Stroke: therapist controlled diet was not clearly better than patient controlled diet in dysphagia.

Clinical bottom line (level 1b-)

  1. Patients with dysphagia following stroke who were given therapist controlled treatment had no clear difference in pneumonia, dehydration or calorie-nitrogen deficit, than those given patient controlled treatment.
DePippo et al: Neurology 1994; 44: 1655-1660
Expires December 2002

The study

Unblinded ?concealed randomised trial with intention-to-treat
Setting: in hospital rehabilitation unit, USA

115 patients (aged median 75 years, 59% male) stroke defined by medical history neurologic examination and CT and MRI scans with evidence of dysphagia (with modified barium swallow)

Excluded if
  • aged <20 or >90 years old
  • history of significant oral or pharyngeal anomaly
  • laboratory values above end point criteria
  • severe dysphagia (aspiration of = 50% of all consistencies presented, continuing after use of compensatory swallowing techniques.


    • Control Group: (n = 38, 38 analysed): Group A- Diet and compensatory swallowing recommendations alone- the patient (or family member) chose a diet appropriate to them. The choice was either a regular diet or one of four graded levels of diet designed for patients with dysphagia, and with all-liquid consistencies or with thickened liquids only. Training in compensatory swallowing techniques was given.
    Experimental Group: (n = 38, 38 analysed): Group B- Therapist-prescribed diet and compensatory swallowing technique recommendations- dysphagia therapist prescribed an appropriate diet, therapist reevaluated the patient every week for the need to change diet.
    Experimental Group: (n = 39, 39 analysed): Group C- Therapist prescribed and controlled diet and provided daily reinforcement of swallowing techniques (most active therapist intervention) dysphagia therapist prescribed and controlled the consistency of the patients, and they were seen daily at a mealtime dysphagia management group where additional instructions and reinforcement of compensatory swallowing techniques were given.
    One formal dysphagia treatment session, with a dysphagia therapist, was given to each group, where patients (or family members) received the diagnostic results of the modified swallowing barium and training in the use of compensatory swallowing techniques.
    100% followed for 12 months with end points: pneumonia, dehydration, and calorie-nitrogen deficit
    Outcome notes:
    • pneumonia (A vs B) : chest x-ray with evidence with three or more of: fever, presence of rales or rhonchi, drop in arterial PO2 >10 torr compared with baseline or sputum Gram's stain with respiratory pathogen
    • dehydration (A vs B) : serum sodium >145 or BUN >50 not due to primary renal insufficiency or use of diuretics
    • calorie-nitrogen deficit (A vs B) : serum albumin <2.2 or sustained ketonuria without glycosuria over 2 weeks

    The evidence

    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    Any end point, A vs. B weeks 6
    (15.8%)    		 7
    (18.4%)    		 -17%
    (-215% to 57%)    		 -2.63%
    (-19.6% to 14.3%)    		 -38
    (NNT = 7 to infinity;
    NNH = 5 to infinity)
    Any end point, A vs. C weeks 6
    (15.8%)    		 5
    (12.8%)    		 19%
    (-144% to 73%)    		 2.97%
    (-12.7% to 18.6%)    		 34
    (NNT = 5 to infinity;
    NNH = 8 to infinity)
    pneumonia (A vs B) 12 months 1
    (2.63%)    		 5
    (13.2%)    		 -400%
    (-3981% to 39.0%)    		 -10.5%
    (-22.4% to 1.37%)    		 -10
    (NNT = 73 to infinity;
    NNH = 4 to infinity)
    pneumonia (A vs C) 12 months 1
    (2.63%)    		 2
    (5.13%)    		 -95.0%
    (-1961% to 82.0%)    		 -2.50%
    (-11.1% to 6.10%)    		 -40
    (NNT = 16 to infinity;
    NNH = 9 to infinity)
    dehydration (A vs B) 12 months 3
    (7.89%)    		 0
    (0.00%)    		 100%
    (% to %)    		 7.89%
    (-0.68% to 16.5%)    		 13
    (NNT = 6 to infinity;
    NNH = 147 to infinity)
    dehydration (A vs C) 12 months 3
    (7.89%)    		 1
    (2.56%)    		 68.0%
    (-199% to 96.0%)    		 5.33%
    (-4.57% to 15.2%)    		 19
    (NNT = 7 to infinity;
    NNH = 22 to infinity)
    calorie-nitrogen deficit (A vs B) 12 months 2
    (5.26%)    		 2
    (5.26%)    		 0.00%
    (-574% to 85.0%)    		 0.00%
    (-10.0% to 10.0%)    		 inf
    (NNT = 10 to infinity;
    NNH = 10 to infinity)
    calorie-nitrogen deficit (A vs C) 12 months 2
    (5.26%)    		 3
    (7.69%)    		 -46.0%
    (-727% to 74.0%)    		 -2.43%
    (-13.4% to 8.54%)    		 -41
    (NNT = 12 to infinity;
    NNH = 7 to infinity)

  • 6 patients in group A, 7 patients in group B and 5 patients in group C reached any end point.
  • There was no clear difference in death (no death occurred in any of the groups), calorie-nitrogen deficit or recurrent upper airway obstruction either.

    • Comments

    1. There was no significant difference in baseline characteristics between the three groups.
    2. Only 18 patients reached one or more of the study end points during the inpatients stay.

    Citation

    1. DePippo KL, Holas MA, Reding MJ, et al: Dysphagia therapy following stroke: A controlled trial. Neurology 1994; 44: 1655-1660
    Contributor: Clare Wotton and Musab Hayatli, December 1999
    Reviewer:

    Clinical Question.
    Patient stroke
    Intervention or Exposure Graded levels of intervention by a dysphagia therapist
    Comparison patient controlled diet
    Outcome death