A study to assess the Effectiveness of

Swallowing exercises on Swallowing Ability

among Patients
with Cerebrovascular Accident in selected
Hospitals
 
D. Maria Diana , Dr.(Mrs) S.S Sharmila Jansi Rani2
1
1
Msc(N), Department of Medical Surgical Nursing, Christian College of Nursing, Neyyoor
2
Professor, Christian College of Nursing, Neyyoor, Kanyakumari Dt, Tamil Nadu.
*Corresponding Author Email: mariadianad@ymail.com
 
ABSTRACT:
Background: Dysphagia is one of the most frequent symptoms in patients with stroke which is paralysis of throat
muscles. This condition can disrupt the swallowing process and make eating, drinking, taking medicine and breathing
difficulty.
Objectives: This study was carried out to assess the effectiveness of swallowing exercises on swallowing ability among
patients with cerebrovascular accident.
Materials and Methods: The research design selected for this study was pre-experimental design (one group pretest
posttest design). The study was conducted in Muthu Neuro Centre, Nagercoil. The investigator selected
30 cerebrovascular accident patients with mild and moderate swallowing difficulty. Non probability purposive sampling
technique was used. The tools used for data collection are demographic, clinical data and Modified Mann Assessment of
Swallowing Ability scale. Pretest was conducted to assess the severity of swallowing difficulty by using Modified Mann
Assessment of Swallowing Ability scale. Then swallowing exercises was demonstrated for 30 subjects with mild and
moderate swallowing difficulty. Intervention was done continuously for 7 days in the morning before breakfast. After one
week of interventions posttest done with same tool and data were analyzed.
Results: The study revealed that the pretest mean swallowing ability score was 50.46 with standard deviation 12.045
among the cerebrovascular accident patient. The posttest mean swallowing ability score 77.06% with standard deviation
9.54 among the cerebrovascular accident patient. Conclusion: Swallowing exercises were effective among
the cerebrovascular accident patients regarding their swallowing ability.
 
KEY WORDS: Assess Effectiveness,Cerebrovascular accident, Swallowing ability, Swallowing exercises
 

INTRODUCTION:
Swallowing is a complex function that affects the physical and mental health of all human beings. The mechanism of
swallowing is coordinated by operation of the mouth, pharynx, and esophagus. Human beings swallow 600 times per day.
Under normal circumstances, swallowing is performed without thought or effort 1. Dysphagia is the health profession’s
term used to describe difficulty swallowing both solid and liquid foods. The term dysphagia is derived from
Greek dys- (bad, difficult) + phagein (to eat). Dysphagia results from problems in nerve or muscle control that may
accompany various medical conditions.
 
These conditions cause weakness and structural problems in the stroke patients in the coordination of the mouth and throat
muscles that direct food and/or liquids to travel down the trachea (windpipe) instead of the esophagus (food pipe) 2. The
initial steps in assessment of swallowing include a careful history to assist in defining the reason for the patient's
swallowing disorder, generally followed by a clinical evaluation 3. The clinical assessment generally includes an evaluation
of the patient's mouth, throat or pharynx, and larynx or voice box. The clinician in the area of evaluation and treatment
of dysphagia, looks at the range of motion of structures, the speed of movement of structures, and the coordination of
movement of the structures in the mouth and pharynx 4. Stroke is the leading cause of dysphagia, which is paralysis of the
throat muscles. This condition can disrupt the swallowing process and make eating, drinking, taking medicine and
breathing difficult5. More than 70 percent of stroke survivors experience dysphagia at some point after a stroke. The most
common treatment for dysphagia is swallow therapy, which includes compensatory exercises. In adults with stroke
swallowing exercises increase strength and awareness, to compensations to make swallowing safer, to modifying food
textures to make food easier to manage6. World stroke day is celebrated on 29 October. The global campaign to fight
stroke around the world in the year 2013 theme was “Because I Care”. This theme reminds us that caring about ourselves,
our families and our friends is the key to preventing strokes and to helping those experiences a stroke (Medscape, 2013).
In worldwide dysphagia is estimated that 400,000 to 800,000 individuals worldwide develop neurogenic dysphagia per
year. In that dysphagia range from 25%-70% in patients who have experienced stroke 7.Thus swallowing exercises was
believed to improve the swallowing ability of patients with dysphagia.
 
Statement of the problem:
“A study to assess the effectiveness of swallowing exercises on swallowing ability among patients
with cerebrovascular accident in selected hospitals at Kanyakumari district”.
 
Objectives:                                                  
1.     To assess the swallowing ability before and after swallowing exercises among patients
with cerebrovascular accident.
2.     To find out the effectiveness of swallowing exercises on swallowing ability among patients
with cerebrovascular accident.
3.     To find out the association between pretest swallowing ability with selected demographic variables among patients
with cerebrovascular accident.
 
Hypotheses:
H1 : There will be a significant difference between swallowing ability before and after swallowing exercises among
patients with cerebrovascular accident.
H2 :There will be a significant association between swallowing ability and selected demographic variables among patients
with cerebrovascular accident.
 
Operational definition:
a)     Effectiveness: It refers to the result of swallowing exercises in improving swallowing ability among patients
with cerebrovascular accident.
b)     Swallowing exercises: It refers to lip, tongue, Shaker swallowing exercises, Hyoid lift manuever for 10-15 minutes
of 10-20 repetitions for 3times a day for 1 week.
c)     Swallowing ability: It refers to ability to swallow food and oral secretions from the mouth to the esophagus of
patients with cerebrovascular accident.
d)     Cerebrovascular accident: It refers to cerebrovascular accident patients with mild and moderate   swallowing
difficulty admitted in selected hospitals.
 
 
Assumptions:
     Most of the cerebrovascular accident patients will have swallowing difficulty.
     Cerebrovascular accident patients follow swallowing exercises to improve swallowing ability.
 
Limitations:
     The study was limited to 6 weeks
     The study was limited to cerebrovascular accident patients with swallowing difficulty.
     The sample size was limited to 30.
 
Conceptual framework:
Conceptual Framework is based on Imogene Kings Open System Model (1981). Humans beings are considered as an open
system and they are in constant interaction with the environment, that nursing focus is human being, interacting with their
environment, and thus nursing goal is to help individuals and groups maintain health. Imogene Kings conceptual model is
composed of three interacting systems: Personal system, interpersonal  system, and Social system. The major
concept in  her theory is the Interpersonal system. The system includes  Interaction, Action, Reaction and Transaction.
 
MATERIALS AND METHODS:
Research approach: Research approach used for this study was quantitative approach based on testing a theory composed
of variables, measured with numbers and analyzed using statistical techniques to evaluate the effectiveness of swallowing
exercises for patients with cerebrovascular accident on improving swallowing ability.
 
Research design: The research design selected for this study was pre experimental design (one group pretest posttest
design) enhances the feasibility of conducting the study.
 
Settings:  The investigator selected 30 patients who are admitted in the private rooms and swallowing exercises were
demonstrated to them. The room was well ventilated and away from  noise.  The study was conducted
in Muthu Neuro Centre Private hospital, Nagercoil. This hospital was situated 13 kilometer from Christian College Of
Nursing, Neyyoor. Total bed strength of Muthu Neuro Centre was 50. In 2013 approximately 550-600 patients were
diagnosed with  cerebrovascular accident  and at the month of May and June  70 patients were diagnosed
with cerebrovascular accident among them 32 patients had swallowing difficulty.
 
Population: The target population selected for this study was cerebrovascular accident patients. The accessible population
was cerebrovascular accident patients with mild and moderate swallowing difficulty, admitted
at Muthu Neuro Centre, Nagercoil.
 
Fig.1-Conceptual framework - imogene kings open system model (1981)
 
 

Sample: 
In this study the sample comprised of cerebrovascular accident patients with swallowing difficulty who fulfilled the
inclusion criteria.
 
Sample size:
The sample size consisted of 30 cerebrovascular accident patients with mild and moderate
swallowing swallowing difficulty.
 
Sampling technique:
In this study non probability purposive sampling technique was used to select the subjects who met the inclusion criteria.
 
Criteria for sample selection:
The sample was collected based on the following criteria.
 
Inclusion criteria:
The study included the samples with the following characteristics.
 
Cerebrovascular accident patients who were
1.     Age group of above 40 years
2.     Understands Tamil and English
3.     Willing to participate in the study
4.     Having mild and moderate swallowing difficulty
5.     GCS score of 13-15
 
Exclusion criteria:
The study excluded the samples with the following characteristics.
 
Cerebrovascular accident patients who were
1.     having severe swallowing difficulty
2.     having cancer in the esophagus, surgery in the head and neck, congestive heart failure, end stage renal disease
 
Variables:
Dependent variable:
In this study the dependent variable was cerebrovascular accident patients with swallowing difficulty.
 

Independent variable:
In this study the independent variable was swallowing exercises (Lip, tongue, shaker exercises and hyoid lift maneuver).
 
Data collection tools and techniques:
The following instruments were prepared and used by the investigator for the data collection.
S.N Tools Techniqu Purpose
o e
1. Demographic Interview Assessment of demographic
  and clinical technique and clinical characteristics
  data   of cerebrovascular accident
      patients with swallowing
      difficulty.
       
      Assessment of severity of
2. Modified Observatio swallowing difficulty
  Mann n Method among patients
  Assessment   with cerebrovascular accide
of  Swallowin nt.
g Ability
scale
 
 
 
Description of the tool:
The study has two tools
 
Tool-I
Demographic variables
This section dealt with demographic variables which included patients age, sex, religion, education, occupation, marital
status, income per month, clinical data which included duration of illness, duration of symptoms of dysphagia
 
Tool-II
Modified Mann Assessment of Swallowing Ability scale
The tool was developed by Mann in the year 2004.This tool consisted of 20 items with maximum score of 100 and it
reflects the severity of swallowing impairment. These items helps to assess how respondents feels towards the clinical
findings. After construction of an initial model of tool it was modified in consultation with experts in the field of medical
surgical nursing.
 
Content validity of the tool:
After having an extensive literature review, a consultation with medical and surgical nursing experts, based on the specific
purpose, a tool was prepared and submitted to the research guide, three experts from medical and surgical nursing, one
Neurologist, one Physiotherapist for validation. They were requested to give their valuable opinion on the appropriateness
and relevance of the item on the tool. The indicator of the tool was modified according to the intervention and the score of
200 was modified to 100. Then the tool was translated into Tamil by language experts
 
Reliability of the tool:
In this study, reliability of the Modified Mann Assessment of Swallowing Ability scale was obtained by interater method.
It is the degree of consistency between two raters. Different raters can measure results from the same subjects at same
time.  Then the two measurements are correlated using Spearman rank correlation coefficient method. In this study the
reliability(r=0.9) was found to be highly reliable.
 
Scoring interpretation:
Tool-I
Demographic and clinical variables
Demographic and clinical variables were collected from the patients with cerebrovascular accident with swallowing
difficulty by interview method. This was not scored. It was used for analysis.
 
Tool-II
Modified Mann Assessment of Swallowing Ability scale
The clinical findings were marked according to the indicator in the Modified Mann Assessment of Swallowing Ability
scale by the investigator. Marks allotted to the clinical findings are 5,4,3,2 and 1respectively.The score was interpreted as
follows:
 
 
SEVERITY GROUPING DYSPHAGIA
OF DYSPHAGIA SCORE
No abnormality detected 78-100
Mild dysphagia 68-77
Moderate dysphagia 39-67
Severe dysphagia <38
 
Pilot study:
Pilot study is a small scale version or trial run, done in preparation for a main study (Polit, 2012). The pilot study was
conducted in the month of May 2013 in Kanyakumari Medical Mission Hospital, Neyyoor.  Before conducting the pilot
study formal permission was obtained from the Medical superintendent. Oral consent was obtained from the
3 cerebrovascular accident patients with swallowing difficulty after explaining the purpose of the study. Pretest was
conducted to assess the swallowing ability by using Modified Mann Assessment of Swallowing Ability scales.  Pretest
mean value was 67. Posttest was conducted by using the same tool. Posttest  mean value was 78  .The ‘t’ value
was  5.55.The study results showed swallowing exercises has positive effect on swallowing ability
among cerebrovascular accident patients. The study was found to be feasible to continue the main study.
 
Data collection procedure:
The main study was conducted at Muthu Neuro Centre, Nagercoil. Data collection was done for a period of 6 weeks.
Before conducting the study formal permission was obtained from the Chairman,  Muthu Neuro Centre. Oral consent was
obtained from the samples after explaining the purpose of the study. Thirty samples were selected and demographic
variables of samples were gathered by interview technique. Pretest was conducted to assess the severity of swallowing
difficulty by using Modified Mann Assessment of Swallowing Ability scale. Then swallowing exercises was demonstrated
for 30 subjects with mild and moderate swallowing difficulty. Intervention was done for 7 days continuously in the
morning before breakfast. After one week of the intervention posttest was done with the same tool and the data were
analyzed.
 
Data analysis:
Data analysis was done based on the objectives and hypotheses of the study by using descriptive statistics(frequency,
percentage, mean, standard deviation) and inferential statistics(‘t’test and chi square 2).
 
Ethical consideration:
The proposed study was conducted after the approval of the dissertation committee of Christian College of
Nursing, Neyyoor. Permission was obtained from Chairman, Muthu Neuro Centre, Nagercoil. Oral consent was obtained
from each samples before starting the data collection. Assurance was given to the study samples that anonymity of each
individual would be maintained. This was done for assuring the normal and ethical as well as for the legal safety of the
investigator.
 

RESULTS:
Table 1.Determination of overall swallowing ability score before and after administration of exercises among
the cerebrovascular accident patient
Overall Mini-Max Score Pretest Mean ± SD Posttest Mean ± SD Paired ‘t’ df 5% Level of
Swallowing test Significance
Ability Score 0-100 50.46 ± 12.045 77.06 ± 9.54 17.62 29 2.04 significance
 

Table 1 summarizes the effectiveness of the swallowing exercises among the cerebrovascular accident patients regarding
their swallowing ability. The pretest mean was 50.46±12.045. The posttest mean was 77.06±9.54. The mean difference
was found out using paired ‘t’ test. The difference was high and significant. Hence the exercises were effective among
the cerebrovascular accident patients regarding their swallowing ability.
 

Table 2. Association between pretest level of swallowing ability and the selected demographic variables among
the cerebrovascular accident patients
Sl. Demographic Level of Swallowing Ability Total χ2 P df 5% level of
No Variables Mild Moderate value Significance
1 Age in Years              
  40-50 5 1 6 9.8 7.82 3 Significance
  51-60 3 9 12
  61-70 1 7 8
   71 and above 0 4 4
  Total 9 21 30
2 Sex              
  Male 5 11 16 0.025 3.84 1 Not Significance
  Female 4 10 14
  Total 9 21 30
3 Religion              
  Christian 6 7 13 2.882 5.99 2 Not Significance
  Hindu 2 9 11
  Muslim 1 5 6
  Others 0 0 0
  Total 9 21 30
4 Education              
  Illiterate 1 3 4 0.753 7.82 3 Not Significance
  Schooling 2 7 9
  Diploma/Under Graduate 3 5 8
  Post Graduate 3 6 9
  Total 9 21 30
5 Occupation              
  Unemployed 1 7 8 2.67 7.82 3 Not Significance
  Labourers 2 5 7
  Non- professional 3 6 9
  Professional 3 3 6
  Total 9 21 30
6 Marital Status              
  Married 7 17 24 0.034 5.99 2 Not Significance
  Unmarried 1 2 3
  Widow / widower 1 2 3
  Separated / Divorced 0 0 0
  Total 9 21 30
7 Income per month              
  <5000 1 6 7 5.86 7.82 3 Not Significance
  5001-10,000 1 7 8
  10,001-15,000 3 6 9
  15,001 and above 4 2 6
  Total 9 21 30
8 Duration of illness              
  Less than 6 months 7 6 13 10.69 7.82 3 Significance
  6 months to 1 year 0 12 12 1
  1 year to 2 years 2 1 3
  2 years and above 0 2 2
  Total 9 21 30
9 Duration of symptoms              
of dysphagia
  Less than 1 week 0 0 0 8.57 5.99 2 Significance
  1 week to 1 month 3 0 3
  1 month to 6 months 6 18 24
  6 months and above 0 3 3
  Total 9 21 30
 

Table 2 shows that there is no association between swallowing ability of cerebrovascular accident patients with their
demographic variables like sex, religion, education, and marital status, income per month, except age, duration of illness,
and duration of symptoms of dysphagia. These findings showed that the swallowing exercises was effective among
patients with cerebrovascular accident regarding their swallowing ability.
 
DISCUSSION:
Sample characteristics:
Majority of the samples 40% were in the age group of 51-60 years, 26.67% were in the age group of 61-70 years, 20%
were in the age group of 40-50 years and 13.33% were in the age group of above 70 years.  Dysphagia is common in
people who are elderly or who have had a neurological event such as a stroke (Grief, 2010).Majority of the samples
53.33% were males and 46.67% were females. Majority of the samples 43.33% were Christians, 36.67% were Hindus,
20.00% were Muslims and no one were in the other religion. Majority of the samples 30.00% were schooling and post
graduate, 26.67% were diploma / undergraduate and 13.33% were illiterate. Majority of the samples 30.00% were
nonprofessional, 26.67% were employed, 23.33% were labourers and 20.00% were professional. Majority of the samples
80.00% were married, 10.00% were unmarried and widow / widower and no separated/ divorced samples present.
Regarding income per month, majority of the samples 30.00% were10,001-15,000/- , 26.67% were 5001-10,000/-, 23.33%
were <5000/- and 20.00% were 15,001 and above. Majority of the samples 43.33% were less than 6 months, 40.00% were
6 months-1year, 10.00% were 1 year-2 years and 6.67% were 2 years and above in the duration of illness. Majority of the
samples 80.00% were 1 month to 6 months, 10.00% were 1 week to 1 month and 6 months and above and no other
samples in less than 1 week in the duration of symptoms of dysphagia.
 
H1-significant difference between swallowing ability before and after swallowing exercises among patients
with cerebrovascular accident
 In the pretest mean swallowing ability score was 50.46 with standard deviation 12.045 among
the cerebrovascular accident patient. The overall percentage score of swallowing ability was 50.46%. Majority of the
samples 70% had moderate dysphagia (39-67), 30% had mild dysphagia (68-77).In the posttest mean swallowing ability
score was 77.06 with standard deviation 9.54 among the cerebrovascular accident patient. The overall percentage score of
swallowing ability was 77.06%. Majority of the samples 66.67 had mild dysphagia (68-77), 33.33% had no abnormality
detected (78-100) and no one had moderate dysphagia (39-67).Thus swallowing exercises were effective among
the cerebrovascular accident patients regarding swallowing ability. The pretest mean was 50.46±12.045. The posttest
mean was 77.06±9.54.The paired t test value was 17.62, the difference was 29, significance at 0.05%. The difference was
high and significant. Hence the hypothesis that (there would be a significant difference between swallowing ability
before and after swallowing exercises among patients with cerebrovascular accident) is accepted.
 
H2 - there will be a significant association between swallowing ability and selected demographic variables among
patients with  cerebrovascular accident
Table 2.Showed that chi square value of the demographic variables among the  cerebrovascular accident patients such as
sex was 0.025, religion was 2.882, education was 0.753, occupation was 2.67, marital status was 0.034, income per month
was 5.86 were not significant at 0.05 level and in case of age was 7.82, duration of illness was 10.691, duration of
symptoms of dysphagia was 8.57 would be a significant at 0.05 level. Precisely  exercises were effective among
the cerebrovascular accident patients regarding their swallowing ability. Bedside exercise program showed an
improvement of swallowing function and exhibited a positive secondary effect, such as mood state and quality of life, on
sub-acute stroke patients with dysphagia. For improvement of rehabilitation results on sub-acute stroke patients
with dysphagia, this study suggests that additional intensive bedside exercise would be necessary (Jamine, 2008).
 
CONCLUSION:
The following conclusion were drawn from the study,
1.     Swallowing exercises was effective in improvement of swallowing ability among patients
with cerebrovascular accident.
2.     There was a significant association between pretest swallowing ability with selected demographic variables among
patients with cerebrovascular accident.
 
IMPLICATIONS:
The study has several implications in the following fields.
 
Nursing practice:
1.     The findings of this study enlighten the fact that swallowing exercises can be used to improve the swallowing ability
among patients with cerebrovascular accident.
2.     The study facilitates to educate regarding swallowing exercises to improve the swallowing ability.
3.     Nursing personnel are in the best position to create awareness regarding swallowing exercises in improvement of
swallowing ability.
 
Nursing education:
1.     This study serves as a base for the nurse educator to teach on the aspect of evidenced based practice.
2.     The educator can take initiative to include the topic of effectiveness of swallowing exercises on improvement of
swallowing ability among patients with cerebrovascular accident.
3.     Nurse educator must arrange facilities and opportunities for student nurses to attend workshops, conferences to
imparting their knowledge.
4.     The nurse should be equipped with up to date knowledge on swallowing exercises. So they will be able to impart
appropriate knowledge on improvement of swallowing ability.
5.     The nurse educators should emphasize and encourage the student nurses to conduct periodic health
education programmes to create awareness on swallowing exercises in improvement of swallowing ability.
 
Nursing research:
1.     This study finding can be utilized for literature review for researchers.
2.     This study can use for guidance of researcher to make their study effective.
3.     Researchers can gain knowledge regarding swallowing exercises.
4.     Extensive research must be organized to identify more effective methods to improve swallowing ability.
 
Nursing administration:
1.     Nurse administrators should provide fund for conducting seminar, workshop and conferences regarding the benefits
of swallowing exercises.
2.     Nurse administrators should announce the importance of swallowing exercises through media, posters, pamphlets and
handouts.
3.     Nursing personnel on various health setting should be given in service education to update their knowledge.
4.     Nurse administrator can encourage evidence based practice.
 
RECOMMENDATIONS:
Based on the findings of the study, the investigator proposed the following recommendations for the further study,
1.     This study can be conducted with large number of samples for better generalization.
2.     The study can be done with control group.
A similar study can be done by using other teaching strategies.
 
ACKNOWLEDGEMENT:
I would like to thank my Principal Dr. Mrs. Santhi Appavu, Ph.D (N) Christian College of Nursing, Neyyoor for her
tremendous effort and who has helped me to the midst of her terrific administrative responsibilities. I thank my guide Dr.
Mrs. S.S. Sharmila Jansi Rani, Professor, Department of Medical Surgical Nursing for her guidance, genuine concern,
continued encouragement expertise and constructive suggestions throughout this study. My sincere appreciation goes to
patients of Muthu Neuro Centre for being cooperative during the study.
 
Conflict of interest: Nil
Source of funding: Self
 
REFERENCE:
1.     Logemann J. Textbook of evaluation and treatment of swallowing disorder, Tokyo.2006.
2.     Brly C. Evaluation and treatment of swallowing impairments,from www.stroke.com.retrived on Jan 5,2012.
3.     Carnaby M. Stroke. American journal of speech language pathology. 56(34);2003:34-46.
4.     Cleveland R. Swallowing related outcomes. Clinical journal of medicine.18(7);2005:87-95.
5.     Duarte VM. Short term effectiveness of swallowing exercises. Journal of nursing and care.20(7);2013:305-308.
6.     Lazarus CL. Effect of exercise on swallowing and tongue strength., from www.ijoms.com.retrived on sep 10,2013.
7.     Walley S. Stroke incidence, from www.stok.online.com.retrived on April 14,2013.
 
 
 
Received on 04.06.2014          Modified on 05.07.2014
Accepted on 10.07.2014          © A&V Publication all right reserved
Asian J. Nur.  Edu. and  Research 4(4): Oct.- Dec., 2014; Page 429-435