Dysphagia and Diets in Skilled Nursing Facilities When Patient's Health Status Changes: The Role of Imaging

OBJECTIVES

Research suggests that clinical decision making for assessing and treating patients with swallowing dysfunction varies significantly, and decisions may harm patients. The study aimed to investigate clinical practice of speech-language pathologists (SLPs) assessing and treating swallowing in skilled nursing facilities (SNFs).

DESIGN

Retrospective review of 120 medical records of patients recommended for a flexible endoscopic evaluation of swallowing (FEES).

SETTING AND PARTICIPANTS

120 SNF patients.

METHODS

Records from 25 SNFs were reviewed to determine which patients were receiving swallowing therapy, their diet level pre- and post-FEES, and if they received prior imaging studies. Recordings of FEES were assigned severity ratings based on the Dynamic Imaging Grade of Swallowing Toxicity-FEES scores to determine the relationship between diet and liquid recommendations before and after FEES, how often patients consume a modified diet in the absence of dysphagia, percentage of patients without dysphagia receiving swallowing treatment, percentage of patients receiving alternative means of nutrition without dysphagia, and the percentage of patients with a feeding tube without an imaging assessment.

RESULTS

Chi-square tests revealed no agreement between pre- and postimaging diet levels. Ordinal regressions indicated preimaging diets did not fit the DIGEST severity rating model; however, investigators found a good fit with postimaging diet recommendations. Descriptive statistics indicated that 67% of the patients receiving a modified solid and/or liquid did not have dysphagia. Treatment was provided to 100% of the patients without dysphagia. Sixty-one percent of patients with feeding tubes had no dysphagia. Forty-five percent of NPO (nothing by mouth) patients had imaging during their acute stay.

CONCLUSIONS AND IMPLICATIONS

The results strongly suggest that the practice of continuing acute care diet recommendations in a SNF increases cost and may negatively impact patient quality of life. The practice may also lead to negative health consequences. A new imaging assessment is required to inform treatment when medical status changes.

Influence of Three Feedback Conditions on Performing a Swallow Motor Pattern in Healthy Adults

INTRODUCTION

Motor learning is the process involved in acquiring and refining motor skills, which relies on accurate practice and feedback. The purpose of the current investigation was to examine the influence of three types of feedback on successfully performing a swallow motor pattern of a common swallowing intervention known as the Mendelsohn maneuver (MM).

METHOD

One hundred twenty healthy participants were randomized to one of three feedback conditions: (1) visual and verbal feedback (VVF), (2) verbal feedback only (VF), and (3) intrinsic feedback (IF). Participants were asked to perform a swallow motor pattern associated with the MM. Data were collected using surface electromyography.

RESULTS

Percentages of participants who performed the pattern successfully and the time required to complete three successful swallowing patterns were significantly different by the feedback condition. The feedback conditions influenced the performance of the MM swallow motor pattern. One hundred percent of the participants randomized to the VVF condition performed the motor pattern successfully and performed three consecutive successful trails in a shorter time period (211 s; χ2 (2) = 95.95, p < 0.001) when compared to the VF condition (74% performed in 505 s) and the IF condition (18% performed in 826 s; χ2 (2) = 95.96, p < 0.001). However, considering the participants who met the performance criteria, the number of repetition attempts required to correctly produce the MM pattern did not differ significantly between the three feedback conditions (χ2 (2) = 14.86, p = 0.81).

CONCLUSION

Visual and verbal feedback improves the performance of the MM and decreases the time to perform three successful MM swallowing patterns in healthy adults.

The Influence of Surface Electromyography Visual and Clinician Verbal Feedback on Swallow Effort Ratio at Different Bolus Volumes in a Healthy Population

BACKGROUND/AIMS

The effortful swallow is a common treatment intervention requiring increased intensity to facilitate adaptations and modify swallow kinematics. The type of feedback and bolus volume provided may influence the intensity of the effortful swallow. To determine the increased effortful swallow intensity, a clinician can collect the peak amplitude of an effortful swallow and a typical swallow and compute a "swallow effort ratio" (SER). Dividing the effortful swallow surface electromyography (sEMG) peak amplitude by the typical swallow sEMG peak amplitude derives the SER. A higher SER suggests increased intensity. An increase in the SER may have clinical relevance in swallowing therapy as a threshold of intensity is required to elicit neuroplastic change. The purpose of this investigation was to determine whether sEMG visual and clinician verbal feedback increases the SER. Additionally, the investigation examined whether the SER is influenced by different liquid bolus volumes.

METHODS

Eighty-two nondysphagic, healthy adults were assigned at random to 2 groups. One group received no feedback, and the other received verbal and visual feedback while performing typical and effortful swallows at 3 liquid volumes.

RESULTS

An analysis of covariance compared the typical and effortful peak swallow amplitudes among 3 volumes in the 2 feedback groups. There was a significant effect on the peak amplitude values by feedback group F(2, 79) = 22.82, p < 0.001. There were no differences in peak amplitude by volume regardless of feedback F(2, 78) = 0.413, p = 0.663.

CONCLUSION

It appears that sEMG visual and clinician verbal feedback increases the SER, which may be a surrogate for intensity. An increased SER may have a positive effect on swallow intervention as intensity is known to influence outcomes of exercise and elicit neuroplastic change.

Perceptual Anchors and the Dispersion of Nasality Ratings

Objective

This investigation studied the effects of perceptual anchors on the dispersion and reliability of listener ratings of nasality.

Design

Listeners (N = 129) were assigned to one of six listening groups. Each group rated nasality independently for 100 speech samples on a seven-point scale that ranged from 1 = normal nasality to 7 = severe hypernasality. The anchors used were examples of a 1, 3, 4, 5, and/or 7 on the rating scale. These anchors were played selectively to group 2 (4), group 3 (1 and 7), group 4 (3 and 5), group 5 (1, 4, 7), and group 6 (7). Group 1 had no anchor.

Participants

Of the speakers, 95 were children followed by a craniofacial team and five were children without histories of speech disorders.

Main Outcome Measures

The outcome measures were 12,900 ratings of nasality on a seven-point scale.

Results

Q values showed that group 5, which was the only group to receive three anchors, had the lowest, or best, Q value (0.78), and group 1 (no anchor) had the highest, or worst, Q value (0.99). Across groups, the most reliable ratings were those at scale values 1 (Q = 0.46) and 7 (Q = 0.56). The least reliable ratings were at scale values 3 (Q = 1.01), 4 (Q = 1.03), and 5 (Q = 1.06).

Conclusions

Nasality rating reliability/dispersion was influenced by the presence and location of anchor stimuli. Consistent with absolute judgment theory, nasality ratings showed a strong end effect.