## The Unsolvable Puzzle

Did you ever try to solve a sliding tile puzzle?  It is a handheld puzzle composed of tiles in a plastic tray (although they’re now online) and the goal is to use as few moves as possible to move the tiles to an adjacent space to ultimately assemble a complete picture or sequence.  One piece often is left out of place and it’s maddening to try to “solve the puzzle.” At some point the puzzle is cast aside (“why am I wasting my time on this?”).

##### …the lungs have defense mechanisms of their own and are not simply receptacles for pneumonia (Raz, 2007)

Computer programs can determine solution patterns to these as well as determine which puzzles are “unsolvable;” this is even an assignment in a programming class at Princeton University.  Interestingly, the end of the assignment asks the student to Implement a better solution which is capable of solving puzzles that the required solution is incapable of solving.”

(for the curious) Princeton Puzzle Assignment

Helping patients/residents rehabilitate and manage their dysphagia involves its share of “sliding tile puzzles.”  The “solvability” of these puzzles makes every patient their own set of tiles. When can the puzzle be “solved?” What does “solved” even mean?  Are we ultimately better off “implementing a better solution which is capable of solving puzzles that the required solution is incapable of solving?”

## The Simple-Complex Model

Most SLPs took a course in basic communication science with the requisite sender-message-receiver box-and-arrow model of communication (Weaver, 1949).

The model is woefully simplistic and fails to capture the complexity of the communication process. In all fairness the Weaver work is a mathematical analysis of the muddy mess we call communication.  Yet it’s taught to college freshmen as a set of three boxes with connecting arrows. It helps people new to the communication process to conceptualize it, make it a “solvable” puzzle.

##### The “unsolvable puzzle” is less of an issue if SOLVING it is no longer the goal.  And in fact there may BE no absolute solution (Leslie & Coyle, 2010).

How are people taught to conceptualize swallowing and its disorders?  Of course it’s not as simple as a “dysphagia – aspiration – pneumonia” box-and-arrow diagram, but treatment anecdotes suggest that for some this conceptualization persists.

“I have to recommend the safest diet.  He needs puree and thickened liquids.”

“I refuse to work with a patient who will not comply with my diet recommendations because it is my license on the line.”

“My facility requires waivers if patients do not agree to follow diet recommendations.”

Only within a simplistic conceptualization of swallowing and dysphagia do these statements make sense.  But care is not a linear box-and-arrow diagram easily programmed to solve.

## Literature in the Last 25 years

In the last 25 years the speech pathology profession has learned quite a bit, partly from the collective reading and integration of the literature from other professions with our own practice patterns and partly from research from our own dysphagia pioneers.  We have learned…

• That aspiration by itself is not sufficient to cause pneumonia, that there must be other factors (Langmore et al., 1998; Cook et al., 1999)
• That aspirators aspirate more than just food and liquid; they also aspirate saliva and reflux. (Feinberg et al.,1990; Feinberg et al.,1996)
• That sickness as a result of aspiration is a multifactored process (Langmore et al., 1998; Ashford, 2005)
• That the lungs have defense mechanisms of their own and are not simply receptacles for pneumonia (Raz, 2007)
• That despite our best intentions, we cannot view the trajectory of a bolus without imaging (Leder & Espinosa, 2002)
• (The corollary to that, that not all people who aspirate get sick, complicates advocacy for instrumentation, unless we also remember that….)
• That it is possible to rehabilitate the swallowing mechanism but that it’s not possible to plan this without instrumentation (added to the arsenal about advocating for instrumentals) (Crary et al., 2012)
• That we don’t rehabilitate simply a trachea and a pharynx, but a patient, who has choices (Leslie & Krival, 2016).
• That we have very little evidence in our literature about diet consistency recommendations (with one exception that led to SLP outcry at the ASHA convention where it was first presented) (Suiter & Leder, 2008).
• That modifying a bolus does not contribute to positive outcomes if the patient does not eat the provided food (Sura, 2012)
• That without adequate nutrition and hydration, the human organism is far more susceptible to disease due to the impact on the immune system (Chandra, 1997)
• That if patients don’t eat and drink, they are vulnerable to the effects of malnutrition and dehydration (Finestone & Greene-Finestone, 2003)
• That altered diets don’t necessarily lead to improvements in nutrition and hydration (Vivanti et al., 2009; Sura et al., 2012)
• That patients’ preferences matter and that they have a choice in directing their own care (Sharp & Genesen, 1996)
• That it’s not possible to absolve any care providing organization of liability (neglect is never legal), but that documentation of conversations and patient education is evidence of patient centered care (Horner et al., 2016)
• That the best way to be sure that patient with “comply” with a treatment plan is to develop the treatment plan with the patient (Leslie & Krival, 2010)
• To date no one has provided evidence of licensure law language that says one will lose their license if their patient with dysphagia gets sick.

Knowing these facts complicates the “tile puzzle.”  Instead of a nice linear easily organized box-and-arrow model with one single quick solution, we are left with a collection of facts that affect one another and don’t always corroborate earlier practice pattern in our field.  They seem to make the tile puzzle unsolvable.

In reality the problem may be less solvable than manageable. It simply requires the involvement of the patient who is the recipient of and primary participant in the care plan. The “unsolvable puzzle” is less of an issue if SOLVING it is no longer the goal.  And in fact there may BE no absolute solution (Leslie & Coyle, 2010).

## Putting the Pieces Together

Perhaps it’s a better idea to take the approach of the Princeton University programming assignment and think about determining an alternative solution to the puzzle when the original one is unsolvable.  There are no one-size-fits-all approaches to this. It is necessary to look at the physiology of the swallow, to understand the patient’s medical background, to change our practice patterns as new facts have emerged.  Best practice patterns will continue to evolve.

But patients will always have goals, wishes and values. It is necessary to talk to patients and learn what their priorities are as they recover. It is necessary to involve patients in their treatment plans so they can make informed choices. It is necessary to make THAT the puzzle to solve.

### Resources

Ashford, J. R. (2005, March). Pneumonia: Factors Beyond Aspiration. Perspectives in Swallowing and Swallowing Disorders (Dysphagia), 14, 10-16.

Chandra, R. K. (1997). Nutrition and the immune system: an introduction. The American journal of clinical nutrition66(2), 460S-463S.

Cook IJ ,Kahrilas PJ, AGA technical review on management of oropharyngeal dysphagia. Gastroenterology, 1999. 116(2): p. 455-78.

Crary, M. A., Carnaby, G. D., LaGorio, L. A., & Carvajal, P. J. (2012). Functional and physiological outcomes from an exercise-based dysphagia therapy: a pilot investigation of the McNeill Dysphagia Therapy Program. Archives of physical medicine and rehabilitation93(7), 1173-1178.

Feinberg, M. J., Knebl, J., Tully, J., & Segall, L. (1990). Aspiration and the elderly. Dysphagia5(2), 61-71.

Feinberg, M. J., Knebl, J., & Tully, J. (1996). Prandial aspiration and pneumonia in an elderly population followed over 3 years. Dysphagia11(2), 104-109.

Finestone, H. M., & Greene-Finestone, L. S. (2003). Rehabilitation medicine: 2. Diagnosis of dysphagia and its nutritional management for stroke patients. Canadian Medical Association Journal169(10), 1041-1044.

Horner, J., Modayil, M., Chapman, L. R., & Dinh, A. (2016). Consent, Refusal, and Waivers in Patient-Centered Dysphagia Care: Using Law, Ethics, and Evidence to Guide Clinical Practice. American journal of speech-language pathology25(4), 453-469.

Kaizer, F., Spiridigliozzi, A. M., & Hunt, M. R. (2012). Promoting shared decision-making in rehabilitation: Development of a framework for situations when patients with dysphagia refuse diet modification recommended by the treating team. Dysphagia27(1), 81-87.

Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., & Loesche, W. J. (1998). Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia13(2), 69-81.

Leder, S. B., & Espinosa, J. F. (2002). Aspiration risk after acute stroke: comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia17(3), 214-218.

Leslie, P & Krival, C. (2010) How To Practice “Undefensively.” Perspectives on Gerontology 15:2, 54-64.

Leslie, P. & Coyle, J (2020) Complex decisions involving gastrostomy feeding tubes: When you’re never right or wrong?  Perspectives on Gerontology, December 2010, American Speech-Language Hearing Association; DOI: 10.1044/gero15.2.42.

Marik, PE., & Kaplan, D (2003) Aspiration pneumonia and dysphagia in the elderly. Chest 124:1, 328-336.

Raz, E. (2007). Organ-specific regulation of innate immunity. Nature immunology8(1), 3.

Shannon, C. E., & Weaver, W. (1963). The mathematical theory of communication. 1949. Urbana, IL: University of Illinois Press.

Sharp, H. M., & Genesen, L. B. (1996). Ethical decision-making in dysphagia management. American Journal of Speech-Language Pathology5(1), 15-22.

Suiter, D. M., & Leder, S. B. (2008). Clinical utility of the 3-ounce water swallow test. Dysphagia23(3), 244-250.

Sura, L., Madhavan, A., Carnaby, G., & Crary, M. A. (2012). Dysphagia in the elderly: management and nutritional considerations. Clinical interventions in aging7, 287.

Vivanti, A. P., Campbell, K. L., Suter, M. S., HannanJones, M. T., & Hulcombe, J. A. (2009). Contribution of thickened drinks, food and enteral and parenteral fluids to fluid intake in hospitalised patients with dysphagia. Journal of human nutrition and dietetics22(2), 148-155.