Introduction
Methods
Information Sources
Search Strategy
Study Selection
Data Analysis
Quality Assessment
Results
Study | Aim | Design | Sample size | Age (mean)a | Gender (% male)a | Stroke type (n =) | Measure of recovery | Rate of recoverya | Predictors/factors considered | Key findings |
---|---|---|---|---|---|---|---|---|---|---|
Calvo et al. [26] | Explore factors and predictors associated with the complete recovery of oral feeding in post-stroke patients with enteral nutrition feeding | Retrospective cohort study | 163 | 75.8 | 49.1 | 107 IS 53 ICH 3 both | Removal of enteral feeding tube | 61.9% resumed oral intake | Gender Age FIM cognitive scores FIM motor scores Time from stroke to admission Stroke location BLB swallow trigger BLB signs of aspiration | • Patients without any signs of aspiration during the water swallow test had a higher probability of resuming complete oral feeding • Patients between 73 and 79 years of age, evidence of aspiration and/or penetration, and presence of pharyngeal residue during FEES had a lower probability of returning to complete oral feeding |
Choi et al. [25] | To evaluate the longitudinal changes with a kinematic analysis of VFSS in subacute stroke | Retrospective cohort study | 69 | 67.0 | 62 | 51 IS 18 ICH | Diet at follow-up VFSS | 30% change from tube feeding to oral diet at follow-up VFSS | Change in epiglottic folding angle; Hyoid displacement; and Vocal cord displacement -measured on VFSS | •Higher epiglottic folding angles may be associated with swallowing function recovery and suitability for oral feeding in subacute stroke patients |
Crisan et al. [18] | Determine predictors of early recovery of functional swallow in patients who had PEG placement | Retrospective cohort study | 32 | – | 44 | 17 IS 15 ICH | Removal of PEG | 62.5% did not remain PEG dependent | Age Side of stroke | • Patient age as a continuous variable is a significant predictor of recovering swallowing ability |
De Stefano et al. [27] | To understand the factors contributing to the severity of oropharyngeal dysphagia and its persistence in the subacute phase of stroke | Retrospective cohort study | 54 | 75.1 | 55 | – | Change in ASHA- NOMS and PAS | – | Age Stroke location Stroke type NIHSS Tube feeding on admission DRS PAS ASHA-NOMS | •NIHSS > 12, PAS 6–8, tube feeding on admission and haemorrhagic stroke were associated with persistent dysphagia (ASHA-NOMS 1–4) in the subacute phase •Stroke location and patient’s age were not associated with prognosis of dysphagia |
Galovic et al. [32] | Describe the Predictive Swallowing Score (PRESS), for predicting the recovery of functional swallowing after ischaemic stroke | Development/ validation of a prognostic model | 279 | – | – | IS only | Change in FOIS score | 70% FOIS > 5 | Initial FOIS Frontal operculum lesion Risk of aspiration on initial CSE (measured with the any 2 test) Age Admission NIHSS | • Five predictors remained in the final simplified model: initial impairment of oral intake lesion of the frontal operculum, initial risk of aspiration, age, and NIHSS score at admission |
Ickenstein et al. [29] | Null hypothesis of this study was an early prediction of severe/chronic dysphagia within 72 h of acute stroke isn't sufficiently possible | Prospective cohort study | 114 | – | – | 103 IS 11 ICH | Change in ASHA- NOMS at day 90 | – | Age Gender Stroke category Stroke location ASHA NOMS level 1–3 within 72 h PAS 5–8 within 72 h | • Clinical swallowing examination combined with a swallowing endoscopy can reasonably predict continued supplemental tube feeding |
Kim et al. [19] | Investigate the association between infract location and the duration of dysphagia recovery | Retrospective cohort study | 59 | 65.8 | 50.8 | IS only | Recovery to stage 3 diet | – | Stroke location | • Patients with lesions in the posterior limb of the internal capsule and/ or in the caudate nucleus had longer recovery times |
Kumar et al. [8] | Analyse clinical, radiologic, and treatment-related factors that are independently associated with persistent dysphagia at hospital discharge | Retrospective cohort study | 323 | 75.9 | 41 | IS only | Change in oral diet | 30% resumption of full or mildly modified diet | Gender Intubation Bilateral infarcts Acute stroke therapy NIHSS ≥ 12 Dysarthria Nil aspiration on VFSS Positive aspiration on VFSS | • Presence of aspiration, severe dysarthria, baseline NIHSS score ≥ 12, bilateral infarcts, and intubation during hospitalisation are independently associated with persistent dysphagia at hospital discharge in acute ischaemic stroke |
Lee et al. [20] | Demonstrate associating factors regarding NG removal in patients with dysphagia after stroke | Retrospective cohort study | 138 | – | – | IS only | Removal of NG | – | Stroke location | • Non-brainstem group: NIHSS and mRS showed a positive correlation with NG removal time; MMSE and MBI showed a negative correlation with NG removal time • Brainstem group: none of the factors studied showed correlation • For both groups: change in mean PAS was significantly different according to NG removal status |
Lee et al. [33] | Develop a machine learning based prognostic model for long-term swallowing outcomes | Development/ validation of a prognostic model | 137 | 68.7 | 50.4 | IS only | Nil feeding tube or diet modification at 6 months | – | Tube feeding recommended at initial VFSS Male sex Clinical dysphagia scale score ≥ 20 Bilateral lesions at the corona radiata, basal ganglia or internal capsule Sever white matter hyperintensities | • The duration of post-stroke dysphagia significantly differed by tube feeding status; clinical dysphagia scale; sex; severe white matter hyperintensities and bilateral lesions at the corona radiata; basal ganglia or internal capsule |
Lee et al. [28] | To investigate hyoid kinematic features for poor swallowing prognosis | Retrospective cohort study | 36 | – | 66.7 | IS only | Nil feeding tube or diet modification at 6 months | – | Hyoid displacement and velocity during VFSS | • Reduced horizontal hyoid displacement and velocity, and decreased angle of hyoid movement for the early phase of swallowing is observed in patients with poor swallowing prognosis |
Lin et al. [21] | To study the applicability of NIHSS in early prediction of prognosis of post-stroke dysphagia | Retrospective cohort study | 165 | 71 (median) | 66.7 | IS only | Change in FOIS score | 56.4% FOIS at discharge higher than FOIS at admission | Sex Age Old lesions on MRI Comorbidities In-hospital pneumonia Admission FOIS Speech therapy interval Days of hospital stay Each item of the NIHSS | • High NIHSS scores of facial palsy and language/aphasia showed significantly negative effects on the early improvement in dysphagia |
Mann et al. [5] | To study the prognosis of swallowing function over the first 6 months after acute stroke | Prospective cohort study | 128 | – | 64 | 117 IS 10 ICH 1 both | Return to pre-stroke diet | 87% return to pre-stroke diet | Age Sex Stroke category Stroke syndrome Barthel Index Abnormality on CSE Abnormality on VFSS Communication abnormality | • Delayed oral transit on VFSS was an independent predictor of failure to achieve the patient’s pre-stroke diet at 6 months |
Oh et al. [31] | To explore if outcome of post-stroke swallowing disturbance could be affected by single-nucleotide polymorphisms | Prospective cohort study | 206 | 63.8 | 66 | 119 IS 81 ICH | Return to oral intake within 3 months | 64% returned to oral intake at 3 months | Age Stroke location NIHSS score Tracheostomy insertion Single-nucleotide polymorphisms related to an increasing risk of dysphagia in the elderly or related to affect post-stroke motor recovery | • Age, stroke location (multiple), NIHSS score, and tracheostomy insertion was associated with increased risk of poor swallowing outcome • No single gene was associated with increased risk of poor swallowing at 3 months |
Schroeder et al. [22] | Determine specific neurological predictors associated with dysphagia and recovery in acute stroke patients | Retrospective cohort study | 65 | 67 | – | IS only | Diet at discharge and change in PAS on repeat VFSS | 75% oral diet at discharge | Hemispatial neglect;aphasia | • Hemispatial neglect was associated with non-oral intake on initial swallowing evaluation only • Aphasia was not associated with swallowing outcomes |
Seo et al. [23] | Evaluate longitudinal changes of swallowing in stroke patients with aspiration | Retrospective cohort study | 28 | 66.9 | 67 | 23 IS 5 ICH | Resolved aspiration on VFSS | 50% resolved aspiration | Temporal and spatial elements related to hyoid and epiglottic movement | • Delayed swallowing triggering at initial VFSS is associated with poor recovery from aspiration in subacute stroke patients |
Smithard et al. [30] | Assess the frequency and natural history of swallowing problems following an acute stroke | Prospective cohort study | 121 | 79 (median) | 44 | 59 IS 22 ICH 40 not classified | Change in risk of aspiration on CSE or VFSS | 89% no identified risk of aspiration at 6 months post-stroke | Gender Side of weakness Presence of neglect Incontinence Abbreviated mental test score Barthel score Side of stroke | • No significant difference in clinical features were identified between those with new and persistent dysphagia to predict unsafe swallow at day 28 |
Wang et al. [34] | To identify the factors for dysphagia recovery and develop a model that predicts dysphagia trajectory | Development/ validation of a prognostic model | 485 | 62.1 | 70.3 | IS only | Change in FOIS score | 71.2% FOIS = 7 at 30 days | Age Stroke type Stroke location Stroke treatment NIHSS Glasgow Coma Scale Barthel Index Body Mass Index Dysarthria FOIS | •Predictors at day 7 included age, FOIS, NIHSS, hemispheric stroke, and brainstem stroke on admission •Day 14 predictors included age, FOIS, and NIHSS on admission •Day 30 predictors included age, FOIS, NIHSS, bilateral stroke, and body mass index on admission |
Wilmskoetter et al. [24] | Assess clinical factors and their relationship with the acute recovery of post-stroke dysphagia | Retrospective cohort study | 44 | 67.5 | 48 | IS only | Change in FOIS score | 70% FOIS 4–7 at discharge | Age Comorbidity score Length of stay MBSImp components Total lesion volume | • Damage to the left hemisphere in the 1) superior frontal gyrus, 2) dorsal anterior cingulate gyrus, 3) hypothalamus, and 4) nucleus accumbens, were significantly associated with less improved oral intake • Age independently predicted change in FOIS |
Participant Characteristics
Measures of Dysphagia and Recovery
Study | Measure of dysphagia severity | Instrumental assessment (%) | Period of follow-up | Follow up provided |
---|---|---|---|---|
Calvo et al. [26] | BLB FEES | 85 | Until discharge from inpatient rehabilitation | BLB performed at discharge |
Choi et al. [25] | VDS score ASHA NOMS VFSS | 100 | Not clearly stated | 100% completed repeat VFSS at least 1 week after initial VFSS |
Crisan et al. [18] | CSE VFSS | 34 | Until discharge from inpatient rehabilitation | Not clearly stated |
De Stefano et al. [27] | DRS FEES ASHA NOMS PAS | 100 | Until discharge from subacute rehabilitation | 100% completed repeat FEES after 15–20 days and 60 days from initial assessment |
Galovic et al. [32] | 50 ml water swallow test Any 2 scale Parramatta Hospitals Assessment of Dysphagia FOIS FEES | As deemed clinically necessary | ≥ 4 weeks | Clinical evaluation at baseline and 7 days Phone interview > 4 weeks post-onset |
Ickenstein et al. [29] | ASHA NOMS FEES | 100 | 3 months | Phone interview at 90 days |
Kim et al. [19] | VFSS | 100 | Time to prescription of dysphagia diet stage 3 | 100% completed VFSS performed at intervals of one week |
Kumar et al. [8] | CSE VFSS | 36 | Until discharge from acute hospital | CSE at discharge |
Lee et al. [20] | VFSS PAS | 100 | Until recovery or discharge from inpatient rehabilitation | 100% completed VFSS at follow- up every 2 weeks |
Lee et al. [33] | CDS VFSS | 100 | 6 months | Interval of VFSS was < 4 weeks during the initial phase and gradually prolonged to 1–3 months |
Lee et al. [28] | CDS VFSS | 100 | 6 months | 100% completed VFSS at outpatient follow- up review up to 6 months post-stroke |
Lin et al. [21] | FOIS VFSS | As deemed clinically necessary | Until discharge from inpatient rehabilitation | FOIS at discharge |
Mann et al. [5] | CSE VFSS | 100 | 6 months | 60% completed repeat VFSS |
Oh et al. [31] | MASA FOIS VFSS PAS EAT-10 | 100 | 3 months | 100% repeated the battery of assessments at 3 months |
Schroeder et al. [22] | CSE VFSS PAS | 55 | Until discharge from inpatient rehabilitation | 28% completed repeat VFSS |
Seo et al. [23] | VDS score ASHA NOMS VFSS | 100 | Not clearly stated | 100% completed repeat VFSS 2–4 weeks after initial |
Smithard et al. [30] | CSE VFSS | 79 | 6 months | 85% completed repeat VFSS at 28 days |
Wang et al. [34] | Water swallow test CSE VFSS or FEES FOIS | As deemed clinically necessary | 30 days | Repeat assessment to score FOIS at day 7, 14 and 30 |
Wilmskoetter et al. [24] | FOIS VFSS | 100 | Until discharge from acute hospital | SLP assessment before discharge |
Clinical Predictors of Dysphagia Recovery
Study | Sample | Outcome examined | Predictor variables considered | Positive predictors of recovery | Negative predictors of recovery | AUC | OR | 95% CI | p = |
---|---|---|---|---|---|---|---|---|---|
Calvo et al. [26] | 139 | Complete recovery of oral feeding at discharge defined as removal of enteral feeding support | Gender Age FIM cognitive scores FIM motor scores Time from stroke to admission Stroke location BLB swallow trigger BLB signs of aspiration FEES aspiration/ penetration FEES residue | No signs of aspiration on BLB | 3.57 | 1.07–11.89 | 0.03 | ||
Age 73–79 years | 0.096 | 0.01–0.58 | 0.01 | ||||||
Aspiration/ or penetration on FEES | 0.22 | 0.07–0.72 | 0.01 | ||||||
Residue on FEES | 0.14 | 0.04–0.43 | < 0.01 | ||||||
Crisan et al. [18] | 34 | Recovery of swallow function following PEG placement defined as discontinuation of PEG dependence | Age Side of stroke | Younger Age | 0.89 | 0.82–0.98 | 0.016 | ||
Left sided stroke | 15.15 | 1.32–173.34 | 0.016 | ||||||
Ickenstein et al. [29] | 114 | Prediction of 90-day outcome | Age Gender Stroke category Stroke location ASHA NOMS level 1–3 within 72 h PAS 5–8 within 72 h | Combined tube feeding dependency (ASHA NOMS 1–3) and aspiration on FEES (PAS 5–8) within 72 h of admission | 0.782 | 11.8 | 0.036–0.096 | < 0.001 | |
Kumar et al. [8] | 323 | Presence of dysphagia at discharge from acute hospital, defined as any swallowing impairment leading to ≥ 2 dietary modification | Gender Intubation Bilateral infarcts Stroke Treatment NIHSS ≥ 12 Dysarthria Nil aspiration on VFSS Positive aspiration on VFSS | Intubation | 0.892 | 2.857 | 1.106–7.38 | 0.0301 | |
Bilateral infract | 3.725 | 1.33–10.43 | 0.0123 | ||||||
NIHSS ≥ 12 | 2.510 | 1.189–5.296 | 0.0157 | ||||||
Dysarthria | 3.4 | 1.572–7.355 | 0.0019 | ||||||
Positive aspiration on VFSS | 10.50 | 3.351–32.955 | < 0.001 | ||||||
Lin et al. [21] | 165 | Early improvement of dysphagia defined as positive value of: discharge FOIS—admission FOIS | Sex Age Old lesions on MRI Comorbidities In-hospital pneumonia Admission FOIS Speech therapy interval Days of hospital stay Each item of the NIHSS | NIHSS item 4—facial palsy | 0.731 | 0.484 | 0.279–0.838 | 0.0096 | |
NIHSS item 9—language/aphasia | 0.714 | 0.562 | 0.321–0.982 | 0.043 | |||||
Mann et al. [5] | 15 | Different diet at 6 months after stroke | Age Sex Stroke category Stroke syndrome Barthel index Abnormality on CSE Abnormality on VFSS Communication abnormality | Delayed oral transit on VFSS | 32 | 4.1–26.1 | |||
Oh et al. [31] | 206 | Increased risk of nil per oral status at 3 months | Age Stroke location NIHSS score Tracheostomy insertion Single-nucleotide polymorphisms related to an increasing risk of dysphagia in the elderly or related to affect post-stroke motor recovery | Age | 0.774 | 1.05 | 1.02–1.09 | 0.0027 | |
Stroke location | 3.65 | 1.15–11.57 | 0.00276 | ||||||
NIHSS score | 1.07 | 1.01–1.13 | 0.0149 | ||||||
Tracheostomy insertion | 26.1 | 6.5–104.13 | < 0.001 | ||||||
Wilmskoetter et al. [24] | 44 | FOIS change from first to last speech pathology encounter | Age Comorbidity score Length of stay MBSImp components Total lesion volume | Age | β = 0.03 | 0.04 |
Study | N = | Outcome | Predictor variables included | Model type | Validation | Model discrimination | Model calibration |
---|---|---|---|---|---|---|---|
Galovic et al. [32] | 153 derivation cohort 126 validation cohort | Primary: persistence of severely impaired oral intake (FOIS score > 5) at follow-up on day 7 and day 30 Secondary: return to pre-stroke diet | Initial FOIS Frontal operculum lesion Risk of aspiration on initial CSE (measured with the any 2 test) Age Admission NIHSS | Cox proportional hazards model | Split- sample | C- statistic for predicting the recovery of oral intake on day 7 = 0.84 (95% CI 0.76–091; p < 0.001) | Calibration plots for day 7 and day 30 Hosmer- Lemeshow test |
C- statistic for predicting the recovery of oral intake on day 30 = 0.77 (95% CI 0.67–0.87; p < 0.001) | |||||||
C- statistic for predicting return to pre-stroke diet on day 7 = 0.94 (95% CI 0.87–1.00; p < 0.001) | |||||||
C- statistic for predicting return to pre-stroke diet on day 30 = 0.71 (95% CI 0.61–0.82; p < 0.001) | |||||||
Lee et al. [33] | 137 | Swallowing function at 6 months post-stroke | Tube feeding recommended at initial VFSS Male sex Clinical dysphagia scale score ≥ 20 Bilateral lesions at the corona radiata, basal ganglia or internal capsule Sever white matter hyperintensities | Machine learning—Bayesian network model | Fivefold cross validation | ROC curve = 0.802 | |
Wang et al. [34] | 340 training set 145 validation set | To predict dysphagia recovery (FOIS = 7) at follow-up on day 7, day 14 and day 30 | Age Stroke type Stroke location NIHSS GCS BI BMI FOIS | Multivariable logistic regression nomogram | Bootstrapping | C indices for prediction nomograms were: day 7: 0.847 (95% CI 0.804–0.884) day 14: 0.817 (95% CI 0.772–0.857) day 30: 0.786 (95% CI 0.739–0.829) | Calibration curve of the nomogram for the probability of day 7, day 14, and day 30 swallowing recovery |
Study Quality
Design/study | Purpose and Literature (-/2) | Selection Bias (-/2) | Attrition Bias (-/1) | Outcome Measures (-/2) | Results (-/2) | Conclusions (-/2) | Total (max 11) |
---|---|---|---|---|---|---|---|
Development/validation of a prognostic model | |||||||
Galovic et al. [32] | 2 | 2 | 1 | 2 | 2 | 2 | 11 |
Lee et al. [33] | 2 | 2 | 1 | 1 | 2 | 1 | 9 |
Wang et al. [34] | 2 | 1 | 1 | 2 | 2 | 2 | 10 |
Prospective cohort studies | |||||||
Ickenstein et al. [29] | 2 | 0 | 1 | 2 | 2 | 1 | 8 |
Oh et al. [31] | 2 | 2 | 1 | 2 | 2 | 2 | 11 |
Mann et al. [5] | 2 | 1 | 1 | 0 | 2 | 2 | 8 |
Smithard et al. [30] | 2 | 1 | 1 | 0 | 1 | 0 | 5 |
Retrospective cohort studies | |||||||
Calvo et al. [26] | 2 | 2 | 1 | 0 | 2 | 2 | 9 |
Choi et al. [25] | 2 | 1 | 1 | 2 | 2 | 2 | 10 |
Crisan et al. [18] | 2 | 2 | 1 | 2 | 2 | 2 | 11 |
De Stefano et al. [27] | 2 | 1 | 1 | 0 | 2 | 2 | 8 |
Kim et al. [19] | 2 | 2 | 1 | 0 | 2 | 1 | 8 |
Kumar et al. [8] | 2 | 2 | 1 | 0 | 2 | 1 | 8 |
Lee et al. [20] | 1 | 1 | 1 | 0 | 2 | 2 | 7 |
Lee et al. [28] | 2 | 1 | 1 | 1 | 2 | 1 | 8 |
Lin et al. [21] | 2 | 2 | 1 | 2 | 2 | 2 | 11 |
Schroeder et al. [22] | 2 | 2 | 1 | 0 | 2 | 2 | 9 |
Seo et al. [23] | 2 | 2 | 1 | 1 | 2 | 2 | 10 |
Wilmskoetter et al. [24] | 2 | 1 | 1 | 2 | 2 | 2 | 10 |