Therapeutic Interventions for Dysphagia as Guided by Evidenced-Based Practice

1. Therapeutic Interventions for Dysphagia as Guided by Evidenced-Based Practice Debra Tarakofsky, M. S., CCC-SLP Michelle Kravatsky, M. S., CCC-SLP Frederick DiCarlo, Ed.D, CCC-SLP

2. Learner Outcomes • Recognize why evidenced-based practice (EBP) is so important? • Gain suggestions for merging EBP into clinical-decision making • Apply a framework of analysis for choosing therapeutic interventions as they apply to the physiology of the swallow

3. INTRODUCTION • In a featured article in JAMDA, clinical neuroscientist Irene Campbell-Taylor states, "there is no evidence to support the suggested need for such management [of swallowing impairment]" and that "the majority of SLPs and other allied health professionals engaged in the management of OPD [oropharyngeal dysphagia] are inadequately trained." The attack rallied ASHA and members of Special Interest Division 13, Swallowing and Swallowing Disorders, to counter a sweeping disparagement of the value of dysphagia intervention and the training of SLPs. A total of 14 authors developed and submitted an article, "Oropharyngeal Dysphagia Assessment and Treatment Efficacy: Setting the Record Straight," to JAMDA.

4. Response re: use of MBS • In the case of pharyngeal phase abnormalities which include such impairments as inadequate airway protection or incomplete and inefficient transport of material through the pharynx …the videofluoroscopy provides a direct opportunity to evaluate the effectiveness of compensatory maneuvers that may reduce the impact of these abnormalities on airway protection … • The risks of implementing dysphagia interventions without instrumented demonstration of beneficial effect are increasingly recognized in regulatory documents. • Oropharyngeal Dysphagia Assessment and Treatment Efficacy: Setting the record straight in response to Campbell-Taylor (Coyle et al., 2009)

5. Additional Support • “Why is an instrumental evaluation of swallowing needed? (Swigert, 2007, accompanying CD-Materials for Education Staff /Physicians) • * “A Bedside Clinical Evaluation is a thorough assessment of oral phase disorders. However for disorders of the pharyngeal phase “ • * “the Bedside Clinical Exam is incomplete and serves as a screening …” • * “The instrumental diagnostic evaluation is crucial in determining which treatment techniques are needed.” If these are Swigert quotes they need a page # for example (Swigert, 2007,accompanying CD-Materials for Education Staff/Physicians)

6. Understanding theunderlying physiology of the disordered swallow has to be the baseline from which you develop your treatment program Miller and Groher (1992) indicated …become familiar with the clinical pathologic mechanism of certain disease processes (p.197). … include a thorough understanding of effects on the neuromuscular system, clinical course and expected prognosis The interaction of these factors should determine the proper approach to treatment (p.197) Swigert (2007) indicated • The evaluation must include information about the physiological cause of the symptoms (p.101) • …the symptom may have more than one physiological cause. (p. 102)

7. MBS Example – Case History • 87 yo female admitted to the hospital with shortness of breath and Pneumonia with a history of Bronchitis, Anxiety, Coronary Artery Disease, and Myocardial Infarction. Pt was consuming a regular diet with thin liquids prior to admission and was downgraded to Puree/Nectar after she is observed to be coughing intermittently with and without PO. On clinical examination she is found to have reduced lingual strength with ROM and coordination WFL. Labial strength, ROM and Coordination are WFL. Velar elevation and retraction are judged to be WFL. Laryngeal Elevation appears reduced. to the

8. The Ugly Swallow • VIDEO With Suggestions

9. Evidence-Based Practice (EBP) Defined • “…the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients…[by] integrating individual clinical expertise with the best available external clinical evidence from systematic research” (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996, p. 71).

10. Why is EBP so Important? • Clinicians need to be able to use efficacy and outcome data (American Speech-Language-Hearing Association, 2005; Dollaghan, 2004) • Clinicians need to be accountable to clients, families and third-party payers for the services they provide (Apel, & Self, 2003) • ASHA Code of Ethics dictates that SLPs and audiologists must provide services that are based on professional and careful decision-making (Apel, & Self, 2003)

11. ASHA STATES • When Evaluating Any Treatment Procedure, Product, or Program Ask Yourself the Following Questions (ASHA, 2009) • What are the stated uses? • To which population does it apply? • Are outcomes with supporting data clearly stated?

12. Levels of EvidenceClassification • 1A: Meta-analysis • 1: Well designed randomized controlled • 2: Well-designed non-randomized controlled • 3: Observational studies with controls • 4: Observational studies without controls (ASHA, 2004a)

13. SLPs and audiologists can make clinical practice evidence-based by: • Recognizing factors of individuals and families, and integrating those factors along with expertise and research evidence • Acquiring and maintaining skills related to EBP necessary in providing high quality care • Evaluating and using diagnostic, screening, and prevention protocol based on EBP literature • Evaluating and using treatment protocols based on EBP literature • Evaluating the quality of evidence appearing in the literature • Continuing to acquire and incorporate high quality EBP into clinical practice (ASHA, 2005)

14. Dispelled Myths regarding EBP • The only acceptable basis for making a clinical decision is from evidence that is found from systematic research • Clinicians are required to review all the literature in search for the highest quality scientific evidence • Only individuals who have completed years of specialized training can critically appraise the results from research (Dollaghan, 2004, April 13)

15. Putting it all together

16. Lingual Strengthening Exercises “The tongue plays a major role in propulsion of the bolus of food or liquid through the oral cavity or pharynx” (Lazarus , 2005, p.2) Oral phase swallowing impairments have been observed in a number of patient populations including the neurologically impaired who often demonstrate impairment in tongue strength(Lazarus , 2005 )(This is a summarization of her)

17. Lingual Strengthening Exercises • TYPE: Resistance Exercises, IOPI • Robbins et al. (2007) in Archives of PM&R • Lazarus (2005) in Perspectives HOW TO: Traditional tongue exercises working against resistance USE: Deficits of bolus manipulation and clearance • OUTCOMES: Strength increases significantly with resistive exercises

18. Example 1 • Video

19. Example 2 • Video

20. Example 3 • Video

21. Thoughts • LSVT

22. Effortful Swallow • USE: To reduce residue in the valleculae and on the base of tongue caused by reduced lingual and base of tongue strength resulting in reduced oral and upper pharyngeal pressure • How to perform: The pt. is instructed to push their tongue hard against their palate and swallow as hard as they can • Outcomes: This technique can be used as a compensation during a meal to reduce valleculae residue and its efficacy can be viewed during the evaluation. It can also be used during therapy to increase BOT strength and improve early onset of pharyngeal pressures. (Swigert, 2007 pg. 135)

23. Example 1 • Video

24. Example 2

25. Example 3 • Video

26. Thoughts • One subject in a study by Garcia et al. (as cited in Swigert, 2007), developed timing issues with nasal backflow.

27. Masako Maneuver • USE: To increase posterior pharyngeal wall movement by restricting the base of tongue. • How to Perform: Ask the pt. to protrude his tongue slightly and hold it between his teeth while he swallows (Complete with saliva only) • Outcomes: Use of the maneuver therapeutically may result in increased bulge of the posterior pharyngeal wall allowing for increased pressure at the junction of the BOT and pharyngeal wall. Swigert 2007 p.(130)

28. Example 1

29. Example 2

30. Example 3

31. Thoughts • Doeltgen (2009) [need this article for your reference list] in theAJSLP Evaluation of manometric measures during tongue hold swallows • On fluoroscopy-Increased valleculae residues, reduced airway closure times and increased pharyngeal delay times when performed

32. Esophageal Dysphagia • ASHA (2004b) in there Guidelines for SLP’s performing VFSS • The standard VFSS typically views bolus flow from the oral cavity to the cervical esophagus. • The role of the SLP ….. Includes identifying disorders of the …… oral, pharyngeal and cervical esophageal regions. • Clinicians should be aware that oropharyngeal swallowing function is often altered in Patients with esophageal motility disorders and dysphagia. • …. the SLP should recognize the need for an extended VFSS with an esophageal screening

33. Esophageal Dysphagia • ASHA (2004b) [need this article or reference for your list] in there Guidelines for SLP’s performing VFSS • A basic understanding of oropharyngeal and esophageal swallowing relationships will allow the clinician to provide optimal services, thus reducing the risk that underlying causes of a patient’s dysphagia will go undetected during an examination. The SLP plays a primary role in addressing all aspects of the patient’s dysphagia. As with any aspect of dysphagia management the team approach is vital.

34. Esophageal Dysphagia • Esterling (2007) in___? ( Need the article for your reference list) ASHA Esophageal Swallowing Physiology and Disorders • MBS Indicators of possible esophageal swallowing abnormalities * Large air column just below UES * Pocket of contrast just posterior and distal to UES (Zenker’s Diverticulum) * Slow or obstructed esophageal clearance in the upright position (+/- tertiary contraction)

35. Example 1

36. Example 2

37. Example 3

38. Final Thought EBP is neither the cure-all nor the fear that is often suggested by its framework. Rather, it is a set of tools that will facilitate improved clinical decision-making, and allow us to be better clinicians, investigators, and educators (Dollaghan, 2004, April 13)

39. ADDITIONAL RESOURCES • The Source for Dysphagia-Third Edition , Nancy B. Swigert • ASHA Product: The Role of Therapeutic Exercises in the Treatment of Dysphagia

40. Internet Access to “High-Yield” Sources www.guideline.gov sponsored by the Agency for Healthcare Research and Quality www.ncbi.nlm.nih.gov sponsored by the National Library of Medicine www.update-software.com/cochrane sponsored by the Cochrane Library (Dollaghan, 2004, April 13)

41. References • American Speech-Language-Hearing Association. (2004a). Example of levels of evidence. Retrieved April 30, 2009 from http://www.asha.org/about/publications/leader-online/archives/2004/040413/f040413a2a.h • ASHA (2004b) [need this article or reference for your list] in there Guidelines for SLP’s performing VFSS • American Speech-Language-Hearing Association. (2005). Evidence-based practice in communication [position statement]. Retrieved April 30, 2009 from http://www.asha.org/members/deskref-journals/deskref/default • American Speech-Language-Hearing Association. (2009). What to ask when evaluating any treatment procedure, product or program. Retrieved April 30, 2009 from http://www.asha.org/members/evaluate

42. References • Apel, K., & Self, T. (2003). Evidence-based practice: The marriage of Research and clinical Services. Retrieved April 30, 2009 from http://www.asha.org/about/publications/leader-online/archives/2003/q3/030909.html • Coyle , J. L., Davis, L. A., Easterling, C., Graner, D. E., Langmoore, S., & Leder, S. B. et al. (2009). Oropharyngeal dysphagia assessment and treatment efficacy: Setting the record straight (response to Campbell-Taylor). Retrieved ___________(Not sure what this…the date we downloaded it? • Doeltgen (2009) [need this article for your reference list] • Dollaghan, C. (2004, April 13). Evidence-based practice: Myths and realities. The ASHA Leader, 4-5, 12.  • Easterling (2007)( Need the article for your reference list)

43. References • Lazarus , (2005), I need the article • Miller [need initials] Groher [need initals] (1992). Dysphagia diagnosis and management (2nd ed.). [need city, state, and publisher] • Robbins, (up to the first 6 authors need to be listed) (2007), I do not have the article • Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M., Haynes, R. B., & Richardson, W. S. (1996). Evidence-based medicine: What it is and what it isn’t. British Medical Journal, 312, 71-72. • Swigert, N. (2007) The source dysphagia (3rd ed.). [need city, state, and publisher]