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Tuesday, 9 July 2013

Blogging about research - Is surgery the answer for people with cerebral palsy who have trouble eating?

Already I am learning so much from the #SLPbloggers and by blogging about research myself! The summary for last month by Rachel Wynn is HERE.

And below is my offering for this month. A totally different subject to last month, but a topic that has come up so often in my work in the last 10 years. 

Ferluga, E. D., Sathe, N. A., Krishnaswami, S. and Mcpheeters, M. L. (2013), Surgical intervention for feeding and nutrition difficulties in cerebral palsy: a systematic review. Developmental Medicine & Child Neurology.
Here is the entire review from AHRQ. This full review looks into other, non-surgical therapies and their effectiveness. 

Clinical bottom-line:
The abstract for this article is very succinct and sums everything up with this simple sentence...
Evidence for the effectiveness of surgical interventions is insufficient to low.
There is more to be learned from the detail but what the authors are telling us is that there are not enough studies with quality data that show outcomes from surgical intervention. Their literature search produced many single series studies, which is problematic. Single series studies are the most common study design in the disability field, however the risk of bias can be very high. Despite the risk of bias, the authors chose to include a number of case series studies as there was only one prospective cohort study.

What does this mean for our practice?
Conveniently, the authors tell us "what this paper adds (to our knowledge base)"!

- Not many studies provide data on the effectiveness of surgical intervention
- Gastrostomy consistently leads to weight gain
- There are often adverse effects after surgery (including reflux or respiration problems)
- We still don't understand the balance of risk related to surgery and risks of not treating

The interesting bits
Chronic pulmonary disease related to aspiration is a leading cause of death among patients with severe CP.

This article starts with the information that we already know on this topic. We know that the severity of motor impairment (rated via the GMFCS) is linked with feeding problems.

The cyclic nature of feeding problems appears like this...
That is, feeding problems place a burden on carers resulting in stress and fatigue, which unavoidably impacts on the feeding situation.

The data
Studies focused on children.
The authors were looking for data on outcomes in:
- Growth
- Nutrition
- Swallowing
- Hospitalisations
- Antibiotic use
- Quality of Life (the person and/or their carers)
- Satisfaction and stress (of the person and/or their carers)
- Reflux
and adverse effects such as:
- Aspiration
- Gastrointestinal problems
- Respiratory problems
There were few studies that reported on many of these items. Most seemed to focus on weight and growth measurements, overall health (and hospitalisations) and QoL.

Treating Reflux
Two studies focused on surgery for treatment of reflux for people with CP - one randomised controlled trial (RCT) and one case series.
The RCT randomised 14 children to either fundoplication or gastric plication. Both groups showed clinically significant improvement in reflux symptoms.
The case series focussed on Nissen fundoplication by either laprascopic or open approach for 20 children. Reflux an pH monitoring were reported to improve in both groups, however 6 patients had a relapse of symptoms and complications were reported for both groups.

Adverse Events
Three studies focused on analysing adverse effects and two of these found studies fround associarions with outcomes such as overfeeding and reflux. The links between adverse events and risks associated with not intervening are unclear and the authors recommend careful consideration on a case by case basis.

Now, pop down to your library and find the article to read for yourself! As always I recommend that you read this with a critical mind and a questioning eyes.

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