Electrical Stimulation Improves Swallowing After Stroke

Daniel M. Keller, PhD

October 28, 2014

ISTANBUL, Turkey — Electrical pharyngeal stimulation (EPS) can help accelerate the rehabilitation of swallowing after a stroke, meta-analysis of three small randomized trials shows.

Researchers led by Polly Scutt of the Stroke Trials Unit at the University of Nottingham, United Kingdom, found that dysphagic patients who underwent EPS had less clinical and radiologic evidence of dysphagia and possibly a shorter hospital length of stay compared with patients who had sham treatments.

Dysphagia is common after stroke and leads to poor outcomes, often from aspiration pneumonia. Their findings were presented here at the 9th World Stroke Congress (WSC).

For the meta-analysis, the researchers electronically searched the Cochrane Library, PubMed, and reference lists of included publications. They included completed randomized controlled trials that compared EPS to no EPS within 3 months of a stroke.

They identified three completed trials (one unpublished) with a total of 66 patients, who had a mean age of 72 years, a mean National Institutes of Health Stroke Scale score of 10.2, a mean dysphagia severity rating scale (DSRS) score of 7.2 (out of 12), and a cumulative penetration aspiration scale (PAS) median score of 26 (out of 48).

At baseline, the patients randomly assigned to EPS were in worse shape, with higher DSRS, cumulative PAS, and modified Rankin Scale scores than patients not receiving EPS. PAS scores were determined by using videofluoroscopy.

Compared with sham treatment at 2 weeks after stroke, EPS therapy was associated with a lower cumulative PAS score and less unsafe swallowing. There was a trend toward a shorter length of hospital stay with EPS (47.4 vs 72 days; P = .081). As one would expect, the use of EPS did not affect the modified Rankin Scale score because the score does not include a measure of dysphagia.

For those having a penetration aspiration score greater than 3, EPS treatment was associated with an odds ratio of 0.13; for a DSRS score greater than 3, the odds ratio was 0.2.

The researchers reported that in an analysis of prespecified subgroups, EPS had the greatest effect on the penetration aspiration scale score for patients with more dysphagia (DSRS > 7) and for patients with intracerebral hemorrhage (P = .001).

Table. Dysphagia Outcome at 2 Weeks by Treatment

Outcome EPS No EPS P Value
Cumulative PAS scorea 20 (10.2) 24.81 (10.13) .01
PAS scores >3 (%)b 1 (1, 4) 4 (1, 5) .001
DSRS scorea 3.73 (3.83) 4.88 (4.16) .089
DSRS scores >3 (%)a 10 (33.33) 15 (57.69) .024

aMean (standard deviation).

bMedian (interquartile range).

 

Didier Leys, MD, PhD, professor of neurology at the University of Lille, France, commented to Medscape Medical News that the study is of major interest "because one of the reasons why patients die in the acute stage of stroke, especially after 2 or 3 weeks, is pneumonia, and pneumonia is usually the consequence of poststroke dysphagia at the acute stage."

He said that good stroke care can prevent some of these problems, but even in good stroke units, some cases of pneumonia still occur.

Although the 3 trials included in the meta-analysis were small, Dr Leys noted, "they were randomized, and they suggest less clinical and radiological evidence of dysphagia in patients treated and also a shorter hospital length of stay, which means probably less pneumonia" because of shorter exposure to the hospital environment.

He said this trial in itself does not confirm EPS as a treatment for poststroke dysphagia, but it supports performing a larger study of the modality. The stimulation can be done by using a nasopharyngeal tube, which, judging by distance of insertion, can be placed precisely in the area of interest in the pharynx.

The study was not commercially funded. Ms Scutt and Dr Leys have disclosed no relevant financial relationships.

9th World Stroke Congress (WSC). Abstract #39. Presented October 23, 2014.

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