Objective-To determine the incidence of dysphagia and associated pulmonary compromise in stroke patients through a systematic review of the published literature. Methods-Databases were searched (1966 through May 2005) using terms "cerebrovascular disorders," "deglutition disorders," and limited to "humans" for original articles addressing the frequency of dysphagia or pneumonia. Data sources included Medline, Embase, Pascal, relevant Internet addresses, and extensive hand searching of bibliographies of identified articles. Selected articles were reviewed for quality, diagnostic methods, and patient characteristics.Comparisons were made of reported dysphagia and pneumonia frequencies. The relative risks (RRs) of developing pneumonia were calculated in patients with dysphagia and confirmed aspiration. Results-Of the 277 sources identified, 104 were original, peer-reviewed articles that focused on adult stroke patients with dysphagia. Of these, 24 articles met inclusion criteria and were evaluated. The reported incidence of dysphagia was lowest using cursory screening techniques (37% to 45%), higher using clinical testing (51% to 55%), and highest using instrumental testing (64% to 78%). Dysphagia tends to be lower after hemispheric stroke and remains prominent in the rehabilitation brain stem stroke. There is increased risk for pneumonia in patients with dysphagia (RR, 3.17; 95% CI, 2.07, 4.87) and an even greater risk in patients with aspiration (RR, 11.56; 95% CI, 3.36, 39.77). Conclusions-The high incidence for dysphagia and pneumonia is a consistent finding with stroke patients. The pneumonia risk is greatest in stroke patients with aspiration. These findings will be valuable in the design of future dysphagia research.

Background and Purpose Hemiparesis resulting in functional limitation of an upper extremity is common among stroke survivors. Although existing evidence suggests that increasing intensity of stroke rehabilitation therapy results in better motor recovery, limited evidence is available on the efficacy of virtual reality for stroke rehabilitation. Methods In this pilot, randomized, single-blinded clinical trial with 2 parallel groups involving stroke patients within 2 months, we compared the feasibility, safety, and efficacy of virtual reality using the Nintendo Wii gaming system (VRWii) versus recreational therapy (playing cards, bingo, or “Jenga”) among those receiving standard rehabilitation to evaluate arm motor improvement. The primary feasibility outcome was the total time receiving the intervention. The primary safety outcome was the proportion of patients experiencing intervention-related adverse events during the study period. Efficacy, a secondary outcome measure, was evaluated with the Wolf Motor Function Test, Box and Block Test, and Stroke Impact Scale at 4 weeks after intervention. Results Overall, 22 of 110 (20%) of screened patients were randomized. The mean age (range) was 61.3 (41 to 83) years. Two participants dropped out after a training session. The interventions were successfully delivered in 9 of 10 participants in the VRWii and 8 of 10 in the recreational therapy arm. The mean total session time was 388 minutes in the recreational therapy group compared with 364 minutes in the VRWii group (P=0.75). There were no serious adverse events in any group. Relative to the recreational therapy group, participants in the VRWii arm had a significant improvement in mean motor function of 7 seconds (Wolf Motor Function Test, 7.4 seconds; 95% CI, −14.5, −0.2) after adjustment for age, baseline functional status (Wolf Motor Function Test), and stroke severity. Conclusions VRWii gaming technology represents a safe, feasible, and potentially effective alternative to facilitate rehabilitation therapy and promote motor recovery after stroke.

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Background-It has been speculated that the conflicting results demonstrated across poststroke aphasia therapy studies might be related to differences in intensity of therapy provided across studies. The aim of this study is to investigate the relationship between intensity of aphasia therapy and aphasia recovery. Methods-A MEDLINE literature search was conducted to retrieve clinical trials investigating aphasia therapy after stroke.Changes in mean scores from each study were recorded. Intensity of therapy was recorded in terms of length of therapy, hours of therapy provided per week, and total hours of therapy provided. Pearson correlation was used to assess the relationship between changes in mean scores of outcome measures and intensity of therapy. Results-Studies that demonstrated a significant treatment effect provided 8.8 hours of therapy per week for 11.2 weeks versus the negative studies that only provided Ϸ2 hours per week for 22.9 weeks. On average, positive studies provided a total of 98.4 hours of therapy, whereas negative studies provided 43.6 hours of therapy. Total length of therapy time was found to be inversely correlated with hours of therapy provided per week (Pϭ0.003) and total hours of therapy provided (Pϭ0.001). define aphasia as "the loss of ability to communicate orally, through signs, or in writing, or the inability to understand such communications; the loss of language usage ability." Darley 2 noted that aphasia is generally described as an impairment of language resulting from focal brain damage to the language-dominant cerebral hemisphere. This serves to distinguish aphasia from the language and cognitivecommunication problems associated with non-languagedominant hemisphere damage, dementia, and traumatic brain injury. 3 However, defining aphasia as purely a disorder of language may oversimplify a complex clinical entity. Kertesz 4 clinically described aphasia as a "neurologically central disturbance of language characterized by paraphasias, word finding difficulty, and variably impaired comprehension, associated with disturbance of reading and writing, at times with dysarthria, non-verbal constructional and problemsolving difficulty and impairment of gesture."The most effective means of treating aphasia after stroke has yet to be determined, and studies investigating the efficacy of speech and language therapy (SLT) for patients See Editorial Comment, page 992 suffering aphasia after stroke have yielded conflicting results. One possible explanation for the observed heterogeneity of findings across studies is a difference in intensity of therapy. 5,6 We have noted that the failure to identify a consistent benefit might have been due to the low intensity of SLT applied in the negative studies, whereas higher intensities of therapy were present in positive studies. 7 A meta-analysis that included all patients suffering from aphasia, not just stroke patients, revealed that the more intensive the therapy, the greater the improvement. 8 The objective of the present study is to investiga...