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A Journal on Physical Medicine and Rehabilitation after Pathological Events

Official Journal of the Italian Society of Physical and Rehabilitation Medicine (SIMFER), European Society of Physical and Rehabilitation Medicine (ESPRM), European Union of Medical Specialists - Physical and Rehabilitation Medicine Section (UEMS-PRM), Mediterranean Forum of Physical and Rehabilitation Medicine (MFPRM), Hellenic Society of Physical and Rehabilitation Medicine (EEFIAP)
In association with International Society of Physical and Rehabilitation Medicine (ISPRM)
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Europa Medicophysica 2000 June;35(2):75-83


language: English

Nutrition and diet in stroke rehabilitation

Finestone H. M., Greene-Finestone L. S.

Department of Physical Medicine and Rehabilitation, London Health Sciences Centre, University Campus, University of Western Ontario, London, Ontario, Canada


Nutri­tional and die­tary ­issues are impor­tant to con­sider in the reha­bil­i­ta­tion of ­patients who ­have sus­tained a ­stroke. ­Stroke ­patients are nutri­tion­ally vul­ner­able ­because ­they ­have a ­large ­number of neu­ro­logic def­i­cits ­that can con­tribute to ­decreased die­tary ­intake and, even­tu­ally, mal­nu­tri­tion. ­This ­article ­focuses on gen­eral prin­ci­ples of nutri­tional assess­ment and the spe­cific nutri­tional and die­tary con­cerns of ­stroke ­patients. ­Among fac­tors con­trib­uting to ­eating dif­fi­cul­ties and nutri­tional impair­ment, dys­phagia is ­common ­after ­acute ­stroke. ­Other neu­ro­logic def­i­cits ­that may ­adversely ­affect the ­stroke ­patient’s ­ability to ­self-­feed ­include ­upper ­extremity par­al­ysis or ­paresis, ­apraxia, ­agnosia, ­right and ­left dis­or­ien­ta­tion, depres­sion, and ­visual ­neglect or ­denial of the par­a­lysed ­extremity. ­Stroke ­patients some­times ­exhibit ­eating-­related beha­viour prob­lems ­such as atten­tion-con­cen­tra­tion def­icits, ­eating too ­fast or too ­slowly, or for­get­ting to ­swallow. In the ­acute meta­bolic ­response to gen­eral ­injury, ­initially ­there is a ­decline in ­energy (­caloric) expen­di­ture and ­increased ­activity of the sym­pa­thetic ner­vous ­system, ­including ele­vated cor­tisol ­output. A hyper­met­a­bolic ­phase fol­lows in ­which ­energy expen­di­ture and ­nitrogen excre­tion are ­increased. ­This ­results in net ­losses ­from the pro­tein and fat com­part­ments of the ­body. The ­goal of the nutri­tional assess­ment is to ­help the ­patient ­attain or main­tain a suf­fi­cient ­level of ­energy and nutri­ents (­normal nutri­tion ­status) to ­reduce the ­risk of ­adverse out­comes asso­ciated ­with ­poor nutri­tion and pro­mote an ­optimal ­level of ­health. The nutri­tional assess­ment may ­take dif­ferent ­forms, ­ranging ­from ­brief ­screening ­tools to com­pre­hen­sive eval­u­a­tion. Anthro­po­metric and bio­chem­ical meas­ure­ments as ­well as phys­ical exam­ina­tion and med­ical and die­tary his­to­ries are ­useful in ­assessing nutri­tional ­status. ­Even ­though die­tary ­intakes can some­times ­appear to be ade­quate on assess­ment, cer­tain ­drugs, dis­ease ­states, or die­tary com­po­nents can ­affect inges­tion, absorp­tion, trans­por­ta­tion, util­iza­tion, or excre­tion of nutri­ents. One of the ­easiest ­ways to esti­mate nutri­tional ­status is to mon­itor ­weight and ­degree of ­weight ­change ­over ­time. The ­Body ­Mass ­Index (BMI) ­scale is a rec­om­mended ­method of ­assessing ­weight ­status. Unfor­tu­nately, it is not val­i­dated for ­adults ­over 65 ­years, who ­form the ­majority of ­stroke ­patient pop­u­la­tion. Under­nu­tri­tion is pre­dic­tive of ­poorer func­tional ­status out­come and ­reduced func­tional improve­ment ­rate in ­acute ­stroke ­patients and ­those under­going reha­bil­i­ta­tion. Fine­stone et al. ­studied the rela­tion­ship ­between MBI ­scores and mal­nu­tri­tion on a reha­bil­i­ta­tion ser­vice: mal­nour­ished ­patients con­sis­tently dem­on­strated ­lower MBI ­scores ­than ade­quately nour­ished ­patients at all inter­vals at ­which ­they ­were eval­u­ated: admis­sion, 1 ­month, 2 ­months, and 2-4 ­months of ­follow-up. ­They ­also had sig­nif­i­cantly ­longer ­lengths of ­stay (p<0.01). The ­risk of dehy­dra­tion in ­stroke ­patients is ­often under­ap­pre­ciated. ­This is par­tic­u­larly ­true of dys­phagic ­patients ­receiving all nutri­tion by ­mouth. ­Guide-­lines for the nutri­tional man­age­ment of ­stroke ­patients are ­described.

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