Perspectives on Swallowing and Swallowing Disorders (dysphagia)

This article discusses oropharyngeal strengthening for swallowing rehabilitation in adults. Reduced oropharyngeal strength is common in older adults and adults with age-related medical conditions resulting in less effective bolus transit and increased risk of aspiration. Specific information is presented regarding scientific and theoretical basis (past), development of devices to facilitate and evidence supporting oropharyngeal strengthening (present), and areas requiring further study (future).

Respiratory muscle strength training (RMST) has received considerable research and clinical interest. There are several studies to support its use in various populations with known airway protective disorders, including Parkinson's disease (PD), multiple sclerosis (MS), and chronic obstructive pulmonary disease (COPD). The goal of this paper is to briefly describe RMST: when it should be used, how it can be used, populations which may benefit from its use, and highlight the gaps which still remain. This goal is achieved through a review of the available literature and practical tips for incorporating RMST into the clinical care of patients with airway protective disorders.

The clinical swallow examination (CSE) is widely used by clinicians evaluating patients with dysphagia, yet this method remains controversial among many. The composition and purpose of the CSE are highly variable by region, facility, age group and individual clinician. This article will review literature on the topic and present clinical practice suggestions to further its usefulness and ongoing investigation.

Dysphagia is a common acute and long-term side effect of curative, non-surgical treatment for head and neck cancer (HNC). Despite what is known about dysphagia associated with HNC treatment in terms of its prevalence, severity, physiological characteristics, and the associated effects on quality of life (QoL), our understanding of the key factors which impact on HNC survivors is only just emerging. Whilst quantitative research studies have demonstrated that most people experience dysphagia in the early post-treatment period, and that many people continue to have ongoing swallowing issues for months and years following treatment, emerging qualitative research in this field has provided insights into the extent to which the presence of dysphagia impacts on the everyday lives of people with HNC. By exploring issues from the perspectives of people living with dysphagia, qualitative research has highlighted those factors that have the greatest impact on oral intake, raised issues for service provision, and highlighted the need for additional professional involvement and better long term supportive care.

Addressing swallowing and feeding in a school system is a team effort. Working closely with parents is essential to the student's progress. This article profiles swallowing and feeding intervention by a school-based team with a 5-year-old Down's Syndrome student with dysphagia and behavioral feeding disorders. The team was able to work successfully with the parents which resulted in the student making significant progress both at school and in the home setting.

Careful consideration should be taken to determine how a swallow screen could be implemented in the pediatric population. A variety of factors to be considered include: age, developmental level, feeding experience of the child, diagnosis, the status of the child's dysphagia, and the setting where the patient is treated. A swallow screen might be feasible in specific situations in the pediatric population to identify aspiration risk in those with a change in normal swallow status. Yet, more research is needed to improve the accurate identification for the pediatric population of aspiration risk and other signs of dysphagia that warrant an instrumental assessment. While risk for aspiration is a concern in this population, it is not the only concern due to the dynamic changes in feeding and swallowing performance that occur throughout childhood. These dynamic changes require a thorough clinical observation that neither a swallow screening nor instrumental assessment can provide the clinician. Thus, the clinical swallow evaluation (CSE) remains the most comprehensive tool available to assess oral feeding skill development and function, as well as, to identify risk factors for not only aspiration, but for other aspects of dysphagia, which may warrant an instrumental assessment.

No AccessPerspectives on Swallowing and Swallowing Disorders (Dysphagia)Article1 Oct 2015Patient-Centered Dysphagia Therapy -The Critical Impact of Self-Efficacy Nicole Rogus-Pulia, and Jacqueline Hind Nicole Rogus-Pulia Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans HospitalMadison, WI Department of Medicine, School of Medicine and Public Health, University of Wisconsin-MadisonMadison, WI Google Scholar More articles by this author and Jacqueline Hind Clinical Affairs, Swallow SolutionsMadison, WI School of Medicine and Public Health, University of WisconsinMadison, WI Google Scholar More articles by this author https://doi.org/10.1044/sasd24.4.146 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationTrack Citations ShareFacebookTwitterLinked In References Allegrante, J. P., & Marks, R. (2003). Self-efficacy in management of osteoarthritis.Rheumatic Diseases Clinics of North America, 29(4), 747–768, vi–vii. 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Croom Volume 24Issue 4October 2015Pages: 146-154 Get Permissions Add to your Mendeley library HistoryReceived: Apr 20, 2015Revised: Jul 20, 2015Accepted: Jul 22, 2015 Published in issue: Oct 1, 2015 Metrics Topicsasha-topicsasha-sigsasha-article-typesCopyright & PermissionsCopyright © 2015 American Speech-Language-Hearing AssociationPDF downloadLoading ...

Necrotizing enterocolotis (NEC) is a common cause of morbidity and mortality in infants that are born prematurely. The exact cause of NEC is not known. Clinical correlations between the use of thickened fluids and the development of NEC have been established. Thickened fluids are commonly used for the treatment of symptoms from both dysphagia and gastroesophageal reflux disease (GERD) in fragile infant populations. Despite its frequent recommendation, there is little empirical evidence to support the use of thickened fluids in pediatric populations for the treatment of dysphagia or GERD. There is emerging evidence to support the use of slower flowing bottle/nipple systems and side lying feeding position to support safe oral intake in infant populations. Speech-language pathologists who work in neonatal intensive care units and who work with other fragile infant populations must be aware of the risks associated with the use of thickened fluids in these populations and be prepared to provide alternative treatment options as appropriate.

Introduction: Simultaneous blinded comparisons between the results of a clinical swallowing evaluation (CSE) and fiberoptic endoscopic evaluation of swallowing (FEES) were performed. Methods: Raters were two groups of speech-language pathologists (SLPs) with expertise in dysphagia. One group analyzed the FEES video alone and the other group analyzed the CSE video alone. No consistent agreement was found between the CSE and FEES raters regarding pharyngeal and laryngeal anatomy and physiology, bolus flow characteristics, and oral diet recommendations. Results: There was also no consensus on the need for instrumental testing. Watching the CSE video alone prevented expert SLPs who use a CSE from determining pharyngeal and laryngeal anatomy and physiology, bolus flow characteristics, silent aspiration, and making informed diet recommendations and intervention strategies. Watching the FEES video alone allowed expert SLPs who use FEES to determine pharyngeal and laryngeal anatomy and physiology and bolus flow characteristics and make evidence-based oral diet recommendations. Discussion: A CSE does not have good clinical utility for determining pharyngeal dysphagia. The consequences of these results will be discussed.

Informed consent requires that patients in clinical settings and participants in research voluntarily agree to a proposed plan based on their understanding of a clear and thorough explanation of purpose, risks, benefits, and alternatives. Although the need to obtain informed consent is well understood in clinical and research environments, the evidence suggests that patients, family members, and participants in research are often unclear about options, risks, and benefits even after providing “informed” consent. Individuals with communication or cognitive disorders are at particular risk for a suboptimal outcome of the informed consent process. There are many barriers to achieving true informed consent, but the use of appropriate strategies can minimize the impact of these barriers and allow clinicians and researchers to improve the process of achieving true informed consent.

Current best practice recommendations for videofluoroscopic swallowing studies (VFSS) suggest that fluoroscopy should be performed either on a continuous setting or at 30 pulses per second (pps). Image capture should likewise be set to maximum resolution (i.e., 30 frames per second [fps]). In this article, we discuss choices in technical settings that may result in the output of fewer than 30 unique images per second or result in image distortions. We also describe a test that can be used to confirm image capture quality and rate using an analog metronome. Clinicians and researchers need to be aware of these issues and the limitations they bring to videofluoroscopy review and analysis.

PurposeWe conducted this retrospective study to identify potential signs of aspiration in preterm infants based on crib-side nursing documentation.Study Design and MethodsA total of 2,590 bottle-feedings were examined for signs of distress across 41 preterm infants who were referred for a swallowing evaluation. All infants underwent either a videofluoroscopic swallow study (VSS) or upper gastrointestinal study (GIS). Physiologic and behavioral warning signs were coded across feedings 10 days prior to the imaging study. Presence or absence of documented aspiration during VSS/GIS was coded for each infant.ResultsDistress signs were documented in seven percent of oral feeding attempts. Aspiration was more common when the crib-side nurse documented coughing (LR+, 8.77; 95% CI, .99–77.09), compromised oxygen saturation levels (LR+, 2.15; CI, .86–5.47), and tachypnea (LR+, 2.15; CI, .28–3.01) during bottle-feeding.Clinical ImplicationsEvidence-based distress signs that signal increased suspicion for prandial aspiration will facilitate correct clinical judgments at crib-side. Early identification and prevention of prandial aspiration improves health outcomes for preterm infants.

No AccessPerspectives on Swallowing and Swallowing Disorders (Dysphagia)Article1 Jun 2015Re-emergence of Surgery in the Management of Head & Neck Cancer David Hamilton, Muhammad Khan, James O'Hara, and Vinidh Paleri David Hamilton Otolaryngology, Head and Neck Surgery, Newcastle upon Tyne HospitalsUnited Kingdom Google Scholar More articles by this author , Muhammad Khan Otolaryngology, Head and Neck Surgery, Newcastle upon Tyne HospitalsUnited Kingdom Google Scholar More articles by this author , James O'Hara Otolaryngology, Head and Neck Surgery, Newcastle upon Tyne HospitalsUnited Kingdom Google Scholar More articles by this author and Vinidh Paleri Otolaryngology, Head and Neck Surgery, Newcastle upon Tyne HospitalsUnited Kingdom Google Scholar More articles by this author https://doi.org/10.1044/sasd24.3.79 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationTrack Citations ShareFacebookTwitterLinked In References Abendstein, H., Nordgren, M., Boysen, M., Jannert, M., Silander, E., Ahlner-Elmqvist, M., … Bjordal, K. 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Google Scholar Additional Resources FiguresReferencesRelatedDetails Volume 24Issue 3June 2015Pages: 79-88 Get Permissions Add to your Mendeley library HistoryReceived: Dec 15, 2014Revised: Mar 19, 2015Accepted: Mar 29, 2015 Published in issue: Jun 1, 2015 Metrics Topicsasha-topicsasha-sigsasha-article-typesCopyright & PermissionsCopyright © 2015 American Speech-Language-Hearing AssociationPDF downloadLoading ...

Treatments for head and neck cancer (HNC) have evolved over time, resulting in an increase in outpatient delivery and shorter hospital stays. Head and neck cancer (HNC) patients experience major changes to basic functions, increasing their dependency on others. With this in mind, the demands placed on family members as carers has increased in complexity and intensity, for which they may have just minimal preparation. Caring for someone with dysphagia presents with specific issues relating to adherence to advice, patient safety, and patient adjustment to their altered self. In addition to this, carers are often coming to terms with major changes to their lifestyle, adjusting to their new role, and dealing with their partner's diagnosis of cancer. Despite its importance, there is minimal research in the field with the burden of care being little understood from this perspective. When issues are not clearly defined, an exploratory research approach is required, which is best conducted using qualitative methodology. Qualitative papers show a number of common themes surrounding the HNC carers' perspective on dysphagia. More work is required to further explore this emerging field with development of ways in which they can be best supported.

Decision-making capacity is a fundamental consideration in working with patients in a clinical setting. One of the most common conditions affecting decision-making capacity in patients in the inpatient or long-term care setting is a form of acute, transient cognitive change known as delirium. A thorough understanding of delirium — how it can present, its predisposing and precipitating factors, and how it can be managed — will improve a speech-language pathologist's (SLPs) ability to make treatment recommendations, and to advise the treatment team on issues related to communication and patient autonomy.

There has been resurgence in surgical interventions for oral cavity and oropharyngeal cancer in tandem with technological advances in reconstructive and ablative procedures. This paper considers the mechanisms of impact of these surgical techniques on swallow function and patient outcomes especially in light of the shifting demographics of human papilloma virus (HPV) associated oropharyngeal cancer. We present a framework for considering physiologic impairment within the context of a holistic approach to patient care based on a series of key underlying considerations.

Infants who have feeding difficulties often struggle with coordinating sucking, swallowing, and breathing, and have difficulty eating sufficient quantities for adequate growth. Speech-language pathologists (SLPs) need advanced expertise across a number of areas (e.g., development, medical, swallowing) to work effectively with these young infants, and they use a variety of strategies when treating this population. Therapists working with infants who have feeding difficulties use bottles as a primary therapy tool; how the infant tolerates the flow rate from the bottle/nipple is a major consideration. Caregivers must understand the influence of bottle/nipple flow rates on eating skills, so they can support the emerging oral skill development for these fragile infants, and help parents decide what bottle system to use in their home. Both infant and equipment factors influence bottle/nipple flow rates. This article discusses the influencing factors that need to be considered when determining the optimal flow rate for an individual infant.

In every setting, as a result of the changes in reimbursement, speech-language pathologists (SLPs) need to re-think how services are provided to patients with dysphagia and feeding/swallowing disorders. In addition to implementing strategies to increase efficiency (and thus productivity), SLPs must understand the changes in the healthcare environment. It is advisable that they explore ways to make their services valuable to their facility in addition to direct patient care. It is also recommended that SLPs familiarize themselves with the challenges the facility faces and consider ways they can help the facility meet those challenges. They should seek to continually improve efficiency while keeping an eye on achieving patient outcomes and providing value. In this way, the SLP can remain an important member of the healthcare team.

In the last decade or more, dysphagia research has investigated the effect of lingual strengthening on oropharyngeal dysphagia with promising results. Much of this research has utilized strengthening devices such as the Iowa Oral Performance Instrument (IOPI) or the Madison Oral Strengthening Therapeutic (MOST) Device. Patients are often given a device to use, and are able to complete an exercise protocol daily or multiple times per day. This case study was completed to determine the effectiveness of using the IOPI in an outpatient clinic where therapy was conducted two to three times per week. The patient was seen post tongue resection due to oropharyngeal cancer. From initiation of IOPI use to patient discharge, the patient demonstrated a 71% increase in lingual strength at the anterior position, a 61% increase at the posterior position, and a 314% increase at the base of tongue position. His diet advanced from NPO to general based on gains in lingual strength and bolus propulsion.

There is controversy about the necessity of clinical (bedside) swallowing examinations. Some argue that screening provides enough information to thoroughly manage a case. In instances in which the risk of an adverse event is very high, screening legitimizes short-term intervention to temporarily mitigate that risk. But comprehensive treatment based on screening is always an unguided and imprecise strategy because screening cannot identify the nature of the problem or the method that best treats the problem. As physicians and public health experts know, the diagnostic process begins with case-finding procedures that predict the presence of risk, and progresses through increasingly precise methods until the clinical problem is resolved. Sometimes the more costly gold standard examination is unnecessary. And sometimes the gold standard test is unavailable because the patient is seen in a system in which the infrastructure and expertise for conducting diagnostic instrumental testing are inaccessible, or because of wait lists, or funding issues. Such situations require the speech-language-pathologist (SLP) to determine how to gather the most and best information available under these constraints. This article will discuss the clinical examinations' role in the diagnostic process and refute the claim that it is unnecessary.