A review of a review

Today was the fourth journal club meeting and, I felt, the most interesting yet. All articles evoked in-depth discussions around both their quailty, and their application to clinical practice: how exciting!

We met at the Jazz Café in Newcastle at 11am-1pm; finally, the perfect venue and the time. From now on we will aim to hold all meetings here (thanks Jazz Café!)

Three articles were discussed, the first of which will be reviewed here today:

Singh, S. & Hamdy, S., (2006). Dysphagia in Stroke Patients. Journal of Postgraduate Medicine, 82, 383-391.

This paper provided a useful overview of dysphagia, assessment, compensatory, and therapeutic, methods. We all felt that it was especially useful for newly qualified SLT graduates as revision.

Although the paper is entitled a ‘review’, there is no clear introduction as to its aims, and the purpose and structure of the paper was muddy at times, though each section was very clearly written and accessible. A significant proportion of the article referenced the author’s own research into the bilateral cortical representation of swallowing and that this neuropathology may be what makes possible the neuroplasticity enabling so many to recover swallow-function after the acute stages of stroke recovery (i.e. swallow function can hop over to the other cortex),

The review highlighted that the goal of assessment in dysphagia was not to determine whether or not someone had dysphagia, but rather to build a profile of that person’s swallowing difficulties (and strengths). It notes that 50% of patients who pass bedside assessment were shown to silently aspirate when assessed using the gold standard of videofluoroscopic assessment. In terms of management, the authors write that the goals of dysphagia therapy are to reduce the morbidity and mortality associated with chest infections, to improve nutritional status and to return patients to a normal diet, with resultant improvement in their quality of life.

It is clear from the paper that there is a lack of good quality evidence for swallowing rehabilitation. The authors suggest this is likely due to the ethical restrictions of randomised control trials in dysphagia studies (using people who aspirate as controls would be unsafe in some instances). The most effective evidence, they note, comes from a study by Shaker et al. (2002), which describes an exercise aimed to strengthen the upper oesophageal sphincter, and thus remove post-swallow pharyngeal residue in patients with chronic dysphagia. This exercise requires the patient to lie in the supine position, raise their head from the bed for a few seconds and then rest their head down again. They are to repeat this 20 times. In addition, pharyngeal electrical stimulation was also found to have a possible therapeutic role (Fraser et al., 2002).

The paper discusses issues around enteral feeding and notes the importance of nutritional considerations when managing dysphagia.

Journal club discussions arising from paper

Interesting that most evidence for dysphagia rehabilitative exercises is anecdotal, or comes from clinical experience (third arm of EBP model).

Paper showed that 50% of patients who passed bedside assessment where shown to be silently aspirating on VFSS. Clinical implication of this and discussion around the fact (not discussed in this paper) that a proportion of the elderly population aspirate without having had a stroke, and some of these are at risk of chest infection and some are not. Without taking pre-stroke baseline, it is impossible to assess effectively. One of the first questions to ask a patient (or care-giver) has to be ‘what was your (their) eating and drinking like before your stroke?’

Some NQPs had seen Shaker’s exercise applied in practice. One felt that most of her (acute) patients would really struggle with this exercise because of mobility impairment/age.

Some people had seen O2 saturation used as a bedside indicator of aspiration within clinical practice.

The paper makes reference to some unpublished data in the authors’ department to support an argument but without giving further details of how to access this data, this was felt to reduce the quality of the review.

There was a quiz at the end of the review to test the reader’s understanding and/or learning. Readers found this very useful: take note potential authors!

References

Fraser, C., Power, M., Hamdy, S., et al. (2002). Driving plasticity in human adult motor cortex is  associated with improved motor function after brain injury. Neuron, 34, 831-840.

Shaker, R., Easterling, C, Kern, M., et al. (2002). Rehabilitation of Swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening. Gastroenterology, 122, 1314-1321.