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Association of Spatial Neglect & Eating and Swallowing

Function post Stroke

Kristen K Maul, Elizabeth E Galletta, Peii Chen, Mooyeon Oh-Park, Yekyung Kong, Kelsea Sandefur,

AM Barrett

AAPMR Annual Meeting 2014

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DisclosureKristen K Maul

Elizabeth E Galletta

Peii Chen

Mooyeon Oh-Park

Yekyung Kong

Kelsea Sandefur

And AM Barrett

have no relevant financial disclosures.

Eating is a complex behaviorVolitional - Oral stage.

Mastication, manipulation and transit of the bolus.Reflexive - Pharyngeal stage.

Initiation of patterned response.Epiglottic inversion.Laryngeal elevation.Upper esophageal sphincter opening. Bolus transit through pharynx into esophagus.

CognitiveBody spatial cognition

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Logemann, 1995; Leopold and Daniels, 2010

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Spatial neglect and eating activity

Spatial neglect & swallowing deficits common post stroke (Flowers, 2013)

Neglect - inattention to left-side affects eating behaviors and patterns may affect volitional stage of swallowing (Andre, 2000)Failure to initiate chewing/swallowing on left side of mouth.Dribbling on the left side of the face.Food retention in the oral cavity.

Neglect may not affect reflexive stage of swallowing and aspiration (Steinhagen et al., 2009)

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Objective of the study is toEvaluate whether the presence of spatial neglect

has an impact on oral phase of swallowing function and eating independence.

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MethodsDesign: Retrospective analysis of Medical RecordSetting: Inpatient Rehabilitation Facility 06/12- 06/13Inclusion:

First time unilateral hemispheric stroke (L or R) being evaluated for spatial neglect

Exclusion:Bilateral lesionsPrevious CVA

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MethodsPredictor variable: Severity of neglect

Catherine Bergego Scale (CBS score via Kessler Foundation-NAP)

Outcome measuresPresence and Type of dysphagia on clinical examination

(oral, pharyngeal, oral-pharyngeal)FIM - eating score

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RESULTS

Demographics & Functional Status (n=82)

Characteristics No Neglect, n = 24 Neglect, n = 58 P value

Age - yrs (sd) 70.5 (16.2) 70.3 (13.3) .958

Female (%) 13 (54.2) 34 (58.6) .711

Rt Stroke (%) 11 (45.8) 48 (82.8) < .001

Days post-onset (sd) 8.8 (5.0) 8.7 (4.7) .971

CBS (sd) 0 10.5 (8.5) N/A

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ResultsDysphagia Dx (type) No Neglect,

n=24Neglect,

n=58P value

Dysphagia, any phase (%) 14 (58.3) 41 (70.1) .279

Oral phase (%) 1 (0.1) 13 (22.4)

.015 Pharyngeal phase (%) 4 (28.6) 1(.02)

Oro-pharyngeal phase (%) 9 (64.3) 27 (46.6)

NDD = National Diet Level (solids)

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Impairment in Oral Stage

Swallowing impairment (%) No Neglect n=14 Neglect n=41

Tongue retraction 2 (14) 8 (20)Tongue pumping 0 1 (2)Extended mastication 2 (14) 14 (34)Premature spillage 2 (14) 10 (24)Anterior leakage 1 (7) 9 (22)Bolus formation 0 7 (17)Bolus propulsion time 0 10 (24)Oral residue 1 (7) 8 (20)Rotary chew 0 5 (12)Piecemeal degluttition 1 (7) 3 (7)Apraxic component 1 (7) 3 (7)Awareness of bolus 0 1 (2)

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Multivariate Logistic Regression

OR (95% Confidence Interval) P value

CBS Score 1.15 (1.05 - 1.26) <.001

Age 0.99 (0.96 - 1.03) .648

Sex (F) 2.99 (1.00 - 8.93) .050

Right Stroke 0.30 (0.09 - 1.03) .065

Neglect predicts diagnosis of dysphagia, controlling for age, sex, & stroke side

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Eating FIM score by Neglect Severity

Mild Moderate Severe0

1

2

3

4

5

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Severity of Neglect

FIM

Ea

tin

g S

co

re

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SummaryIn a sample of 82 first-time stroke survivors,

individuals with spatial neglect were more-likely to have oral dysphagia

Spatial neglect is associated with greater dependence in eating.

Interdisciplinary communication is required in treatment of patients with dysphagia and spatial neglect.

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Future DirectionsRelationship between the type of neglect (personal

neglect vs extrapersonal neglect) and the oral phase dysphagia

Prospective study of oral phase swallowing difficulties to distinguish stroke severity and neglectto assess the morbidity in neglect associated dysphagia

Demographics & Functional Status (n=82)

Characteristics No Neglect, n = 24 Neglect, n = 58 P value

Days post-onset (sd) 8.8 (5.0) 8.7 (4.7) .971

Total FIM-admit (sd) 82.8 (17.1) 57.8 (16.6) < .001

Cog FIM-admit (sd) 26.1 (5.8) 22.1 (2.9) < .001

Motor FIM-admit (sd) 56.7 (13.6) 35.8 (13.5) < .002

CBS (sd) 0 10.5 (8.5) N/A

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ResultsDysphagia Dx (type) No Neglect,

n=24Neglect,

n=58P value

Dysphagia, any phase (%) 14 (58.3) 41 (70.1) .279

Oral phase (%) 1 (0.1) 13 (22.4)

.015 Pharyngeal phase (%) 4 (28.6) 1(.02)

Oro-pharyngeal phase (%) 9 (64.3) 27 (46.6)

NDD 1 2 11

NDD 2 4 7

NDD 3 3 11

NDD 4 11 15

NDD = National Diet Level (solids)

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Impairment in Pharyngeal Stage

Swallowing impairment No Neglect n=14 Neglect n=41

Delayed swallow Initiation 1 (7%) 12 (29%)

Pharyngeal constriction 1 (7%) 7 (17%)

Vallecular pooling 2 (14%) 10 (24%)

Pyriform pooling prior to the swallow 1 (7%) 11 (26%)

Penetration 2 (14%) 13 (32%)

Silent aspiration 1 (7%) 5 (12%)

Pharyngeal transit time 0 3 (7%)

Pharyngeal residue 1 (7%) 2 (5%)

Sensory integrity 0 3 (7%)

Hyolaryngeal elevation 1 (7%) 8 (20%)

Epiglottic retroflexion 0 3 (7%)

No difference in Pyriform /Valllecular residue, aspiration, reduced tongue base retraction

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ReferencesAndré, J. M., Beis, J. M., Morin, N., & Paysant, J. (2000). Buccal

hemineglect.Archives of neurology, 57(12), 1734-1741.

Flowers, H. L., Silver, F. L., Fang, J., Rochon, E., & Martino, R. (2013). The incidence, co-occurrence, and predictors of dysphagia, dysarthria, and aphasia after first-ever acute ischemic stroke. Journal of communication disorders,46(3), 238-248.

Logemann, J. A., & Logemann, J. A. (1997). Evaluation and treatment of swallowing disorders. 2nd Edition, Pro Ed: Austin, TZ.

Leopold, N. A., & Daniels, S. K. (2010). Supranuclear control of swallowing.Dysphagia, 25(3), 250-257.

Steinhagen, V., Grossmann, A., Benecke, R., & Walter, U. (2009). Swallowing disturbance pattern relates to brain lesion location in acute stroke patients.Stroke, 40(5), 1903-1906.