脳卒中後嚥下障害のRCTレビュー論文

少し古いですが、脳卒中後嚥下障害のRCTのレビュー論文を紹介します。
下記HPで無料で論文を入手できます。

http://ageing.oxfordjournals.org/cgi/reprint/37/3/258

一部訳：1966年から2007年の脳卒中後嚥下障害の治療の効果をみた論文（RCTに限定）の系統的レビュー。
15本の論文をレビューした。食形態の工夫、全般的な嚥下治療プログラム、経管栄養、薬物療法、身体・嗅覚刺激の治療が含まれていた。経鼻経管栄養はPEGと比較して死亡率は変わらない。全般的な嚥下治療プログラムは脳卒中急性期の肺炎を少なくする。
同じ治療方法とアウトカムを用いた研究はほとんどなかった。

私の論文解釈：嚥下でもRCTは増えつつあるが、RCTのメタ分析を行えるレベルには達していない。より質の高いエビデンスを出せる研究が必要。なぜShakerの頭部挙上訓練のRCTがこのレビューに含まれていないのか。

私の考え：質の高いエビデンスがあってもなくても、臨床現場での嚥下リハの重要性は確実で取り組むべき。ただし、さらなるエビデンスが出てこなければ今後、摂食機能療法を診療報酬として算定できる日数（開始後90日間）か点数（1日185点）が減らされる可能性がある。

Dysphagia treatment post stroke: a systematic review of randomised
controlled trials.
Foley N, Teasell R, Salter K, Kruger E, Martino R.
Age Ageing. 2008 May;37(3):258-64.

BACKGROUND: dysphagia is common following stroke and is associated
with the development of pneumonia. Many dysphagia treatment options
are available, some still experimental and others already rooted in
common practice. Previous reviews of these treatments were limited due
to a dearth of available studies. Recently, more trials have been
published warranting a re-examination of the evidence. OBJECTIVE: a
systematic review of all randomised controlled trials (RCTs), updating
previous work and evaluating a broader range of therapeutic
interventions intended for use in adults recovering from stroke and
dysphagia. METHODS: using multiple databases, we identified RCTs
published between the years 1966 and August 2007 examining the
efficacy of dysphagia therapies following stroke. Across studies,
results of similar treatments and outcomes were compared and
evaluated. RESULTS: fifteen articles were retrieved assessing a broad
range of treatments that included texture-modified diets, general
dysphagia therapy programmes, non-oral (enteral) feeding, medications,
and physical and olfactory stimulation. Across the studies there was
heterogeneity of the treatments evaluated and the outcomes assessed
that precluded the use of pooled analyses. Descriptively these
findings present emerging evidence that nasogastric tube feeding is
not associated with a higher risk of death compared to percutaneous
feeding tubes; and general dysphagia therapy programmes are associated
with a reduced risk of pneumonia in the acute stage of stroke.
CONCLUSIONS: dysphagia is known to be a common and potentially serious
complication of stroke. Despite the recent newly published RCTs, few
utilise the same treatment and outcomes thereby limiting the evidence
to support the medical effectiveness of common dysphagia treatments
used for patients recovering from stroke.