Clinical, endoscopic and ultrasonographic evaluation of dysphagia rehabilitation effectiveness in stroke patients

Objectives: The aim of this study was to investigate the efficacy of dysphagia rehabilitation in stroke patients with dysphagia. Dysphagia was evaluated by using clinical-dysphagia criteria, fiberoptic endoscopy and ultrasonographic parameters. Data of the patients compared with the healthy individuals. Methods: Our study included 30 patients suffering from swallowing difficulty after stroke and 30 healthy individuals without any history of swallowing and stroke admitted to Celal Bayar University Faculty of Medicine Hafsa Sultan Hospital Physical Medicine and Rehabilitation Clinic. Demographic characteristics, history and medications of all cases were questioned. Functional status of the patients were evaluated by the functional independence scale (FIM). In addition bedside neurological evaluation-bedside swallowing evaluation, EAT-10, functional oral intake scale (FOIS), functional outcome swallowing scale (FOSS), MD Anderson dysphagia index (MDADI) were used for dysphagia. Mandibular - hyoid, hyoid - thyroid distance and tongue thickness were measured using ultrasonography (USG) in resting position in patients and healthy individuals. These measurements were repeated during swallowing of liquid-water and yoghurt. Ultrasound elastography (UE) of the tongue was evaluated at rest. Ultrasonographic swallowing duration was calculated from number of the frames at the begining to the end in a swallowing cycle. Patients were evaluated with fiberoptic endoscopy (FES) and penetration aspiration scale (PAS) was assessed during FES examination. Dysphagia exercises were performed under the supervision of a physiotherapist for 5 days a week along 1 month. Patients were visited 3 times; before treatment, 1 and 3 months after treatment. And control group was assessed only once. Results: Bedside neurological evaluation-bedside swallowing evaluation, EAT-10 and MDADI scales improved significantly from 1. month after treatment (p <0.000). The PAS values of the patients improved significantly at 1. month but no difference was observed at 3. months. USG evaluation parameters; mandibular hyoid measurement (during fluid and yogurt swallowing) and frame-time showed a significant improvement during follow-up from 1. month after treatment (p <0.001). On the other hand, there was no significant change in the tongue thickness. When both groups were compared, only frame-time showed significant difference at 1. month post-treatment and this difference continued throughout the follow-up. Other USG parameters did not show statistically significant difference approaching control values, especially at 3. months after treatment. FIM scores improved significantly after neurological rehabilitation. Among the dysphagia criteria, significant correlation was found only between FOSS and FIM. No significant correlation was found between FIM and USG parameters. Generally, a significant correlation was found between frame and scales, which is one of the USG parameters. Symptoms associated with dysphagia also improved significantly after treatment. Conclusions: B-mode and elastography technique of USG is a non-invasive, radiation free imaging method that evaluates the oral and pharyngeal phase in patients with dysphagia. In particular, frame-swallowing time is an objective valued parameter indicating improvement after rehabilitation. It can be also distinguish swallow disturbance between patient and control values. Our results showed that elastography was more sensitive than tongue thickness measurement. Particularly there was a correlation between frame of USG parameters and dysphagia scales. There was no correlation between FIM and USG findings. So dysphagia may be overlooked even if the patient's functional status is good. Stroke patients should be evaluated in detail by clinical examination and using imaging methods for dysphagia. Symptoms associated with dysphagia (multiple swallowing, saliva increase, taste change, etc.) also improve after the rehabilitation programme. Key Words: Dysphagia, stroke, ultrasonograph, dysphagia scales, elastography.