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Post-CVA Dysphagia

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As many as 15 million Americans have dysphagia, and an estimated 51 percent to 73 percent of patients with cerebral vascular accident (CVA) experience dysphagia, according to the American Speech-Language Hearing Association (ASHA).1

Pneumonia is the third highest cause of death the first month after a stroke. Not all cases of post-CVA pneumonia are related to stroke, but it is very important to identify dysphagia in this group to prevent aspiration pneumonia.2

Although dysphagia can resolve itself within a few weeks, many patients continue to struggle with the disorder long after the CVA event. Undiagnosed cases can result in excess morbidity and mortality due to bronchopulmonary infections and malnutrition, making diagnosis and treatment high priorities.1

Improved outcomes of dysphagia treatment are associated with a multidisciplinary team approach that begins with early evaluation by a speech-language pathologist or occupational therapist.3 Traditional allopathic treatments include surgery, dietary modification, rehabilitative techniques and medications.

However, many patients and practitioners are interested in complementary and alternative medical practices (CAM). Even where allopathic treatments are the order of the day, it is good for practitioners to be informed of alternative therapies that relate to their profession because more people are utilizing them.

Although CAM treatments have enjoyed a long history, widespread interest in these therapies among allopathic users and practitioners is a recent phenomenon. Allopathic practitioners traditionally eschew alternative therapies because most interventions are based on a philosophical context instead of quantifiable, research-driven therapy.4 CAM providers may not be medically trained, therapies are not rigorously regulated, research is scant, and effectiveness and safety frequently are unproven.5

Yet, consumers report that CAM is attractive because it is less expensive, even though the person may have to pay out of pocket; addresses prevention instead of cure only; provides for more personal interaction with practitioners, as compared to allopathic professionals; has reduced side effects; and incorporates the whole person in treatment. The latter gives the person a sense of self-control or empowerment in disease treatment.6

It is estimated that nearly half of Americans utilize CAM.5 This underscores the rise in interest and incidence of these treatments.5 Because allopathic treatments for dysphagia have varying degrees of success, some may look to CAM therapies, which include acupuncture, biofeedback and herbal therapies.

Chinese legend records the story of a soldier who was injured by an arrow in battle. The soldier reported to his doctor that the stomach pain he had endured for many years disappeared after the arrow pierced him. The physician examined the point of entry and investigated how pressure at one point might relieve pain at another. This was the dawn of the 5,000-year-old history of acupuncture.

Interest in acupuncture in the United States began to emerge in 1971 when a New York Times writer reported that acupuncture relieved his pain after an emergency appendectomy in Peking.7

In 1996 the U.S. Food and Drug Administration (FDA) classified acupuncture needles in the same category as surgical instruments. The following year the National Institutes of Health (NIH) issued a report stating, "Needle acupuncture is an effective treatment for postoperative dental pain and for nausea and vomiting caused by anesthesia, chemotherapy and pregnancy."8

Traditional Chinese medicine holds that illness is caused in part by an imbalance in the flow of Qi (chee), or life force energy. To restore Qi in acupuncture therapy, needles are inserted at points along meridians, which are pathways of energy flow. These needles are conical in shape and push the tissue aside so that insertion is painless. They are rotated, twirled, or accompanied by a weak electrical current. Treatments usually last 15 to 20 minutes. Some acupuncturists apply heat along with the needles to alter the flow of Qi.

Numerous acupuncture studies have shown improvement in dysphagia and dysphagia-related diagnoses.9-15 (See Table 4 .) Interestingly, success is realized even when there are variations in the types of acupuncture used, treatment duration, and methods of measuring improvements.

Studies from China "get little credence from the Western medical community because researchers in China do not appear to be published unless their results are highly positive, so publication bias is possible," Russ Erickson, MD, pointed out.12

Acupuncture studies are becoming more quantitative compared to initial investigations. This reflects a general trend in CAM research to be more rigorous and adhere to a more allopathic paradigm.16 A Cochrane review that includes only truly randomized controlled trials of post-acute stroke status also diagnosed with dysphagia via videofluoroscopy is under way.17

Biofeedback is used in many allopathic therapies as a complementary treatment. It is defined as the use of equipment to measure body functions that cannotbe monitored consciously by the patient or practitioner.

Measurements gathered by surface electrodes are converted to signals that enable the patient to develop more control over a particular function or exercise. Successful uses of biofeedback include management of hypertension, physical therapy exercises, anxiety, pain, incontinence and dysphagia.18,19

The technique is not to be confused with electrical stimulation. Biofeedback does not stimulate muscle action but provides a measure of muscle function, both voluntary and involuntary.

The placement of electrodes in biofeedback is imprecise, so it is not recommended that amplitudes be compared from day to day. In addition, subcutaneous fat and amounts of loose skin vary among patients and prevent determination of standardized baseline or optimal signaling. Consequently, signal interpretation should be based on the individual client.18

Biofeedback has obvious limitations in patients with diminished cognitive function.

With regard to dysphagia, studies involving patients with varied etiologies of swallowing disorder show marked improvement when biofeedback is a part of the standard exercise therapy.19

Surface electromyography (SEMG) feedback first was used in dysphagia treatment in 1991 and reported in a case study. A total of 27 physical therapy sessions over a period of nine weeks involved monitoring of SEMG signals while the client practiced effortful swallows. This patient was able to regain complete oral intake skills.19

SEMG was used to treat dysphagia in five patients with poor laryngeal elevation. By observing the computer-generated signals, adjustments were made in the therapy techniques, positioning, food textures and compensatory techniques to elicit the greatest swallow effect. This enabled the patient and therapist to observe which technique was most successful in treatment. SEMG helped to guide the therapy toward treatments that were most useful and engaged the cooperation of the client who could observe improvement via the SEMG feedback.20

A retrospective observational study compared SEMG efficacy for treating dysphagia in patients with stroke and those with head and neck cancer. While both groups experienced positive outcomes in treatment, the stroke group realized the greatest benefit of SEMG-supplemented physical therapy.21

In general, ASHA recommends SEMG biofeedback in dysphagia treatment.19 However, comparison studies that include experimental and control groups are needed to measure the degree that SEMG feedback helps patients with therapy.

More studies also are needed to determine which patients with dysphagia would realize the greatest benefit from biofeedback techniques. The patient's own performance can be used as a baseline comparison for efficacy of biofeedback treatments.

Herbalists cite numerous herbs and homeopathy treatments to improve swallowing function, though very few claims are supported by scientific research. Capsaicin and Banxia Houpo Tang have been studied and shown to improve swallowing function in patients with dysphagia. Capsaicin increases substance P and acts as a stimulant to improve swallowing, while the mechanism of action by Banxia Houpo Tang is not known. (See Table 3.)

However, the studies on these herbals were small, and more are needed to identify which patients would realize the most benefit. Table 3 summarizes the herbals recommended for swallowing problems by herbalists. Note that this table includes herbals that address non-CVA causes of dysphagia, including antispasmodics, those thought to have a sedating effect, and others. Other related tables: Herbal Therapies and Dysphagia, Herbs in Tea or Tincture

Reasonable CAM treatments for dysphagia exist. These include acupuncture, biofeedback, and at least two herbal therapies that may have a direct effect on swallowing. Other herbals may exert a beneficial effect on the gastrointestinal system as to effect normal swallowing.

The application of these therapies to dysphagia may yield varying results depending on the cause of the dysphagia. For example, a patient with dysphagia who has minimal cognitive functioning following a CVA will not benefit from biofeedback.

Given that CAM use is expected to continue to increase, there are several considerations for the practitioner. Therapists need to educate themselves on these therapies and learn to carefully and critically review the scientific studies that support or negate a CAM modality.

Study designs in CAM therapy present with unique challenges, such as use of placebo, blinding, and methods of measuring efficacy of treatments. Despite these problems, scientific studies in this area continue to mount due to high consumer demand.

Allopathic treatments for dysphagia vary in efficacy, perhaps due to the many underlying causes of swallowing problems. Therefore, dysphagia treatment is perhaps an area where CAM modalities might offer a synergistic effect if used alongside current allopathic treatments. For example, the use of a capsaicin troche before a meal for patients with stroke who have dysphagia?provided the patient would accept it?could augment feeding therapy responses.

Biofeedback also could provide benefit in patients with adequate cognitive function. Acupuncture along with electrical stimulation therapy might show benefit as well. The challenge is to identify the patients with dysphagia who would receive the greatest benefit from CAM therapies. This should drive future research.

The CAM treatments for dysphagia offer little or no risk compared to allopathic treatments such as surgery or some medications. Improving a patient's swallowing ability can greatly enhance quality-of-life issues and prevent respiratory infection.

Therapists should not discount CAM therapies for dysphagia. Given that the aging population in the United States is likely to result in an increased incidence of stroke-related dysphagia, it is reasonable to focus research on methods that are less costly, provide safe and efficacious results, and are grounded in sound scientific inquiry.

Therapists should caution individuals interested in utilizing CAM therapies that legitimate practitioners, such as licensed acupuncturists, should be utilized. For those interested in herbal therapies, the dietitian should direct the patient to those that have shown proven efficacy in the scientific literature with a caveat regarding the limitations of scientific studies for CAM treatments.

Furthermore, patients should be cautioned that herbals are not regulated for content, so the buyer should be prudent in selecting a legitimate brand. Patients should be given directions on product purchase and dosing as well as potential side effects and food and drug interactions.

The U.S. Department of Health and Human Services maintains a list of acupuncture and biofeedback practitioners on its Web site (www.healthfinder.gov).

References

1. American Speech-Language-Hearing Association, Special Interest Division 13-Swallowing and Swallowing Disorders, Professional Advocacy Committee. Dysphagia. Powerpoint presentation. Accessed online at www.asha.org.

2. Paik, N.J. (2006). Dysphagia. Accessed online at www.emedicine.com.

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18. Steele, C. (2004). Treating dysphagia with sEMG biofeedback. ASHA Leader, July 20.

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20. Reddy, N.P., Simcox, D.L., Gupta, V., et al. (2000). Biofeedback therapy using accelerometry for treating dysphagic patients with poor laryngeal elevation: Case studies. Journal of Rehabilitation Research & Development, 37 (3): 361-73.

21. Crary, M.A., Giselle, D., Groher, M.E., Helseth, E. (2004). Functional benefits of dysphagia therapy using adjunctive sEMG biofeedback. Dysphagia, 19: 160-64.

22. University of Maryland Medical Center. (2004). Complementary and alternative medicine. Accessed online at: www.umm.edu/altmed/index.html

23. Brinckmann, J., Sigwart, H., van Houten, T. (2003). Safety and efficacy of a traditional herbal medicine (Throat Coat) in symptomatic temporary relief of pain in patient pharyngitis: A multicenter, prospective, randomized, double-blinded, placebo-controlled trial. Journal of Alternative and Complementary Medicine, 9 (2): 282-98.

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Teresa Johnson is an instructor at the Troy University School of Nursing and a doctoral student in clinical nutrition at the University of Medicine and Dentistry of New Jersey. She can be contacted at tjohnson@troy.edu.




 
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