Intervention by Speech Therapists to Promote Oral Intake of

Patients with Acute Stroke: A Retrospective Cohort Study

Tomoko Nakazora, MD,* Junko Maeda, RST,* Konosuke Iwamoto, MD,*,

Sayori Hanashiro, MD, Yoshikazu Nakamura, MD, PhD,
Tetsuhito Kiyozuka, MD, PhD, and Kazuhisa Domen, MD, PhD

Objective: Early rehabilitation for acute stroke patients is widely recommended.

We tested the hypothesis that daily intervention by speech therapists promotes
safe oral intake of patients with acute stroke. Methods: We analyzed hospitalized
patients who experienced cerebral infarction and cerebral hemorrhage and who
underwent rehabilitation between October 2010 and September 2014 at our hos-
pital. In total, 936 patients were analyzed, and 452 patients underwent daily speech
therapy. We examined the association of training frequency and eating status. Results:
Multiple linear regression analysis indicated that daily speech therapy was cor-
related significantly and positively with a reduction in the number of days of
hospitalization until oral intake commenced (coefficient, .998; 95% confidence in-
terval, 1.793 to .202; P < .05), and was not correlated with the cessation of oral
intake due to aspiration pneumonia after resuming oral intake. Conclusion: Our
retrospective cohort study demonstrated that daily intervention by speech thera-
pists in patients with acute stroke shortens the number of days until oral intake
without increasing the incidence of aspiration pneumonia. Key Words: Acute
strokedysphagiaspeech therapistdaily.
2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Stroke often alters a patients dietary intake because
of dysphagia or impaired consciousness. The high inci-
dence of dysphagia and pneumonia, a poor prognosis,
as well as a higher risk of death are consistently ob-
served in stroke patients1-3; therefore, swallowing function
should be assessed in acute stroke patients at the start
of oral intake. Early swallow screening and dysphagia
management, including active therapeutic approaches
From the *Division of Rehabilitation Medicine, Mishuku Hospi-
tal, Tokyo, Japan; Division of Neurology, Mishuku Hospital, Tokyo,
Japan; and Department of Rehabilitation Medicine, Hyogo College
of Medicine, Nishinomiya, Hyogo, Japan.
Received October 5, 2016; revision received November 18, 2016;
accepted December 8, 2016.
Address correspondence to Tomoko Nakazora, MD, Division of
Rehabilitation Medicine, Mishuku Hospital, 33-12, 5-chome,
Kamimeguro, Meguro-ku, Tokyo 153-0051, Japan. E-mail:
supertomokohime@hotmail.com.
1052-3057/$ - see front matter
2017 National Stroke Association. Published by Elsevier Inc. All
rights reserved.
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2016.12.007
and dietary modification, reduce the risk of aspiration
pneumonia and assure quality care with optimal
outcomes.4-9 Abnormal volitional cough, abnormal gag
reflex, dysphonia, closure insufficiency of mouth, higher
National Institutes of Health Stroke Scale (NIHSS)
scores, and cranial nerve palsy are warning factors of
dysphagia.10
Although swallowing screening tests, including the re-
petitive saliva swallowing test (RSST) and water-
swallowing test, are simple and beneficial, the sensitivity
and specificity of detecting aspiration in these screening
tests have limitations. Therefore, a comprehensive eval-
uation of some screening items has been recommended.11-13
For the diagnosis of aspiration and dysphasia,
videofluoroscopic swallow examination (VF) 14 and
videoendoscopic examination of swallowing (VE)15 are used
as standard tests. Abnormal findings in these tests are
related to the incidence of aspiration pneumonia.
Based on the results of these tests, instructing patients
and families how to modify diets and use compensato-
ry swallowing techniques is effective in preventing medical

480 Journal of Stroke and Cerebrovascular Diseases, Vol. 26, No. 3 (March), 2017: pp 480487
PROMOTING ORAL INTAKE AFTER ACUTE STROKE
complications, such as aspiration pneumonia, dehydra-
tion, and malnutrition.16,17
Our hospital opened a stroke center in October 2007
and is an acute care hospital with a 19-bed stroke ward,
including a 6-bed stroke care unit (SCU). We have been
providing speech therapy every day for stroke patients
since October 2012. We hypothesized that daily speech
therapy for acute stroke patients correlates with a re-
duction in the number of days until resuming oral intake
without increasing the incidence of aspiration pneumo-
nia. To test this hypothesis, we performed a retrospective
cohort study to clarify the impact of daily speech lan-
guage therapy for inpatients on eating status after acute
stroke.
Subjects and Methods
Study Design
We conducted a before-and-after retrospective cohort
study of patients who were admitted to our institution
between October 2010 and September 2014. A daily in-
tervention program that included speech therapists (STs)
who counseled patients on swallowing was introduced
in October 2012. Thus, we defined the frequency of therapy
from October 2010 to September 2012 as every weekday
and the frequency of therapy from October 2012 to Sep-
tember 2014 as everyday.
Study Population
Cerebral infarctions or cerebral hemorrhages were based
on symptoms, neurologic signs, and the results of a brain
computed tomography or magnetic resonance imaging
scan. We excluded patients who used tube feeding before
hospitalization. The data selection criteria are shown in
Figure 1. Because the functional recovery of patients has
been reported to differ between subarachnoid hemor-
rhage and other subtypes of stroke,18 we also excluded
patients with a diagnosis of subarachnoid hemorrhage
from this study.
Procedures
Patients who were hospitalized between October 2010
and September 2012 were provided speech therapy at least
20 minutes per weekday. Patients who were hospital-
ized between October 2012 and September 2014 were
provided speech therapy at least 20 minutes every day.
Figure 1. Data selection criteria.
481
All patients initiated speech therapy within 48 hours of
stroke onset.
Commencement of Oral Intake and Behavioral
Intervention
The timing of initiating oral intake, the patients posture,
and the food texture were eventually left to the attend-
ing physicians discretion and in reference to the opinion
of STs. Patients were considered eligible to commence trials
of oral intake when they regained consciousness (spon-
taneous eye opening), were afebrile (temperature <38C),
and were able to maintain a supported sitting position.7
The patients were then screened for dysphagia with bedside
swallowing screening tests, such as the RSST and the 3-mL
water-swallowing test. These evaluations were also pro-
vided for all patients by STs. VF and VE were performed
only in selected patients with a long fasting period, a poor
food test score, or suspicion of aspiration.
Before the initiation of oral intake, training for sitting,
proper relaxation, and the placement of the neck in the
chin-tuck position was performed daily by physical thera-
pists (PTs), occupational therapists (OTs), or ward nurses.
To initiate oral intake, a diet of the appropriate texture
was chosen, and the patient was fed following postural
adjustment while oxygen saturation levels were moni-
tored. Ward nurses performed an intervention during oral
intake 3 times per day. The patients posture or food texture
was adjusted according to the patients response. Spe-
cialized training from STs was also provided for patients
with severe dysphagia.
Nutritional intake was monitored weekly by members
of a nutritional support team to ensure adequate nutri-
tion during the hospital stay.
Oral Care
Oral care with brushing and rinsing was primarily con-
ducted by ward nurses and was performed at least 3 times
per day, regardless of the level of consciousness and in-
tubation status. After oral intake was initiated, oral care
was provided before and after meals.
Physical Therapy and Occupational Therapy
The patients who were hospitalized between October
2010 and September 2012 received more than 80 minutes
of therapy on weekdays (physical therapy and occupa-
tional therapy each for 40 minutes or more) and 40 minutes
482
of therapy on weekends (physical therapy or occupa-
tional therapy) in the SCU. These patients were provided
with 80 minutes or more of rehabilitation only on week-
days after leaving the SCU. The patients who were
hospitalized between October 2012 and September 2014
were provided more than 80 minutes of therapy every
day (physical therapy and occupational therapy each for
40 minutes or more). All patients initiated rehabilitation
within 48 hours of stroke onset.
Data Collection and Outcome Assessment
Data were extracted from electronic medical charts
(EGMAIN-GX, Fujitsu Co. Ltd., Tokyo, Japan). Clinical
parameters (sex, age, duration of hospitalization, stroke
severity, activities of daily living [ADL], eating situa-
tion, stroke subtype, previous stroke, swallowing
evaluations [VE or VF], and comorbidities [heart failure,
deep venous thrombosis, pneumonia, and recurrence])
were recorded for all patients during hospitalization.
Neurologic severity was evaluated using the NIHSS
score upon admission. The ADLs before admission were
assessed using the modified Rankin Scale (mRS). The
ADL at the time of admission and discharge was as-
sessed using the Barthel Index (BI). Swallowing at the
time of admission and discharge was retrospectively
assessed with the Eating Status Scale based on the
medical records on food intake and the need for nutri-
tional supplementation. A diagnosis of clinically defined
heart failure was based on the criteria of the Framing-
ham study.19 The diagnosis of clinically defined deep
venous thrombosis was based on the Guidelines for the
Diagnosis, Treatment and Prevention of Pulmonary Throm-
boembolism and Deep Vein Thrombosis (JCS 2009),
which considers venous thrombosis as occurring in a
vein that is deep to the fascia.20 The diagnosis of clini-
cally defined pneumonia was based on the criteria of
the Centers for Disease Control and Prevention.21 Briefly,
clinically defined pneumonia is diagnosed by the pres-
ence of a new and persistent infiltrate or consolidation
on at least 1 chest x-ray or computed tomography with
one of the following clinical signs: fever, leukopenia or
leukocytosis, and altered mental status in patients with
greater than 70 years of age in the absence of other
causes. This study was approved by the Institutional
Review Board of Mishuku Hospital (2016-05). All clini-
cal investigations were conducted in accordance with
the principles expressed in the Declaration of Helsinki.
Because the data were analyzed anonymously, no in-
formed consent was obtained.
Statistical Analysis
Associations between baseline characteristics and clin-
ical outcomes in the 2 groups of patients who resumed
oral intake and in each stroke subtype group of
T. NAKAZORA ET AL.
patients who resumed oral intake were assessed using
the 2 test or Fishers exact test for categorical variables
and an unpaired t-test for continuous variables.
Multiple linear regression analysis with the number of
days of hospitalization during which patients engaged
in oral intake being the dependent variables was per-
formed to calculate the correlation coefficients of the
following independent variables: daily speech therapy,
age, sex, NIHSS score upon admission, prestroke mRS,
subtype of stroke, and history of stroke. Furthermore, 2
subanalyses were performed after dividing the patients
into 2 groups based on subtypes of stroke, including 1
subanalysis of patients with cerebral infarction which was
performed based on the NIHSS score on admission. Sta-
tistical analysis was performed using the StatPlus 6.0
(AnalystSoft Incorporated, WALNUT, CA, USA). Statis-
tical significance was assumed when P < .05.
Results
In total, 947 stroke patients were admitted to our hos-
pital during the study period. Among them, 936 patients
consumed orally prior to admission and were consid-
ered eligible for the present study.
Table 1 shows the clinical characteristics of the study
patients. In total, 452 patients (48.3%) were provided daily
speech therapy. The NIHSS score upon admission was
significantly lower and the prestroke mRS was higher in
the everyday group compared with the weekday group.
Furthermore, the duration of hospitalization was signifi-
cantly shorter for the everyday group.
Table 2 shows the clinical characteristics of study pa-
tients who resumed oral intake during hospitalization.
Among them, 408 patients (49.0%) were provided with
daily speech therapy. The NIHSS score upon admission
was significantly lower and the prestroke mRS was higher
for the everyday group compared with the weekday group.
The number of days of hospitalization prior to resum-
ing oral intake was significantly shorter for everyday group.
Table 3 shows the clinical characteristics of patients with
various subtypes of stroke who resumed oral intake. The
age, prestroke mRS, BI upon admission and discharge,
and the Eating Status Scale upon admission were sig-
nificantly lower in patients with cerebral hemorrhage
compared with those with cerebral infarction. The du-
ration of hospitalization was significantly longer and the
number of days of hospitalization prior to which pa-
tients resumed oral intake was significantly larger in
patients with cerebral hemorrhage than in those with ce-
rebral infarction.
Multiple linear regression analysis identified the in-
volvement of the everyday group as a significant positive
factor in shortening the number of days of hospitaliza-
tion prior to resuming oral intake (coefficient, .998; 95%
confidence interval, 1.793 to .202; P = .001; Table 4). We
divided patients into 2 groups based upon subtype of
PROMOTING ORAL INTAKE AFTER ACUTE STROKE 483
Table 1. Patient characteristics

Characteristics Total (N = 936) Weekday (n = 484) Everyday (n = 452) P value

Gender
Female 442 (47.2) 225 (46.5) 217 (48.0) .64
Male 494 (52.8) 259 (53.5) 235 (52.0)
Age upon admission (y) 73.43 14.38 72.73 15.10 73.20 13.54 .06
Duration of hospitalization (d) 36.98 34.46 39.07 38.15 34.74 29.90 <.05
NIHSS upon admission 8.988 8.934 9.591 9.143 8.343 8.669 <.05
BI upon admission 22.81 28.20 21.53 28.63 24.18 28.70 .08
ESS upon admission 1.845 1.531 1.826 1.536 1.865 1.528 .35
Prestroke mRS 1.067 1.571 .983 1.519 1.157 1.623 <.05
Cerebral infarction 684 (73.1) 355 (73.3) 329 (72.8) 85
BI upon discharge 57.94 38.94 56.97 39.29 58.98 38.59 .22
ESS upon discharge 4.018 1.423 3.979 1.491 4.060 1.346 .19
Tube feeding only 103 (11.0) 59 (12.2) 44 (9.7) .25
Past history of stroke 219 (23.4) 105 (21.7) 114 (25.2) .20
VE or VF 33 (3.5) 19 (3.9) 14 (3.1) .60
Death 37 (4.0) 25 (5.2) 12 (2.7) .056
Comorbidities
Heart failure 46 (4.9) 28 (5.8) 18 (4.0) .23
Deep venous thrombosis 9 (.9) 7 (1.4) 2 (.4) .18
Pneumonia 131 (14.0) 66 (13.6) 65 (14.4) .78
Recurrence 14 (1.5) 8 (1.7) 6 (1.3) .79

Abbreviations: BI, Barthel Index; ESS, Eating Status Scale; mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke
Scale; SD, standard deviation; VE, videoendoscopic examination of swallowing; VF, videofluoroscopic examination of swallowing.
Values are expressed as the mean SD or number of patients (%).

Table 2. Characteristics of patients who resumed oral intake

Characteristics Total (N = 833) Weekday (n = 425) Everyday (n = 408) P value

Gender
Female 381 (45.7) 194 (45.6) 187 (45.8) .96
Male 452 (54.3) 231 (54.4) 221 (54.2)
Age upon admission (y) 72.29 14.37 71.59 15.24 73.04 13.38 .07
Duration of hospitalization (d) 34.81 33.06 36.54 36.62 33.01 28.83 .06
NIHSS upon admission 7.358 7.498 8.000 7.966 6.689 6.924 <.01
BI upon admission 25.58 28.69 24.44 29.37 26.78 27.94 .11
ESS upon admission 1.950 1.592 1.941 1.606 1.958 1.580 .43
Prestroke mRS .908 1.460 .819 1.393 1.000 1.523 <.05
Cerebral infarction 617 (74.1) 317 (74.6) 300 (73.5) .73
BI upon discharge 64.90 35.46 64.53 35.74 65.29 35.21 .38
ESS upon discharge 4.391 1.004 4.393 1.061 4.390 .942 .48
The number of days of hospitalization 3.419 6.300 4.146 7.241 2.662 5.039 <.001
prior to resuming oral intake (d)
ESS1 upon discharge 42 (5.0) 26 (6.1) 16 (3.9) .15
Due to pneumonia 27 (3.2) 14 (3.3) 13 (3.2) 1.00
Due to higher brain dysfunction 10 (1.2) 7 (1.6) 3 (.7) .34
Due to others 5 (.6) 5 (1.2) 0 (0) .06
Past history of stroke 181 (21.7) 83 (19.5) 98 (24.0) .12
VE or VF 29 (3.5) 16 (3.8) 13 (3.2) .71

Abbreviations: BI, Barthel Index; ESS, Eating Status Scale; mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke
Scale; SD, standard deviation; VE, videoendoscopic examination of swallowing; VF, videofluoroscopic examination of swallowing.
Values are expressed as mean SD or number of patients (%).
484 T. NAKAZORA ET AL.
Table 3. Characteristics of patients who resumed oral intake for each stroke subtype

Characteristics Cerebral infarction (n = 617) Cerebral hemorrhage (n = 216) P value

Daily speech therapy 300 (48.6) 108 (50.0) .73

Age upon admission (y) 74.18 13.29 66.92 15.94 <.001
Duration of hospitalization (d) 33.28 31.01 39.18 38.07 <.05
NIHSS upon admission 6.614 7.375 9.481 7.458 <.001
BI upon admission 29.12 29.91 15.49 21.96 <.001
ESS upon admission 2.130 1.686 1.435 1.143 <.001
Prestroke mRS .976 1.485 .713 1.371 <.05
BI upon discharge 67.81 35.25 50.14 37.18 <.001
ESS upon discharge 4.399 .972 4.370 1.092 .37
The number of days of hospitalization 2.944 5.237 4.773 8.517 <.001
prior to resuming oral intake (d)
Past history of stroke 140 (24.4) 41 (19.0) .26

Abbreviations: BI, Barthel Index; ESS, Eating Status Scale; mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke
Scale; SD, standard deviation.
Values are expressed as mean SD or number of patients (%).

stroke (i.e., cerebral infarction or cerebral hemorrhage).
The results of subgroup analysis showed that there was
no significant difference in the number of days of hos-
pitalization prior to resuming oral intake in patients with
cerebral infarction (Table 5). There was a significantly pos-
itive decrease in the number of days of hospitalization
prior to resuming oral intake in patients with cerebral
hemorrhage (Table 6). We divided patients with cere-
bral infarction into 2 groups based on the calculated mean
of the NIHSS score upon admission in patients with ce-
rebral hemorrhage (mean, 9.48 7.46, 8 and 9). The
results of subgroup analysis showed that there was a sig-
nificantly positive relationship between a reduction in the
number of days of hospitalization prior to resuming oral
intake in the patient group and a higher NIHSS score
(NIHSS score 9; Table 7).

Table 4. Multiple linear regression analysis for the number of days of hospitalization prior to resuming oral intake

Coefficients () 95% CI P value

Daily speech therapy .998 1.793 to .202 <.05

Age upon admission (y) .035 .019 to .050 <.001
Female gender .287 1.123 to .549 .50
NIHSS upon admission .297 .244 to .350 <.001
Prestroke mRS .300 .631 to .031 .08
Cerebral infarction .915 1.857 to .027 .06
Past history of stroke .952 .170 to 2.073 .10

Abbreviations: , standardized partial regression coefficient; CI, confidence interval; mRS, modified Rankin Scale; NIHSS, National In-
stitutes of Health Stroke Scale.

Table 5. Multiple linear regression analysis of cerebral infarction for the number of days of hospitalization prior to resuming
oral intake

Coefficients () 95% CI P value

Daily speech therapy .165 .944 to .613 .68

Age upon admission (y) .020 .001 to .031 <.001
Female gender .084 .909 to .742 .84
NIHSS upon admission .250 .196 to .303 <.001
Prestroke mRS .194 .508 to .121 .23
Past history of stroke .184 .885 to 1.252 .74

Abbreviations: , standardized partial regression coefficient; CI, confidence interval; mRS, modified Rankin Scale; NIHSS, National In-
stitutes of Health Stroke Scale.
PROMOTING ORAL INTAKE AFTER ACUTE STROKE 485
Table 6. Multiple linear regression analysis of cerebral hemorrhage for the number of days of hospitalization prior to resuming
oral intake

Coefficients () 95% CI P value

Daily speech therapy 3.403 5.514 to 1.292 <.01

Age upon admission (y) .045 .011-.078 <.01
Female gender .827 2.980 to 1.325 .45
NIHSS upon admission .378 .244-.511 <.001
Prestroke mRS .338 1.340 to .663 .51
Past history of stroke 2.721 .627 to 6.070 .11

Abbreviations: , standardized partial regression coefficient; CI, confidence interval; mRS, modified Rankin Scale; NIHSS, National In-
stitutes of Health Stroke Scale.

Discussion NIHSS score upon admission. Cerebral hemorrhage is the

most disabling form of stroke. A large percentage of pa-
The present study showed that daily intervention by
tients with cerebral hemorrhage require nutritional
STs in patients with acute stroke shortened the number
supplementation during the early phase of their illness.7
of days until resuming oral intake without increasing the
Stroke severity upon admission is also a major indepen-
incidence of aspiration pneumonia.
dent risk factor for dysphagia after stroke.10 These findings
This is the first study on the association between the
indicate that the daily intervention by STs does not seem
daily ST intervention and the start of oral intake for acute
to be beneficial in reducing the number of days of hos-
stroke patients with dysphagia. The guidelines for the
pitalization prior to resuming oral intake in mildly disabled
provision and assessment of nutrition support therapy
acute patients. We consider that the lack of significant
in critically ill adult patients (2009) recommend that enteral
association between daily intervention by STs and eating
feeding should be started early within the first 24-48 hours
status in mild cases is due to the normal swallowing func-
following admission.22 Feeding started within 72 hours
tion or slight dysphagia upon admission.
following admission and was associated with reduced gut
This reduction in the number of days prior to resum-
permeability, diminished activation, and release of in-
ing oral intake following daily ST intervention may be
flammatory cytokines.23 Importantly, we demonstrated in
the result of doctors decision to start oral intake in mod-
this study that oral intake resumed within 72 hours, on
erately or severely impaired patients. Usually, in these
average, following admission without increasing the in-
patients, doctors carefully determine the timing of re-
cidence of aspiration pneumonia by daily ST intervention.
suming oral intake and are greatly influenced by the
The role of STs in dysphagia management is to evalu-
feedback of the STs. Swallowing screening tests, such as
ate and treat patients with swallowing problems, including
the RSST and the 3-mL water-swallowing test by STs, are
direct modifications of physiological responses and in-
effective in shortening the number of days until oral intake
direct approaches, such as diet modifications. Therefore,
without increasing the incidence of aspiration pneumo-
we think that both the dose of exercise effect and the
nia. Furthermore, enteral nutrition can be provided within
prompt recognition of some findings were effective in in-
72 hours in patients who are not expected to safely resume
creasing frequency.
oral intake.
Two subanalyses in this study found a positive impact
Patients with dysphagia require intervention by mul-
for the everyday group in patients with cerebral hem-
tiple medical or therapeutic specialists. It is therefore
orrhage and those with cerebral infarction, with a higher
preferable that patients with complex issues are managed
by a multidisciplinary team of specialists. These special-
ists work together and with the patient to achieve the
Table 7. Subgroup analysis of cerebral infarction of daily best outcome. During periods of daily ST intervention,
therapy for the number of days required before resuming the physical or occupational therapies on the weekend
oral intake were simultaneously added. The roles of PTs or OTs on
dysphagia management are to evaluate and treat body
Subgroup Coefficients () 95% CI P value positioning, and sensory and motor movements that are
necessary for safe and efficient swallowing, recommend
NIHSS
appropriate seating equipment required during feeding,
9 2.197 4.151 to .242 <.05
and assess prosthetic needs related to self-feeding and
8 .389 .423 to .120 .35
swallowing. Thus, PT or OT intervention can influence
Abbreviations: , standardized partial regression coefficient; CI, the timing of resuming oral intake, especially in stroke
confidence interval; NIHSS, National Institutes of Health Stroke Scale. patients with a dulled or reduced level of alertness or
486
consciousness; however, we believe that the effects of these
treatments are trivial, as interventions by PTs or OTs in
patients with dysphagia take a maximum of 80 minutes
per day. In the SCU, intervention by nurses would have
greater influence on patients in the SCU. Nurses provide
oral care, screen for dysphagia, and work in implement-
ing and maintaining safe swallowing techniques and
compensatory or facilitation strategies during meals and
when taking medications, in both groups.
There are several possibilities concerning why the in-
cidence of pneumonia after the start of oral intake was
not significantly lower in the everyday group than in the
weekday group. The first reason is that nurses might have
not fed patients safely. Colodny found that nurses were
compliant with the ST feeding recommendations for dys-
phagia patients less than 50% of the time. The major reason
for this noncompliance of registered nurses was a lack
of knowledge.24 Feeding often becomes one of the first
tasks that nurses delegate to less-skilled personnel.25 In
our hospital, there are many nurses who have a wide
variety of experience, and less-experienced nurses might
lack the knowledge and experience about feeding tech-
niques. The second reason is that a lack of professional
oral care might be associated with the incidence of as-
piration pneumonia. A previous study demonstrated that
professional oral care by dentists or dental hygienists might
reduce the incidence of pneumonia in acute stroke pa-
tients even if nurses performed routine oral care to all
patients.26 The third reason is that we have already ef-
fectively prevented aspiration pneumonia in both groups:
daily swallowing compensation strategies and diet pre-
scription within an onset of 7 days9 and oral care by nurses
more than 3 times a day.7
We must further reduce the incidence of aspiration pneu-
monia. Nurses demonstrate and maintain both an accurate
and reliable ability to screen for dysphagia in patients
with acute stroke with feedback and repeated opportu-
nities to practice.27 Bedside swallowing assessments
conducted by the certified nurse in dysphagia nursing
can inform nurses about feeding techniques in a way that
creates consensus.28 We are scheduled to arrange for hiring
a certified nurse in dysphagia nursing beginning in January
2017.
This study has certain limitations. First, this is a ret-
rospective cohort study with unavoidable biases and
limitations; however, it is difficult to conduct a prospec-
tive intervention trial on daily rehabilitation by STs when
stroke patients and their family members prefer more dedi-
cated care. Furthermore, it is also difficult to conduct a
double-blind study of behavioral intervention since pa-
tients who are involved in the study may eventually
recognize that they were placed into separate control
groups. Second, this study is an analysis in a single fa-
cility and a meta-analysis is desirable in the future;
however, a multi-site study will be challenged by the com-
plications of initiating daily speech therapy, such as
T. NAKAZORA ET AL.
requiring many STs and holiday work. Third, because all
data were not available after our hospital discharge, the
impact of daily speech therapy in the acute ward on the
long-term outcome of stroke remains unknown. To eval-
uate the long-time effects of daily ST intervention, more
clinical measures and outcomes are required, such as serum
albumin levels, which reflect the effect of nutrition man-
agement or mortality.
Conclusions
In this retrospective cohort study, the daily interven-
tion by STs in patients with acute stroke shortened the
number of days until oral intake without increasing the
incidence of aspiration pneumonia. Nevertheless, this in-
tervention did not result in a decrease in the incidence
of aspiration pneumonia. We would like to study the effect
of interventions by a certified nurse in dysphagia nursing
in patients with acute stroke.
Acknowledgment: We would like to thank Editage
(www.editage.jp) for English language editing.
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