Adherence to Dysphagia Treatment Recommendations: A Conceptual Model

Improving swallowing function with thickening agents in post-stroke oropharyngeal dysphagia: a real-world experience

INTRODUCTION

Post-stroke dysphagia (PSD) is a widely prevalent and possibly life-threatening consequence that may lead to aspiration pneumonia, malnutrition, dehydration, and higher mortality risk. Recommending thickened fluids (TF) is a longstanding practice in the management of dysphagia. Augmenting liquid viscosity with a xanthan gum-based thickener benefits patients with PSD by aiding in the enhancement of bolus control, facilitating improved coordination in the swallowing mechanism, and lowering the risk of aspiration. Despite the widespread use of TF, limited high-quality evidence supports its benefits in PSD.

CASE REPORT

This manuscript presents the clinical experience with four varied cases of PSD. A comprehensive approach to management with TF decreased the risk of aspiration pneumonia and facilitated effective management of dietary recommendations both during hospitalization and after discharge (all Cases). In addition, TF maintained nutrition and hydration in patients with multiple hospital admissions (Case 2), maintained hydration in those unable to engage in swallow rehabilitation due to complex medical conditions (Cases 2, 3, and 4), and those who needed slow and longer recovery due to long-term risk of silent aspiration (Cases 2, 3, and 4). In one case (Case 4), the use of TF was extended for more than two years post-stroke with no reported incidence of chest infection.

CONCLUSION

In routine clinical practice, a comprehensive management approach with xanthan gum-based TFs reduces the risk of aspiration and aspiration pneumonia in patients with PSD while maintaining nutritional and hydration and improving swallowing function based on formal instrumental assessments. This clinical experience highlights the pivotal role of instrumental assessment, patient education, and informed decision-making to optimize outcomes with TF.

Implementing flexible endoscopic evaluation of swallow screening within annual cancer surveillance appointments to monitor for late-stage radiation-induced dysphagia: A feasibility study

BACKGROUND

Late-stage progressive decline of swallowing function after radiotherapy for head and neck cancer (HNC) is often difficult to monitor. This study examined the feasibility and clinical outcomes of speech-language pathology implementing flexible endoscopic evaluation of swallow (FEES) screening during annual cancer surveillance visits to monitor late-stage swallowing function.

METHODS

Patients >2 years post treatment who attended routine oncological visits underwent FEES screening. Feasibility (service data, stakeholder survey) and swallowing outcomes (oral intake, secretions, internal lymphedema, penetration-aspiration, and residue) were collected.

RESULTS

Screening was completed with 70% (50/71) of eligible patients. Medical staff and speech-language pathologists indicated the protocol was worthwhile and achievable to incorporate into practice. Almost all patients were willing to complete the protocol annually. FEES outcomes identified 84% with dysphagia versus only 26% self-reported dysphagia.

CONCLUSION

Findings indicate FEES screening incorporated into annual oncological reviews is feasible and effective at monitoring late-stage swallowing function following HNC.

Adherence to commercial food thickener in patients with oropharyngeal dysphagia

BACKGROUND

Oropharyngeal dysphagia (OD), a common symptom in the elderly, uses commercial thickener (CT) as part of its treatment. This is often accompanied of dislike and poor compliance.

AIM

Describe adherence to CT and possible differences according to dwelling location in an area of influence of approximately 400.0000 inhabitants.

METHODS

Cohort prospective observational study. Randomized patients from Nutrition and Dietetic (NDU)-database (4 calls-interviews/year).

VARIABLES

Age, diagnostic, gender, dwelling/location: Home (H) / Nursing Home (NH), viscosity (nectar, honey, pudding), days with CT. Adherence measured with a questionnaire, considering implementation of treatment by combining CT use and consumption data, categorised in three groups good, moderate and poor. Change in patterns (improvement, maintenance, worsening) and non-adherence reasons.

RESULTS

One hundred sixty-eight patients recruited with indicated viscosity: Nectar 39.7%, honey 29.3% and pudding 30.8%. Average age of 82.6 ± 11.1 years; 57.8% women (46.4% at H vs. 67% at NH, p < 0.01). Dwelling/location: 80 (47.6%) live at H and 88 (52.4%) at NH. Days with CT prior study were 509 ± 475.28. Implementation found in first call: good in 50%, moderate in 20.2% and poor in 29.8%. At first call, adherence parameters were more favourable in NH compared to H. However these parameters were reversed during the study period as there was an improvement at H vs. NH. Also in terms of change in patterns a significant improvement of implementation was found in patients living at H, 31.1% vs. those living at NH, 15.7%, p < 0.05. CT persistence throughout study was 89.7%.

CONCLUSIONS

Low adherence to CT found in our community. Telephone follow-up resulted in improved adherence, especially in the H population. Our data provides valuable insights into the variability and changes in CT adherence among patients with OD. Adherence is complex and subject to many factors and dwelling/location is one of them. This study reveals the need to approach CT treatment for OD differently in NH.

Clinician perspectives on the development of a web portal for remote monitoring of mHealth facilitated dysphagia home exercise: A qualitative study

PURPOSE

Mobile health (mHealth) technologies for dysphagia management may allow patients to complete rehabilitation exercises from home and their clinicians to remotely monitor them. However, clinicians are rarely formally consulted in the early stages of ideation. This study aimed to determine necessary elements to be included in a clinician web portal that would allow for remote monitoring of patients completing dysphagia exercises using mHealth equipped with surface electromyography (sEMG).

METHOD

Ten dysphagia clinicians were consulted individually using convergent interviewing. Interviews were transcribed and analysed using thematic analysis to identify themes and sub-themes.

RESULT

Themes identified included: perceived benefits of an mHealth system; clinical uptake of an mHealth system; clinical targets desired; preferred communication method; notification style and frequency; and user interface considerations. There was no consensus regarding clinical targets to display, notification frequency, method of clinician-patient communication, or layout for the user interface. Agreement existed on the importance of the simplicity and customisability for the clinician web portal user interface.

CONCLUSION

Lack of consensus on specific elements to be included in a clinician web portal could reflect low clinical exposure to sEMG. This study provides an example of formal end user feedback in the ideation phase of design.

A randomized controlled study evaluating the head-lift exercise in head and neck cancer patients with radiation-induced dysphagia: effect on swallowing function and health-related quality of life over 12 months

PURPOSE

Dysphagia is common after radiotherapy for head and neck cancer (HNC) and can affect health-related quality of life (HRQL). This randomized controlled trial aimed to evaluate the effect of the head-lift exercise (HLE) over 12 months in HNC patients with radiation-induced dysphagia.

METHODS

Sixty-one patients with dysphagia were randomized to intervention group (n = 30) and control group (n = 31) at 6-36 months after completion of radiotherapy for HNC. Dysphagia-specific HRQL was measured with the MD Anderson Dysphagia Inventory (MDADI); general and HNC-specific HRQL was measured with the European Organization for Research and Treatment of Cancer Quality of Life questionnaire Core 30 (EORTC QLQ-C30) and QLQ-H&N35. Measurements were made at baseline, and at 8 weeks and 12 months after start of intervention.

RESULTS

Adherence to the intervention was good throughout the year. When comparing change from baseline reports to each follow-up no statistically significant differences between the groups were found in any of the HRQL instruments. There were some statistically significant changes within groups compared to baseline. The intervention group improved self-rated swallowing function on the MDADI at 8 weeks (emotional domain, p = 0.03; functional domain, p = 0.007; total score, p = 0.01) and the control at twelve months (emotional domain, p = 0.03; functional domain, p = 0.02; physical domain, p = 0.004; total score, p = 0.002).

CONCLUSION

In this randomized control study, no effect was observed short term or at 12 months on HRQL after use of the HLE as rehabilitation for radiation-induced dysphagia.

Flexibility for Intensity Dosing in Lingual Resistance Exercises: A Large Randomized Clinical Trial in Typically Aging Adults as Proof of Principle

OBJECTIVE

The objective of this study was to determine the effect of intensity dosing during tongue exercise on tongue pressure generation, adherence, and perceived effort.

DESIGN

This was a five-site, prospective, randomized clinical trial. Outcome measures were obtained across multiple baselines, biweekly during exercise, and 4-weeks post-intervention.

SETTING

The general community at each study site.

PARTICIPANTS

Typically aging adults between 55-82 years of age with no history of neurological or swallowing disorders. Eighty-four volunteers completed the study.

INTERVENTIONS

Participants were randomly assigned to one of four exercise groups: (a) maximum intensity/no biofeedback, (b) progressive intensity/no biofeedback, (c) maximum intensity/biofeedback, and (d) progressive intensity/biofeedback. Half of the participants completed a maintenance exercise program.

OUTCOME MEASURES

Maximum isometric pressure (MIP), regular effort saliva swallow pressure, adherence, and the Borg Rating of Perceived Exertion Scale.

RESULTS

All exercise protocols were efficacious for gains in MIP (large effect sizes; Cohen's d). Group 3 made gains in regular effort saliva swallow pressure (medium effect size). There was a significant change in perceived exertion for regular effort saliva swallow pressure at 8 weeks. Tongue pressure gains were maintained at 1 month, regardless of maintenance group status. Mean adherence across groups was high.

CONCLUSIONS

All groups improved pressure generation. Intensity dosing differences did not affect strength gains, adherence, or detraining. Regular effort saliva swallow pressure may be most responsive to maximum intensity with biofeedback. The findings suggest flexibility in approach to tongue exercise protocols. Tongue muscles may differ from limb muscles in terms of dose response and neuroplasticity principles.

Stratifying Risk of Nonadherence in Lingual Strengthening Dysphagia Rehabilitation

PURPOSE

Exercise-based treatments may improve swallowing safety and efficiency; yet, it is not clearly understood which factors predict nonadherence to recommended treatment protocols. The aim of this study was to construct an algorithm for stratifying risk of nonadherence to a lingual strengthening dysphagia treatment program.

METHOD

Using recursive partitioning, we created a classification tree built from a pool of sociodemographic, clinical, and functional status indicators to identify risk groups for nonadherence to an intensive lingual strengthening treatment program. Nonadherence, or noncompletion, was defined as not completing two or more follow-up sessions or a final session within 84 days.

RESULTS

The study cohort consisted of 243 Veterans enrolled in the Intensive Dysphagia Treatment program across six sites from January 2012 to August 2019. The overall rate of nonadherence in this cohort was 38%. The classification tree demonstrated good discriminate validity (C-statistic = 0.74) and contained eight groups from five variables: primary diagnosis, marital status, Penetration-Aspiration Scale (PAS) severity score, race/ethnicity, and age. Nonadherence risk was categorized as high (range: 69%-77%), intermediate (27%-33%), and low risk (≤ 13%-22%).

CONCLUSIONS

This study identified distinct risk groups for nonadherence to lingual strengthening dysphagia rehabilitation. Additional research is necessary to understand how these factors may drive nonadherence. With external validation and refinement through prospective studies, a clinically relevant risk stratification tool can be developed to identify patients who may be at high risk for nonadherence and provide targeted patient support to mitigate risk and provide for unmet needs.

Adherence to swallowing recommendations during (chemo)radiotherapy in head and neck cancer survivors: a scoping review

PURPOSE OF REVIEW

There is a paucity of knowledge regarding patient adherence to dysphagia recommendations. It is recognized that unique barriers and facilitators contribute to poor treatment adherence in head and neck cancer (HNC) survivors. This review aims to identify the key themes and knowledge gaps regarding adherence to swallowing recommendations in HNC survivors during (chemo)radiotherapy (C)RT.

RECENT FINDINGS

Seven studies were identified. Six facilitators to adherence were extracted, namely pain relief, behavioural intervention, attendance at multidisciplinary clinic, individualised swallowing therapy, absence of prophylactic percutaneous endoscopic gastronomy (PEG) and positive social control from a spouse. Barriers to adherence included pain, depression and presence of prophylactic PEG. Adherence to swallowing recommendations positively impacted swallowing outcomes in one study.

SUMMARY

Little is known about adherence to swallowing recommendations during (C)RT in HNC survivors. Capturing adherence is challenging. Several knowledge gaps were identified. Further research is needed to better understand the barriers and facilitators from the survivors' perspective. This will inform development of best practice regarding how swallowing recommendations are provided to promote adherence and improve outcomes.

A Review of Factors Contributing to Adults' Adherence to Dysphagia Dietary Recommendations Through an Ecological Lens

PURPOSE

The purpose of this review was to identify the factors affecting adherence to dysphagia dietary recommendations, a necessary contributor to the effectiveness of this compensatory strategy.

METHOD

A rapid review of two electronic databases was conducted in April 2021. Studies were included based on the following criteria: (a) were empirical studies published in English, (b) included data from the adult population, and (c) measured adherence to dietary recommendations. The ecological model and the health belief model were used as frameworks during the analysis process.

RESULTS

The literature search resulted in 930 unique abstracts, of which 14 articles were included based on the final criteria. Across the literature, multiple factors were identified as having an influence on adherence, classified according to three unique levels: the individual (e.g., dissatisfaction), the caregiver (e.g., knowledge), and the environment (e.g., institutional policies and values).

CONCLUSIONS

Improving adherence to dysphagia dietary recommendations is crucial for the effectiveness of those recommendations. As suggested by the current review, increased adherence will require careful attention to the multiple levels of factors that likely play a role, acknowledging the multifaceted nature of this complex behavior. Furthermore, characterizing the multilevel factors that influence adherence can contribute to future theoretical models, which could help guide speech-language pathologists in their clinical practices.

The Feasibility of Home-Based Treatment Using Vibratory Stimulation in Chronic Severe Dysphagia

PURPOSE

Previously, externally placed vibratory laryngeal stimulation increased rates of swallowing in persons with and without dysphagia. This study examined the feasibility of using a vibratory device on the skin over the thyroid cartilage for home-based swallowing rehabilitation in long-standing dysphagia.

METHOD

Only participants with long-standing dysphagia (> 6 months) following cerebrovascular accident or head/neck cancer who had not previously benefited from dysphagia therapy participated. The device had two modes used daily for 90 days. In automatic mode, participants wore the device when awake, which vibrated for 4-8 s every 5 min to trigger a volitional swallow. In manual mode, participants practiced by activating vibration while swallowing rapidly. Study-related adverse events, such as pneumonia, and device-recorded adherence were tracked. Swallowing function on a modified barium swallow study was assessed at baseline and after 3 months of device use. Outcome measures included the Dysphagia Outcome and Severity Scale (DOSS), Penetration-Aspiration Scale (PAS), and swallowing timing measures. Participants' perceptions of the vibratory device and training were obtained.

RESULTS

The intent to treat analysis showed seven of 11 participants completed the study, all with severe chronic dysphagia. Of those seven participants completing the study, two developed respiratory complications (possibly due to pneumonia) that cleared after antibiotic intervention. For prescribed practice trials, adherence was 80% or greater in four of seven participants (57%) whereas prescribed automatic stimulations were met in only two of seven participants (29%). Three participants (43%) had a modest benefit on DOSS. The time to vestibule closure after the bolus passed the ramus was reduced in five participants (71%) on the modified barium swallow study.

CONCLUSION

Overall, the results have indicated that intensive home-based practice with stimulation may provide limited functional benefits in severe chronic dysphagia.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21498591.

Implementation of the VA Intensive Dysphagia Treatment Program: A Mixed-Methods Evaluation

The Department of Veterans Affairs (VA) Intensive Dysphagia Treatment program serves a critical role in facilitating improvements to quality of care, standardization of outcomes, and increased access to structured therapy for Veterans with dysphagia. It has been implemented at 26 sites nationally and continues expanding. An explanatory sequential mixed-methods design was utilized for program evaluation to identify barriers and facilitators to implementation as reported by speech-language pathologists (SLPs) participating in the program. All 23 IDT program SLPs were invited to participate in an online survey. SLPs were asked to describe etiologies referred for SLP evaluation, most and least clinically useful program aspects, and characteristics of patients recommended for therapy. Qualitative interviews/focus groups were then conducted with 9 SLPs at 3 facilities with varying levels of program experience. Transcripts underwent systems engineering framework informed deductive thematic analysis. Interview/focus groups revealed overall positive feedback. Barriers included data entry challenges and provider understanding of long-term program goals, while facilitators included program structure enabling increased patient follow-up, outcomes tracking, and training in new treatment modalities. Through this evaluation process, program leadership garnered actionable feedback to improve further implementation of the IDT program. Ongoing efforts will further improve data entry, site onboarding procedures, and program communication.

The good, the bad, and the ugly: Unpacking the pros and cons associated with change for adults who stutter

PURPOSE

The purpose of the current study was to document the pros and cons that adults who stutter may consider when deciding to change how they live with stuttering.

METHODS

Semi-structured interviews were conducted with 11 adults who stutter and 12 speech-language pathologists who specialize in stuttering therapy. Participants were asked to identify and discuss the advantages and disadvantages of making a change to how they live with stuttering. Reflexive thematic analysis was used to generate multilevel themes.

RESULTS

Meaningful units were extracted from interview transcripts to develop 37 discrete pros and 15 discrete cons. The pros of change clustered into five organizing themes: enriching one's social relationships, feeling better in social interactions, developing a healthier sense of self, gaining autonomy, and communicating easier. The cons of change clustered into three organizing themes: experiencing discomfort, expending resources, and recognizing that some things may not change.

CONCLUSION

This study documented why adults who stutter may or may not seek change. Identifying the pros and cons of behavior change is an important step in understanding why some clients who stutter are ambivalent about, or resistant to, the therapeutic process.

Innovations in Chewable Formulations: The Novelty and Applications of 3D Printing in Drug Product Design

Since their introduction, chewable dosage forms have gained traction due to their ability to facilitate swallowing, especially in paediatric, geriatric and dysphagia patients. Their benefits stretch beyond human use to also include veterinary applications, improving administration and palatability in different animal species. Despite their advantages, current chewable formulations do not account for individualised dosing and palatability preferences. In light of this, three-dimensional (3D) printing, and in particular the semi-solid extrusion technology, has been suggested as a novel manufacturing method for producing customised chewable dosage forms. This advanced approach offers flexibility for selecting patient-specific doses, excipients, and organoleptic properties, which are critical for ensuring efficacy, safety and adherence to the treatment. This review provides an overview of the latest advancements in chewable dosage forms for human and veterinary use, highlighting the motivations behind their use and covering formulation considerations, as well as regulatory aspects.

Ethical considerations in the care of people with eating, drinking and swallowing difficulties

PURPOSE OF REVIEW

Eating, drinking and swallowing difficulties are low on the list of clinical headlines. Until something affects the process and then we see how pervasive and devastating such issues are. Recent guidelines have been published looking at national competencies to be structured into preregistration education. Professional bodies have addressed the topic from a risk perspective, which may be counter to the patient-centred approach of shared decision making. Our review places the literature in the wider, historical context of bioethics and our experience regarding ethical challenges as we strive to support our patients.

RECENT FINDINGS

Recent literature addressing ethical care for a person with eating, drinking and swallowing difficulties, highlights shared decision-making. This is guided by patient preference, professional roles and approaches, cultural context and informed consent. Studies highlight the importance of appropriate communication and documentation, and ethical decision-making steps.

SUMMARY

We hope to widen clinicians' perspectives and reflection on factors influencing these challenges (including own biases), and how to address them so that the patient and the clinician are satisfied. Ethical approaches require skills and knowledge, and critically also time. Resources should be allocated at the service level to ensure a robust process of informed consent and decision making.

Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors

Purpose A large knowledge gap related to dysphagia treatment adherence was identified by a recent systematic review: Few existing studies report on adherence, and current adherence tracking relies heavily on patient self-report. This study aimed to report weekly adherence and dysphagia-specific quality of life following home-based swallowing therapy in head and neck cancer (HNC). Method This was a quasi-experimental pretest-posttest design. Patients who were at least 3 months post-HNC treatment were enrolled in swallowing therapy using a mobile health (mHealth) swallowing system equipped with surface electromyography (sEMG) biofeedback. Participants completed a home dysphagia exercise program across 6 weeks, with a target of 72 swallows per day split between three different exercise types. Adherence was calculated as percent trials completed of trials prescribed. The M. D. Anderson Dysphagia Inventory (MDADI) was administered before and after therapy. Results Twenty participants (75% male), with an average age of 61.9 years (SD = 8.5), completed the study. The majority had surgery ± adjuvant (chemo)radiation therapy for oral (10%), oropharyngeal (80%), or other (10%) cancers. Using an intention-to-treat analysis, adherence to the exercise regimen remained high from 84% in Week 1 to 72% in Week 6. Radiation therapy, time since cancer treatment, medical difficulties, and technical difficulties were all found to be predictive of poorer adherence at Week 6. A statistically significant improvement was found for composite, emotional, and physical MDADI subscales. Conclusions When using an mHealth system with sEMG biofeedback, adherence rates to home-based swallowing exercise remained at or above 72% over a 6-week treatment period. Dysphagia-specific quality of life improved following this 6-week treatment program.

Contributors to Poststroke Dysphagia-Related Caregiver Burden

Purpose Caregiver burden negatively impacts both stroke survivor and caregiver well-being. Thus, it is important to better understand the individual- and dyadic-level variables that may contribute to dysphagia-related caregiver burden. The aim of this preliminary study was to identify survivor-, caregiver-, and dyadic-specific factors associated with burden in couples experiencing poststroke dysphagia. Method Twenty-eight stroke survivors ("care recipients") with dysphagia and their spouses ("caregivers") participated. Care recipients and caregivers completed a survey from which scores for the following variables were derived: dysphagia-related caregiver burden, survivor- and spouse-perceived impact of dysphagia on mealtimes (social, mealtime logistics), dyadic congruence on perceived impact, International Dysphagia Diet Standardisation Initiative Functional Diet Scale, Swallowing-Related Quality of Life Scale, and Stroke Impact Scale (cognitive, emotional, physical, and social domains). Spearman's rho and point biserial correlation coefficients were calculated to determine the factors related to caregiver burden. Results Increased burden was significantly associated with greater care recipient- and spouse-perceived impact of dysphagia on mealtime logistics; however, burden was not associated with measures of dyadic congruence of perceived impact. Notably, increased burden was also associated with increased diet restrictiveness and decreased swallow-specific quality of life. Dysphagia-related caregiver burden was not associated with measures of stroke impact/severity across any domain. Conclusions Factors related to dysphagia-related caregiver burden are multifactorial and include both care recipient (e.g., International Dysphagia Diet Standardisation Initiative Functional Diet Scale, Swallowing-Related Quality of Life Scale, perceived impact of dysphagia on mealtime logistics) and caregiver (e.g., perceived impact of dysphagia on mealtime logistics) variables. The results of this preliminary investigation support the need to incorporate aspects of counseling and family-centered care into our management practices, a growing area of interest for speech-language pathologists.

Lingual Exercise in Older Veterans With Dysphagia: A Pilot Investigation of Patient Adherence

Purpose Adherence is a concern in dysphagia management. Poor adherence with recommendations can negatively affect treatment efficacy and patient outcomes. For exercise-based therapies, low adherence can alter the dose of exercise delivered to the muscle, which can diminish impact of exercise. It has been established that low adherence is a problem in dysphagia treatments; however, relationships among levels of adherence and outcomes from exercise-based interventions have not been explored. Method In this retrospective pilot study, data were collected from a multicenter clinical demonstration program in the Veterans Affairs hospital system to examine the relationships between patient adherence with a device-facilitated lingual exercise regimen. Outcomes were compared pre- and posttreatment using a paired t test or Wilcoxon matched-pairs signed-ranks test, and relationships among adherence and outcome measures were evaluated using Pearson or Spearman rank correlation coefficients, as appropriate. Results Patient adherence was evenly distributed across participants: Adherence at the front sensor was 59.3% (SD = 28.2), ranging from 5.5% to 95.8%; the back sensor adherence was 55.9% (SD = 29.8), ranging from 1.1% to 97.2%. Maximum isometric pressure (MIP) generation, at both the front and back sensors, was increased from pre- to posttreatment (p < .0001, front; p = .008, back). Functional Oral Intake Scale (FOIS) scores were also significantly improved at the posttreatment time point as compared to baseline (p = .005). However, there were no significant correlations among adherence and outcome measures (front sensor adherence vs. ΔMIP, r = -.161, p = .342; back sensor adherence vs. ΔMIP, r = .002, p = .991; front sensor adherence vs. ΔFOIS, r = -.183, p = .279; back sensor adherence vs. ΔFOIS, r = -.160, p = .399). Conclusions These findings suggest that patient adherence with this lingual exercise program was not related to the increases in lingual pressure generation or improvement in functional oral intake observed in this cohort. These preliminary findings suggest the need for future, prospective, controlled, and randomized clinical trials to further investigate patient adherence with a lingual exercise program and related impacts of adherence on exercise dose and swallowing-related outcomes.