Outcome measurement in dysphagia: not so hard to swallow

Dysphagia Management and Cervical Auscultation: Reliability and Validity Against FEES

This study investigated the reliability and validity (sensitivity and specificity) of cervical auscultation (CA) using both swallow and pre-post swallow-respiratory sounds, as compared with Flexible Endoscopic Evaluation of Swallowing (FEES). With 103 swallow-respiratory sequences from 23 heterogenic patients, these swallows sounds were rated by eight CA-trained Speech-Language Pathologists (SLPs) to investigate: (1) if the swallow was safe (primary outcome); (2) patient dysphagia status; (3) the influence of liquid viscosity on CA accuracy (secondary outcomes). Primary outcome data showed high CA sensitivity (85.4%), and specificity (80.3%) with all consistencies for the safe measurement, with CA predictive values of [Formula: see text] 90% to accurately detect unsafe swallows. Intra-rater reliability was good (Kappa [Formula: see text] 0.65), inter rater reliability moderate (Kappa [Formula: see text] 0.58). Secondary outcome measures showed high sensitivity (80.1%) to identify if a patient was dysphagic, low specificity (22.9%), and moderate correlation (r_s [Formula: see text] 0.62) with FEES. A difference across bolus viscosities identified that CA sensitivities (90.1%) and specificities ([Formula: see text] 84.7%) for thin liquids were greater than for thick liquids (71.0-77.4% sensitivities, 74.0-81.3% specificities). Results demonstrate high validity and moderate-good reliability of CA-trained SLPs to determine swallow safety when compared with FEES. Data support the use of CA as an adjunct to the clinical swallow examination. CA should include pre-post respiratory sounds and requires specific training. Clinical implications: The authors advocate for holistic dysphagia management including instrumental assessment and ongoing CSE/review [Formula: see text] CA. Adding CA to the CSE/review does not replace instrumental assessment, nor should CA be used as a stand-alone tool.

Dysphagia management: Does structured training improve the validity and reliability of cervical auscultation?

Purpose: Cervical auscultation (CA) uses a stethoscope or microphone to complement the clinical swallow examination by interpreting swallowing sounds and swallow-respiratory coordination. This study investigated the effects of structured CA training on CA-rating agreement with Flexible Endoscopic Evaluation of Swallowing (FEES) and CA rater reliability.Method: Thirty-nine speech-language pathologists participated in a structured CA training course at Gothenburg University. They rated nine swallow-respiratory sound recordings which were simultaneously recorded during FEES. Swallow sounds were rated six weeks prior to the CA-workshop using two binary yes/no questions, (1) Safe, (2) Dysphagia, and a third Dysphagia Severity rating. Swallow sounds were rated again (re-randomised) one month post CA-workshop.Result: Agreement with FEES (validity) improved significantly (p < 0.05) pre-post training for the Safe and Dysphagia questions, with post training sensitivities >90% and specificities at 76% and 85% respectively. Dysphagia severity rating improved non-significantly. Intra-rater reliability improved significantly with kappa statistics >0.90 post training. Improvements for inter-rater reliability were noted, though non-significant.Conclusion: Results demonstrate that with structured training, the validity of CA (to detect a Safe/Dysphagic swallow) significantly improves, as does intra-rater reliability. This is congruent with literature identifying the positive effects of structured training improving instrumental dysphagia assessment.

Creation and Initial Validation of the International Dysphagia Diet Standardisation Initiative Functional Diet Scale

OBJECTIVE

To assess consensual validity, interrater reliability, and criterion validity of the International Dysphagia Diet Standardisation Initiative Functional Diet Scale, a new functional outcome scale intended to capture the severity of oropharyngeal dysphagia, as represented by the degree of diet texture restriction recommended for the patient.

DESIGN

Participants assigned International Dysphagia Diet Standardisation Initiative Functional Diet Scale scores to 16 clinical cases. Consensual validity was measured against reference scores determined by an author reference panel. Interrater reliability was measured overall and across quartile subsets of the dataset. Criterion validity was evaluated versus Functional Oral Intake Scale (FOIS) scores assigned by survey respondents to the same case scenarios. Feedback was requested regarding ease and likelihood of use.

SETTING

Web-based survey.

PARTICIPANTS

Respondents (N=170) from 29 countries.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Consensual validity (percent agreement and Kendall τ), criterion validity (Spearman rank correlation), and interrater reliability (Kendall concordance and intraclass coefficients).

RESULTS

The International Dysphagia Diet Standardisation Initiative Functional Diet Scale showed strong consensual validity, criterion validity, and interrater reliability. Scenarios involving liquid-only diets, transition from nonoral feeding, or trial diet advances in therapy showed the poorest consensus, indicating a need for clear instructions on how to score these situations. The International Dysphagia Diet Standardisation Initiative Functional Diet Scale showed greater sensitivity than the FOIS to specific changes in diet. Most (>70%) respondents indicated enthusiasm for implementing the International Dysphagia Diet Standardisation Initiative Functional Diet Scale.

CONCLUSIONS

This initial validation study suggests that the International Dysphagia Diet Standardisation Initiative Functional Diet Scale has strong consensual and criterion validity and can be used reliably by clinicians to capture diet texture restriction and progression in people with dysphagia.

Vagus nerve magnetic modulation facilitates dysphagia recovery in patients with stroke involving the brainstem - A proof of concept study

BACKGROUND & AIMS

Stroke involving the brainstem (SBS) causes severe oropharyngeal dysphagia (OD). Research on the therapeutic efficacy of vagus nerve modulation (VNM) by using repetitive transcranial magnetic stimulation (rTMS) in SBS patients with OD has been limited thus far. We aimed to assess the effect of VNM by using rTMS in improving swallowing function after SBS.

METHOD

We conducted a sham-controlled, double-blinded, parallel pilot study in 28 SBS patients with OD randomly allocated to a real rTMS group (n = 13; TMS_real) or a sham group (n = 15; TMS_sham). For VNM, 5-Hz rTMS was applied to the left mastoid in 10 sessions. We evaluated all patients for swallowing function before and after rTMS conditioning, assessed on the 8-point Penetration-Aspiration Scale (PAS) through videofluoroscopy and the Australian Therapy Outcome Measures-Swallowing scale (AusTOMs). We measured the amplitude and latency of cricopharyngeal motor evoked potentials (CP-MEPs) as the neurophysiological parameters.

RESULTS

TMS_real exhibited significant improvement in all swallowing outcomes-neurophysiological, radiological, and functional-compared with TMS_sham: We noted higher CP-MEP amplitude (p = 0.004), shorter CP-MEP latency (p = 0.004), a lower PAS score (p = 0.001), and a higher AusTOMs score (p < 0.001) following rTMS in TMS_real. Moreover, the neurophysiological improvements were significantly correlated with the functional outcomes (p < 0.05).

CONCLUSIONS

Our results encourage the application of VNM by using rTMS for improving swallowing function after SBS. The immediate therapeutic effects suggest that this novel intervention can be an effective complementary therapy to traditional oropharyngeal rehabilitation.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT02893033.

Multimodal Swallowing Evaluation with High-Resolution Manometry Reveals Subtle Swallowing Changes in Early and Mid-Stage Parkinson Disease

BACKGROUND

Parkinson disease (PD) has detrimental effects on swallowing function. Treatment options are largely behavioral; thus, patients would benefit from an earlier start to therapy. Early swallowing changes in PD are not well-known, so patients do not typically receive swallowing treatment until later in the progression of PD.

OBJECTIVE

We used predictive modeling to determine what quantitative swallowing variables best differentiate individuals with early to mid-stage PD from healthy controls.

METHODS

Participants included twenty-six individuals with early to mid-stage PD and 26 healthy, age- and sex-matched controls. Swallowing was evaluated by simultaneous high-resolution manometry and videofluoroscopy as well as the Sydney Swallow Questionnaire (SSQ). Binomial logistic regression was performed on 4 sets of data: 1) high-resolution manometry only; 2) videofluoroscopy only; 3) SSQ only; and 4) all data combined.

RESULTS

A model from a combined data set had the highest accuracy in differentiating individuals with PD from controls. The model included maximum pressure in the velopharynx (soft palate), pressure variability in the velopharynx, and the SSQ item concerning difficulty with swallowing saliva. No significant models could be generated using the videofluoroscopy data.

CONCLUSIONS

Individuals with PD show quantitative changes in pressure generation and are able to self-assess aspects of swallowing function in the early and mid-stages of PD, even in the absence of swallowing changes seen on videofluoroscopy. A multimodal approach for the assessment of swallowing may be more accurate for determining subtle swallowing changes that occur in the early stages of PD.

Use of the Australian Therapy Outcome Measures for Occupational Therapy (AusTOMs-OT) in an early supported discharge programme for stroke patients in Singapore

Introduction

This short report describes the use of the Australian Therapy Outcome Measures for Occupational Therapy (AusTOMs-OT) in an early supported discharge programme for stroke patients in Singapore.

Method

The Australian Therapy Outcome Measures for Occupational Therapy was assessed at the start and end of the early supported discharge programme and differences were statistically analysed.

Findings

All Australian Therapy Outcome Measures for Occupational Therapy scales demonstrated statistically significant change over time. The most commonly used scales were ‘Upper limb use’, ‘Functional walking and mobility’ and ‘Community life, recreation, leisure and play’, reflecting the pertinent types of occupational therapy intervention used in stroke rehabilitation in the home setting.

Conclusion

This study shows that the Australian Therapy Outcome Measures for Occupational Therapy is a useful outcome measure that can be used to articulate the administered occupational therapy interventions to members of the multi-disciplinary team and support the effectiveness of occupational therapy in stroke rehabilitation.

Cervical auscultation as an adjunct to the clinical swallow examination: a comparison with fibre-optic endoscopic evaluation of swallowing

This prospective, single-blinded study investigated the validity and reliability of cervical auscultation (CA) under two conditions; (1) CA-only, using isolated swallow-sound clips, and (2) CSE + CA, using extra clinical swallow examination (CSE) information such as patient case history, oromotor assessment, and the same swallow-sound clips as condition one. The two CA conditions were compared against a fibre-optic endoscopic evaluation of swallowing (FEES) reference test. Each CA condition consisted of 18 swallows samples compiled from 12 adult patients consecutively referred to the FEES clinic. Patients' swallow sounds were simultaneously recorded during FEES via a Littmann E3200 electronic stethoscope. These 18 swallow samples were sent to 13 experienced dysphagia clinicians recruited from the UK and Australia who were blinded to the FEES results. Samples were rated in terms of (1) if dysphagic, (2) if the patient was safe on consistency trialled, and (3) dysphagia severity. Sensitivity measures ranged from 83-95%, specificity measures from 50-92% across the conditions. Intra-rater agreement ranged from 69-97% total agreement. Inter-rater reliability for dysphagia severity showed substantial agreement (rs = 0.68 and 0.74). Results show good rater reliability for CA-trained speech-language pathologists. Sensitivity and specificity for both CA conditions in this study are comparable to and often better than other well-established CSE components.

Dysphagia and swallowing-related quality of life in Friedreich ataxia

Dysphagia in Friedreich ataxia (FRDA) and its impact on quality of life is not adequately understood. The objective of this study was to characterise dysphagia in FRDA and to determine the impact of swallowing dysfunction on activities, participation, and sense of well-being. Thirty-six individuals with a confirmed diagnosis of FRDA were assessed via a clinical bedside examination (CBE), the Royal Brisbane Hospital outcome measure for swallowing, an oral-motor examination and the Australian therapy outcome measures for speech and swallowing (AusTOMS). Data on swallowing function, diet modification and swallowing strategies were collated. Thirty-three (91.67 %) participants exhibited clinical signs of dysphagia according to the CBE, and all participants received ratings indicating swallowing difficulties on at least one other measure. Dysphagia in FRDA is characterised by oral and pharyngeal stage impairment relating to incoordination, weakness and spasticity. A significant positive correlation was found between the severity of impairment, activity, participation and distress/well-being on the AusTOMS, suggesting that swallowing function decreases with overall reductions in quality of life. A significant correlation was found between activity on the AusTOMS and disease duration (r = -0.283, p = 0.012). No significant correlations were found between dysphagia severity and GAA repeat length, age of onset or disease severity. Participants employing diet modification and swallowing strategies demonstrated higher dysphagia severity, activity limitations and participation restrictions. These data advocate a holistic approach to dysphagia management in FRDA. Early detection of swallowing impairment and consideration of the potential impact dysphagia has on quality of life should be key aspects in disease management.

Clinical prognostic indicators of dysphagia following prolonged orotracheal intubation in ICU patients

Introduction

The development of postextubation swallowing dysfunction is well documented in the literature with high prevalence in most studies. However, there are relatively few studies with specific outcomes that focus on the follow-up of these patients until hospital discharge. The purpose of our study was to determine prognostic indicators of dysphagia in ICU patients submitted to prolonged orotracheal intubation (OTI).

Methods

We conducted a retrospective, observational cohort study from 2010 to 2012 of all patients over 18 years of age admitted to a university hospital ICU who were submitted to prolonged OTI and subsequently received a bedside swallow evaluation (BSE) by a speech pathologist. The prognostic factors analyzed included dysphagia severity rate at the initial swallowing assessment and at hospital discharge, age, time to initiate oral feeding, amount of individual treatment, number of orotracheal intubations, intubation time and length of hospital stay.

Results

After we excluded patients with neurologic diseases, tracheostomy, esophageal dysphagia and those who were submitted to surgical procedures involving the head and neck, our study sample size was 148 patients. The logistic regression model was used to examine the relationships between independent variables. In the univariate analyses, we found that statistically significant prognostic indicators of dysphagia included dysphagia severity rate at the initial swallowing assessment, time to initiate oral feeding and amount of individual treatment. In the multivariate analysis, we found that dysphagia severity rate at the initial swallowing assessment remained associated with good treatment outcomes.

Conclusions

Studies of prognostic indicators in different populations with dysphagia can contribute to the design of more effective procedures when evaluating, treating, and monitoring individuals with this type of disorder. Additionally, this study stresses the importance of the initial assessment ratings.

Retrospective ratings of 100 first time-documented stroke patients on the Functional Oral Intake Scale

PURPOSE

This study investigated whether patients originally evaluated on the swallowing portion of the Functional Assessment Measure (SFAM), an instrument that when used independently of the Functional Assessment Measure (FAM) has questionable reliability and validity, would demonstrate clinically and statistically significant gains if measured on an instrument such as the Functional Oral Intake Scale (FOIS), which is valid and reliable. Second, this study questioned how easily the FOIS could be adopted at Rancho Los Amigos National Rehabilitation Center (RLANRC), a rehabilitation facility currently utilising the Functional Independence Measure and the SFAM. Additionally, this research addressed inter-rater reliability, the relationship between the SFAM and FOIS at admission and at discharge, and the clinical and statistical difference in ratings between the two scales.

METHOD

Treatment was given at RLANRC in Downey, California. Subjects for this study consisted of 100 first time-documented acute stroke patients with swallowing disorders. Inter-item correlation, intraclass correlation coefficients and Spearman Rho Correlations were used to establish inter-rater reliability, and descriptive statistics, Spearman Rho Correlations and the Wilcoxon Signed Ranks Test were used to explore relationships between the two scales.

RESULTS

It was found that there was high inter-rater reliability, strong significant relationships between the SFAM and FOIS at admission and discharge, and statistically significant differences and clinical change in scores between admission and discharge on the FOIS.

CONCLUSION

The FOIS is a valid and reliable instrument that is similar in design to the SFAM and requires minimal training for implementation. The transition from the SFAM to the FOIS will provide RLANRC with a reliable and valid assessment protocol.

Protocolo para controle de eficácia terapêutica em disfagia orofaríngea neurogênica (PROCEDON)

OBJETIVO: apresentar uma proposta para o controle de eficácia terapêutica em disfagia orofaríngea neurogênica. MÉTODOS: o protocolo foi proposto em concordância com a literatura atual e aplicado em um indivíduo pós-acidente vascular encefálico (AVE) isquêmico à direita, comprovado por tomografia computadorizada, com disfagia orofaríngea grave crônica, gênero masculino, 66 anos, apresentando aspiração laringotraqueal e em uso de sonda nasoentérica exclusiva pré-fonoterapia. Para controle da eficácia terapêutica do programa de reabilitação fonoaudiológica foi aplicado, pré e pós-fonoterapia, a classificação do grau de comprometimento da disfagia orofaríngea, Functional Oral Intake Scale (FOIS), a avaliação videofluoroscópica da deglutição com medida do tempo de trânsito faríngeo (TTF) da deglutição por meio de software e da percepção do indivíduo. RESULTADOS: na pré-fonoterapia verificou-se disfagia orofaríngea grave, FOIS nível 1, presença de aspiração laringotraqueal para mais de uma consistência e tempo de trânsito faríngeo de 13 segundos. Após fonoterapia verificou-se disfagia orofaríngea moderada, FOIS nível 5, ausência de aspiração laringotraqueal e TTF de 4 segundos. CONCLUSÃO: o protocolo proposto foi capaz de avaliar a eficácia da reabilitação na disfagia orofaríngea neurogênica neste indivíduo pós-acidente vascular encefálico, tanto para mensurar as mudanças ocorridas na fisiopatologia da deglutição quanto na ingestão oral e na percepção do indivíduo. Outros estudos com populações distintas são necessários, sendo que novas propostas devem ainda refletir a inclusão da condição nutricional e pulmonar do indivíduo no controle de eficácia em disfagia orofaríngea.

Functional outcomes of standard dysphagia treatment in first time documented stroke patients

PURPOSE

This retrospective study investigated whether there were statistically and/or clinically significant changes in functional status for patients between admission and discharge as measured by (1) the assistive/independence levels on the swallowing portion of the functional assessment measure (SFAM), and (2) the food and liquid dietary ratings. Also investigated was the relationship between the assistive/independence levels of the SFAM and the specific dietary ratings.

METHOD

Treatment was given at Rancho Los Amigos National Rehabilitation Centre in Downey, California. Subjects for this study consisted of 100 first-time documented acute stroke patients with swallowing disorders. Descriptive statistics, the Wilcoxon signed ranks test and Spearman rho were used to investigate the proposed questions in this study.

RESULTS

There were statistically significant differences in both the dietary ratings and SFAM levels between admission and discharge and a high percentage of these differences were also determined to be clinically significant. In addition, it was found that there was a high level of variability in the dietary ratings at the majority of SFAM levels.

CONCLUSION

These results demonstrate that separate and specific dietary ratings in addition to the SFAM assistive/ independence levels are necessary to obtain a comprehensive assessment of the stroke patient with dysphagia.

Outcomes of speech-language pathology following stroke: Investigation of inpatient rehabilitation and rehabilitation in the home programs

Speech-language pathology outcomes following stroke are poorly understood, and potential predictors of these, such as age and therapy input have not been well documented. For 12 months, the Australian Therapy Outcome Measures (AusTOMs) for Speech Pathology scales were used to rate swallowing and language outcomes for patients (n = 63) receiving rehabilitation post stroke. Outcomes were compared by service type (inpatient versus home based), amount of input and patient age. Greatest improvement was seen on the Swallowing scale. There was no difference in outcomes of inpatients compared to home based rehabilitation patients. There was a trend towards better outcomes with increasing input for the Swallowing scale and for Participation Restriction and Distress/Wellbeing domains. Patients less than 75 years of age had better Participation Restriction and Distress/Wellbeing outcomes, compared to older patients. These results align with previous studies, suggesting that inpatient and home based service models may be equally effective post stroke. Therapy input and patient age were related to some, but not all, domains of the AusTOMs, and these results may have implications for patient management. They should also direct future research to further explore these relationships; for example, to identify optimal input to achieve best outcomes.