio, insufficient diet quality, increased waist/hip ratio, psychosocial factors, current smoking, cardiac causes, heavy alcohol consumption, and diabetes mellitus[2].

Stroke is being observed as a rapidly growing problem and an important cause of illness and death in Saudi Arabia. Therefore, it becomes one of the most imperative social and economic medical issues in the Kingdom [3]. A study conducted prospective clinical phase II study on Efficacy of a novel swallowing exercise program for chronic dysphagia in long-term head and neck cancer survivors. Result showed that feasibility in terms of the program completion rate was 88%. Compliance with the exercises was 97%. After the training, chin tuck, jaw opening, and anterior tongue strength had substantially improved [4].

A study conducted by identified oropharyngeal dysphagia prevailing in 56% of CVA patients were selected. These interventions were instructing patients to swallow thick and consistent food items, which are difficult to transfer from the oral cavity. Even though these interventions are very advantageous in safe swallowing for people with dysphagia, there are newer approaches with different types of exercises to improve and enhance swallowing function[5]. A study conducted in America to see the effects of thermal stimulation and chemical stimulation on liquid swallow in healthy and stroke population It was concluded that combined thermal and chemical stimulation alters swallow mechanism behaviour in healthy as well as stroke population [6]. Efficacy of combined thermal stimulation and electrical stimulation is also documented by another study [7].

A cross-sectional study conducted to establish the prevalence and prognosis of cerebrovascular accidents and its subtypes in Lahore, Pakistan. Data were collected on all patients who experienced CVAs. Out of 215 patients 63.7% were male and 36.3% were female. This highlights the need for early diagnosis, better risk stratification, and preparedness for need for complex long-term care in this vulnerable population [8].

A study conducted to determine the types of stroke and presenting clinical features and modifiable and non- modifiable risk factors associated with development of stroke. Total 110 cases presenting with stroke were included in the study. The study shows that ischemic stroke is commoner than haemorrhagicstroke. The study concluded that the modifiable risk factors pose a huge burden by increasing the morbidity and mortality due to stroke. Proper control of these risk factors can reduce the burden of disease [9].

A study conducted to assess the clinical profile, risk factors and the prognosis of cerebrovascular accident with reference to the risk factors in 100 patients presented with cerebrovascular accident. Study protocol included detailed clinical history, clinical examination and investigations. Ischemic stroke was more common than haemorrhagic stroke and haemorrhagic stroke was associated with poor prognosis. Some of these risk factors can be modifiable by changing lifestyle, people who are prone for cerebrovascular accident need to be screened, counselled and treated .A more extensive prospective case control study in future is required on cerebrovascular accidents in rural population [10].

A study conducted to describe the population and to assess baseline knowledge of stroke type, risk factors, and family history, among others. A retrospective chart review of 253 stroke patients admitted to the University of Puerto Rico Hospital during the fiscal year July 2002 to June 2003 was done. A standardized data collection form was used to obtain the following information from patient records. The prevalence of ischemic strokes outnumbered by far the occurrence of haemorrhagic strokes in the study group. Both men and women demonstrated an increasing tendency of stroke incidence with increasing age. Among death outcome, a difference was evident in the > 65 age group, showing an increase in women fatality com- pared to men. Hypertension was the most prevalent risk factor [11].

A study conducted to determine an effectiveness of conventional swallowing therapy in acute stroke patients with dysphagia. The researchers retrospectively reviewed data from medical records of acute stroke patients with dysphagia who participated a swallowing therapy. Fifty-seven acute stroke patients with dysphagia (26 males and 31 females) were participating in a conventional swallowing therapy (50 minutes a day for 3 days per week). A functional oral intake scale (FOIS) and swallow function scoring system (SFSS) were used to determine an effectiveness of the swallowing therapy. Forty-two percent of patients with tube dependent change to total oral intake. The study concluded that Conventional swallowing therapy is an effective treatment in acute stroke with dysphagia [12].

A study was conducted an update of a 2012 Cochrane review and assesses the effects of swallowing therapy on post stroke dysphagia within 6 months of onset. The researcher assessed the efficacy of swallowing therapy overall for the main outcomes and effects by type of intervention. Subgroup analyses suggested that acupuncture, drug therapy, repetitive transcranial magnetic stimulation, and behavioural interventions may have had beneficial effects on some outcomes[13].

A study conducted to explore the better treatment option among thermal stimulation, swallow maneuvers and the combination of both options for treatment of patients with dysphagia. Three groups A, B and C were made, patients were taken through purposive sample technique and groups were allocated using dice roll method. Group A received thermal stimulation, B group had swallowing maneuvers and group C is given the combination of both. Outcomes were measured through the Function Outcome Swallowing Scale (FOSS). Data was collected from tertiary care units in Lahore and analysed by SPSS 16. More beneficial results are seen in the C group, which was given the combination of swallow maneuvers and thermal stimulation. The study concluded that on the basis of results is concluded that combination of thermal stimulation and swallowmaneuvers are significantly more fruitful for the treatment of dysphagia [14].

A study conducted to evaluate the state of tongue pressure production during supraglottic swallow (SS) and super-supraglottic swallow (SSS) performed by healthy adults, and to investigate the effects of these swallowing maneuvers on the oral stage of swallowing.

The participants were 19 healthy individuals. Tongue pressure against the hard palate during swallowing was measured using a tongue pressure sensor sheet system with five pressure-sensitive points. The tasks comprised swallowing 5 mL of water by normal wet swallow, SS, and SSS, and the parameters for analysis were the duration, the maximal magnitude, and the integrated value of tongue pressure during swallowing. The duration of tongue pressure was significantly longer at the anterior-median part of the hard palate during both SS and SSS than with normal wet swallow. These results show that these two swallowing maneuvers, which are known primarily as techniques to protect the airway, also function to strengthen the tongue pressure produced by the contact between the tongue and the hard palate during swallowing and this effect is more pronounced during SSS [15]. The objectives of the study is to assess the swallowing ability before and after swallow therapy among patient with cerebrovascular accident, effectiveness of swallow therapy on swallowing ability among patients with cerebro vascular accident, to find out the association between the pre-test level of swallowing ability among patients with cerebrovascular accident with selected demographic variables.

MATERIALS AND METHODOLOGY

A evaluative research approach was conducted at the saveetha medical college and hospital using quasi experimental one group pre-test-post-test design. A purposive sampling technique was used to select 30 sample. The purpose of the study was to assess the effectiveness of swallow therapy on swallowing ability among cerebro vascular patients at saveetha medical college and hospital. The data was carried out with the prior permission of the principal, Saveetha College of nursing and from the chief medical officer and nursing superintendent, saveetha medical college and hospital. 30 samples with swallowing ability who fulfilled the inclusion criteria were selected as samples for the study. The patient’s baseline data necessary for the study was collected from the patient, family members and records. A mini mental status examination was done on the first day of data collection to assess the level of consciousness of the patient. Demographic data was collected from each sample followed by the assessment of severity of swallowing inability using the Mann Assessment of Swallowing Ability. After the pre-test, Swallow therapy was administered which in- 150 | Cardiometry | Issue 23. August 2022

cludes the swallowing exercises was then administered to the patients. The exercises were Shaker exercise, Hyoid Lift Maneuver, Effortful swallow, Supraglottic swallow, and Super Supraglottic swallow and tongue exercises. Followed by the exercise the samples were provided with feeding and checked for aspiration. Ongoing post assessment was done using the same tool. The data collected were organized for data analysis and interpretation. Both descriptive statistics and inferential statistics were used for analysing the data. Frequency and percentage distribution was used to analyse the baseline details of the patients with cerebro vascular accident. Mean and standard deviation was used to analyse the baseline details of the patients with cerebro vascular accident. Paired‘t’ test was used to compare the pre-test and post-test level of swallowing ability among patients with cerebro vascular accident. Chi-square test was used to associate the post-test level of swallowing ability among patients with cerebro vascular accident with selected demographic variables.

RESULTS AND DISCUSSION

SECTION A: DESCRIPTION

OF THE DEMOGRAPHIC VARIABLES OF PATIENTS WITH CEREBRO VASCULAR ACCIDENT

The major findings of this study shows that most of the patients with cerebrovascular accident, 18(60%) were aged between 40–60 years, 20(66.7%) were male, 19(63.3%) had primary education, 21(70%) had duration of symptoms of dysphagia for 4–8 days, 22(73.3%) had impaired cognitive status and 17(56.7%) had brain stem stroke.

Hanan Omer, Wajid Hameed and Sara Saleem (2020) conducted a cross-sectional study to establish the prevalence and prognosis of cerebrovascular accidents and its subtypes in Lahore, Pakistan. Data were collected on all patients who experienced CVAs between December 2018–March 2019, used the diagnosis coding program in Services University, Lahore, Pakistan. Out of 215 patients 63.7% were male and 36.3% were female. The overall incidence of ischemic stroke after acute myocardial infarction was 85.26%. Hypertension, diabetes mellitus were shows as more risk factors for ischemic stroke type compared with haemorrhagic stroke, and embolic stroke. The overall status of stroke patients were shown 92.1% live and 7.9% were dead. Incidence of complicating hospital- izations with cerebrovascular accident continues to grow and is associated with increased mortality and adverse discharge. This highlights the need for early diagnosis, better risk stratification, and preparedness for need for complex long-term care in this vulnerable population.

SECTION B: ASSESSMENT OF LEVEL OF SWALLOWING ABILITY BEFORE AND AFTER SWALLOW THERAPY AMONG PATIENTS WITH CEREBROVASCULAR ACCIDENT.

Figure 1 shows the Percentage Distribution of level of swallowing therapy. The major findings of this study shows that before swallow therapy, 19(63.33%) had moderate level swallow disability, 8(26.67%) had mild level of swallow disability and 3(10%) had severe swallow disability .Whereas in the post test, 16(53.33%) had mild level of swallow therapy, 8(26.67%) had no abnormality detected and 6(20%) had moderate level of swallow therapy.

Figure 1. Percentage Distribution of level of swallowing therapy

Bayu Fandhi Achmad, Muhammad Zafrullah Arifin, Aan Nuraeni (2019) conducted a quasi-experimental research involving 16 respondents in the intervention group and 16 respondents in the control group who obtained through consecutive sampling techniques. Data was collected through observations using Gugging Swallowing Screen (GUSS) instruments. Data analysis used in this research was Wilcoxon test to determine the difference of swallowing therapy effect before and after intervention. Mann-Whitney test was also used to determine the difference of swallowing therapy effect between intervention group and control group after intervention. There was a differences of swallowing therapy effect between pre-test and post-test in the intervention group (p = 0.002). In addition, there was no differences between pre-test and post-test in the control group (p = 0.157). The study concluded that swallowing therapy have a positive effect against aspiration prevention in patients with dysphagia stroke, so it can be recommended as an acute care intervention in stroke patients at stroke unit.

SECTION C: EFFECTIVENESS OF SWALLOW THERAPY ONSWALLOWING ABILITY AMONG PATIENTS WITH CEREBROVASCU-LARACCIDENT

Table 1 shows Percentage distribution of pre-test and post-test of swallowing ability. The major findings of this study shows that the mean score of swallowing ability before swallow therapy was 155.0±16.34 and the mean score of swallowing ability after swallow therapy was 170.87±11.12. The calculated paired ‘t’ test value of t = 7.171 was found to be statistically highly significant at p< 0.001 level. This clearly infers that administration of swallow therapy among patients with cerebrovascular accident was found to be effective in improving the post-test level of swallowing ability among patients with cerebrovascular accident.

Table 1

Percentage distribution of pre-test and post-test of swallowing ability n=30

Swallowing Ability	Mean	S.D	Mean %	Mean Difference & %	Paired ‘t’ test Value
Pretest	155.0	16.34	77.5%	15.87 (7.9%)	t = 7.171 p = 0.0001 S***
Post Test	170.87	11.12	85.4%

***p<0.001, S – Significant

Sumera Nawaz Malik, et al., (2017) conductd a study to explore the better treatment option among thermal stimulation, swallow maneuvers and the combination of both options for treatment of patients with dysphagia. An experimental study was conducted to find the better treatment option among thermal stimulation and swallow maneuvers for treatment of the patients with dysphagia. Three groups A, B and C were made, patients were taken through purposive sample technique and groups were allocated using dice roll method. Group A received thermal stimulation, B group had swallowing maneuvers and group C is given the combination of both. Outcomes were measured through the Function Outcome Swallowing Scale (FOSS). Data was collected from Groups A, B and C are given thermal stimulation, swallow maneuvers and combination of both treatment options as a treatment option respectively. More beneficial results are seen in the C group, which was given the combination of swallow maneuvers and thermal stimulation. The study concluded that on the basis of results is concluded that combination of thermal stimulation and swallowmaneuvers are significantly more fruitful for the treatment of dysphagia.

SECTION D: ASSOCIATION

OF PRETEST LEVEL OF SWALLOWING ABILITY WITH SELECTED DEMOGRAPHIC VARIABLES

Table 2 shows Association level of swallowing ability of demographic variables. The major findings of this study shows that the demographic variables age in years, education and cognitive status had shown statistically significant association with pre-test level of swallowing ability among patients with cerebrovascular accident at p< 0.01, p< 0.05 and p< 0.001 level respectively. The other demographic variables had not shown statistically significant association with post-test level of swallowing ability among patients with cerebrovascular accident.

Hathaya Jongprasitkul and Wasuwat Kitisom-prayoonkul (2020) conducted a study on to determine an effectiveness of conventional swallowing therapy in acute stroke patients with dysphagia. The researchers retrospectively reviewed data from med- ical records of acute stroke patients with dysphagia who participated a swallowing therapy. Fifty-seven acute stroke patients with dysphagia (26 males and 31 females) were participating in a conventional swallowing therapy (50 minutes a day for 3 days per week). A functional oral intake scale (FOIS) and swallow function scoring system (SFSS) were used to determine an effectiveness of the swallowing therapy. FOIS and SFSS scores before the first therapy session and after the last therapy session were compared using a paired t-test. The findings revealed that the mean age of the patient was 69:5 ± 15:35 years. The period from stroke onset to the first swallowing therapy session was 7:5 ± 6:69 days. The number of therapy was 5:6 ± 2:83 sessions. Participants showed a significant improvement of the FOIS (mean score increased from 1.74 to 3.30 points, P = 0:001) and SFSS (mean score increased from 2.51 to 3.68 points, P = 0:001). Forty-two percent of patients with tube dependent change to total oral intake. The study concluded that Conventional swallowing therapy is an effective treatment in acute stroke with dysphagia.

CONCLUSION

The central nervous system consisting of brain and spinal cord is a highly specialized system responsible for the control and integration of the body’s entire activities. Brain controls most of the voluntary and involuntary activities of the human body. Any disturbance to the brain cells will alter the complete functioning of the human system. Among CVA patients, dysphagia is the most often reported and widespread symptom.

Table 2

Association level of swallowing ability of demographic variables.n = 30

Demographic Variables	Moderate (139 – 167)		Mild (168 – 177)		No abnormality detected (178 – 200)		Chi-Square Value
	No.	%	No.	%	No.	%
Age in years							χ2=11.481 d.f=2 p = 0.003 S**
40 – 60	0	0	10	33.3	8	26.7
60 – 80	4	13.3	8	26.7	0	0
Education							χ2=6.914 d.f=2 p = 0.032 S*
Primary	3	10.0	14	46.7	2	6.7
Diploma	1	3.3	4	13.3	6	20.0
Cognitive status							χ2=30.000 d.f=2 p = 0.0001 S***
Normal	0	0	0	0	8	26.7
Impaired	4	13.3	18	60.0	0	0
MCA infarct	1	3.3	8	26.7	4	13.3

***P<0.001, **p<0.01, *p<0.05, S – Significant, N.S – Not Significant

For many CVA patients, this poses a serious issue that lowers their quality of life. This study came to the conclusion that dysphagia exercises were a useful tool for patients who had trouble swallowing to increase their capacity to do so. These exercises are a straightforward solution that is simple to put into practise. This disturbance can lead to decreased blood supply to the brain and oxygen deprivation causing the damage of brain cells (Phipps, 2009). Swallowing problems can lead to life threatening infection in the lungs. One in 17 people will develop some form of swallowing problems in their lifetime. Swallowing problems are a common complaint among older individuals and the incidence is higher in patients who have had cerebrovascular accident.

ACKNOWLEDGEMENTS

We could like to extent our gratitude to the authorities of Saveetha College of nursing and saveetha medical college and hospital for this study.