Analysis of the Level of Dysphagia, Anxiety, and Nutritional Status Before and After Speech Therapy in Patients with Stroke

THIEME 172 Original Research Analysis of the Level of Dysphagia, Anxiety, and Nutritional Status Before and After Speech Therapy in Patients with Stroke Daniela Drozdz1 Renata Mancopes2 Ana Maria Toniolo Silva3 1 MSc, Human Communication Disorder, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil 2 PhD, Linguistics, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil 3 PhD, Human Communication Disorder, Universidade Federal de São Paulo, São Paulo, SP, Brazil 4 PhD, Universidade São Francisco, São Paulo, SP, Brazil Caroline Reppold4 Address for correspondence Daniela Drozdz, MSc, Pós Graduação em Distúrbios da Comunicação Humana, UFSM, Av Fernando Ferrari, 1220 ap 302 Av Fernando Ferrari, 1220 Santa Maria, RS 97050801, Brazil (e-mail: ). Int Arch Otorhinolaryngol 2014;18:172–177. Abstract Keywords ► swallowing disorders ► anxiety ► nutritional status ► rehabilitation Introduction: The rehabilitation in oropharyngeal dysphagia evidence-based implies the relationship between the interventions and their results. Objective: Analyze level of dysphagia, oral ingestion, anxiety levels and nutritional status of patients with stroke diagnosis, before and after speech therapy. Method: Clinical assessment of dysphagia partially using the Protocol of Risk Assessment for Dysphagia (PARD), applying the scale Functional Oral Intake Scale for Dysphagia in Stroke Patients (FOIS), Beck Anxiety Inventory (BAI) and the Mini Nutritional Assessment MNA®. The sample consisted of 12 patients, mean age of 64.6 years, with a medical diagnosis of hemorrhagic and ischemic stroke and without cognitive disorders. All tests were applied before and after speech therapy (15 sessions). Statistical analysis was performed using the chi-square test or Fisher’s exact test, McNemar’s test, Bowker’s symmetry test and Wilcoxon’s test. Results: During the pre-speech therapy assessments, 33.3% of patients had mild to moderate dysphagia, 88.2% did not receive food orally, 47.1% of the patients showed malnutrition and 35.3% of patients had mild anxiety level. After the therapy sessions, it was found that 33.3% of patients had mild dysphagia, 16.7% were malnourished and 50% of patients had minimal level of anxiety. Conclusion: There were statistically significant evolution of the level of dysphagia (p ¼ 0.017) and oral intake (p ¼ 0.003) post-speech therapy. Although not statistically significant, there was considerable progress in relation to the level of anxiety and nutritional status. Introduction Swallowing is a complex act that requires control and regulation at all levels of the nervous system. Changes in this process, such as incoordination or weakness of the biomechanics of this function, characterize dysphagia.1 received October 16, 2013 accepted November 18, 2013 DOI http://dx.doi.org/ 10.1055/s-0033-1364169. ISSN 1809-9777. One study found that between 42 and 67% of patients who are affected by stroke have dysphagia, making it the most common result in these cases. The diagnosis of oropharyngeal dysphagia is associated with laryngotracheal aspiration, which may result in pulmonary diseases, malnutrition, dehydration, and death.2–5 Among the already recognized consequences of Copyright © 2014 by Thieme Publicações Ltda, Rio de Janeiro, Brazil Speech Therapy in Patients after Stroke dysphagia, it is also necessary to note the possibility of psychological disorders related to emotional modifications that may generate changes in the swallowing process.6 With the improvement in the care and treatment of stroke, it is important that therapeutic work should not only be focused on the acute phase, because the next or chronic phase can last indefinitely, and its sequelae, such as oropharyngeal dysphagia, should receive the same attention. The treatment during the chronic phase aims to improve the performance of functional tasks and reintegrate the patient to their daily activities.7 It is currently necessary to identify, classify, and organize the goals and procedures of rehabilitation in the care of patients with oropharyngeal dysphagia, which would improve the speech therapy in the rehabilitation process.8 A recent study found that the literature lacks reports of the indicators resulting from dysphagia speech therapy in the hospital. The use of functionality scales, besides the possibility to manage the results of this study, allows comparison of results before and after speech therapy to analyze the effectiveness of treatment and possible actions to be improved.8 The aim of this study was to analyze the level of dysphagia, oral ingestion, anxiety, and nutritional status before and after speech therapy in the Hospital Universitário de Santa Maria (HUSM) in patients with stroke. Methods This quantitative cross-sectional study was conducted by collecting data of adult patients of both sexes admitted to the HUSM with neurogenic oropharyngeal dysphagia. This study was approved by the Ethics in Research Committee of the institution of origin under number 0196.0.243.000-11. Inclusion criteria specified adult patients of both sexes with neurogenic oropharyngeal dysphagia, stroke diagnosis, stable condition for the realization of the screening, plans to be admitted to hospital, and clinical signs of aspiration and/or complaints of dysphagia. Exclusion criteria specified having previously undergone speech therapy and having a diagnosis of mechanical dysphagia and craniofacial malformations. All patients were in acute phase and were evaluated about 8 days after admission. Initially, clinical assessment of swallowing in bed was performed by using partial Protocol of Risk Assessment for Dysphagia9 (testing only volumes of 3, 5, 10 and 20 mL) for the determination and classification of the diagnosis of oropharyngeal dysphagia. In this assessment, the patient sat upright in bed (90 degrees). Swallowing of water and pasty food was observed only in volumes of 3 and 5 mL. Larger volumes (10 and 20 mL) were used when necessary to facilitate the identification of signs suggestive of penetration/ aspiration and defining the conduct.10 The water was supplied with a glass, and the pasty food was offered with a spoon. The general appearance of the patient was analyzed, along with symmetry and posture and mobility and tone of the organs and muscles involved in chewing and swallowing (lips, teeth, jaw, palatoglossus muscle, palatopharyngeal muscle, and the posterior pharyngeal wall). The extra- and intraoral sensitivity was also observed. Presence or absence of gagging Drozdz et al. or coughing during and after swallowing, the labial sealing, the movement of the tongue, and the use of compensatory movements to propel the food bolus were observed. During the assessment, cervical auscultation was used to verify the presence or absence of noise before or after swallowing. Furthermore, as defined in the protocol, the oximeter was used to check the heart rate and oxygen saturation during swallowing. (...truncated)