The early days
As a second year doctoral student in the early 1970’s, our team began evaluating dysphagic patients on the neurology service. The impetus for this involvement came from our mentor, Dr. George Larsen. Larsen’s interest came from a challenge from the chief of the neurology service who commented that if our service could help patients with their swallowing disorders, that would help move them faster to discharge. After all, we were the experts in the oropharyngeal components of speech and vocal production mechanisms; why could we not apply this knowledge to swallowing? Larsen went to the literature and found a considerable amount of data on how an individual swallows, but nothing about rehabilitation. Combining his methods in the clinical evaluation of the nervous system, including the upper airway by indirect laryngoscopy, Larsen developed protocols for the clinical examination of swallow that led to recommendations for the management of those with dysphagia. At this time, there was no use of imaging studies as part of the evaluation process. Larsen published the first papers written by a Speech-Language Pathologist (SLP) in JSHD in 1972, and in the Journal of Neurosurgical Nursing in 1974. In these papers, he talked about the importance of posture, breath-hold, swallowing one’s own feeding tube as an exercise, dietary adjustments, and the use of trained volunteers to assist in feeding. Consults for SLP services were generated by our involvement in neurology and otolaryngology inpatient rounds. Larsen also described the use of faradic (electrical) stimulation to the larynx to facilitate swallow in patients with brainstem stroke in the Archives of Physical Medicine in 1973.
The first text
At about the same time, Dr. Jeri Logemann was completing post-doctoral studies focused on the speech characteristics of patients with Parkinson’s disease using videofluoroscopy. As part of her work, she became aware of the concomitant problems of swallowing in this patient group. In 1976, she presented her work with swallow management in patients with head and neck cancer at the ASHA convention in Houston. Afterward, I approached her and we had a discussion about how difficult it was for her to get her paper accepted by the review committee, because at that time ASHA did not recognize the role of the SLP in swallowing management, nor did they have a category that recognized the issue for purposes of paper submission! Describing her swallow evaluation as the ‘cookie swallow” test or modified barium swallow (MBS), she advocated for an imaging evaluation on every patient before initiating treatment. In her classic 1983 text (revised in 1994) she described the role of the SLP in dysphagia management with specific recommendations for treatment approaches that emanated from the results of the MBS.
The SLP as a recognized team member
In 1978, I was assigned to the neurology service at the VA Medical Center in New York. While working with dysphagic patients, the chief of the service encouraged me to collaborate with him on a text that focused on the diagnosis, evaluation, and treatment interventions of swallowing in those patients with neurologic impairments. Before we could complete our work, he was tragically killed in an automobile accident. I made the decision to complete the text, but with a multidisciplinary focus, asking representatives from nursing, occupational therapy, gastroenterology, neurology, otolaryngology, radiology, and nutrition, to write individual chapters.
…it now has become obvious to physicians that when they are confronted with a patient with suspected oropharyngeal dysphagia that the consult should be directed to the SLP because we have the expertise needed to assist the patient in the recovery of their swallowing disorder.
Published in 1984, and revised in 1992 and 1997, the roles of dysphagia team members served to highlight the importance of cooperation among hospital departments in dysphagia management. After the book was published, to my surprise, I received many invitations to speak about the topic. Because of this, I realized that SLPs were on board and interested in this topic. However, ASHA did not recognize this role and there were many letters to the editor in the ASHA Leader against our involvement with dysphagia, ostensibly because of our lack of training. Interestingly, the role of the SLP in dysphagia management was recognized in 1986 by the Health Insurance Organization of America, by the Joint Commission on Hospital Accreditation in 1988, and in a NIH technical report in 1989. It was not until 1999 -2007 in numerous official publications that ASHA seemed to acknowledge the role of the SLP in the care of those with dysphagia. It was not until these publications that universities were required to have a course in dysphagia at the graduate level. Prior to this, all training was done in post-graduate CEU activities.
Other disciplines became aware of the role of the SLP as early as 1984. At the center of this recognition was the newly-formed swallowing center at Johns Hopkins under the leadership of Dr. Martin Donner (a radiologist) and Dr. James Bosma (a pediatrician). Emphasizing the multidisciplinary approach, they included the SLP to provide rehabilitation strategies. I contacted Dr. Donner in 1984 suggesting the need for a journal on dysphagia and its ramifications. Donner told me he had thought such a journal was needed and invited myself and Dr. Logemann to be participants on the first editorial board. The first issue appeared in 1986. Finding people to write in the first 4 volumes was difficult, however, the journal now is well-established, and continues to reflect the work of many disciplines from all parts of the world.
Establishment of the journal Dysphagia led to the formation of the Dysphagia Research Society in 1991. Meeting annually, attendance by SLPs usually exceeds 50%, reflecting a keen interest in the topic, a major role as conference organizers, and as podium and poster presenters. Other societies with similar interests such as the European Society for Dysphagia Disorders (1991), the Japanese Society of Dysphagia rehabilitation (1994), and the Australasian Conferences of 1996 and 1998 have followed. All these are demonstrations of the growing interest in managing the dysphagic patient with a multidisciplinary approach.
How far we have come
In a 2013 ASHA survey of SLPs practicing in adult and pediatric settings, 60% of an adult caseload in acute care requires services targeted for the dysphagic patient, while 36% of a pediatric caseload requires services. In both settings, those in intensive care units require the majority of services. In general, the care of the dysphagic patient has evolved from placing feeding tubes in anyone with dysphagia, to providing clinical and imaging evaluations that guide compensatory and rehabilitative strategies, to an understanding that with specific evaluations and subsequent treatment, patients can return to eating orally, ultimately leading to an improved quality of life. What thrills me most about this approach is that the SLP has been in the forefront of providing these services with the use of an evidence-based approach, and that it now has become obvious to physicians that when they are confronted with a patient with suspected oropharyngeal dysphagia that the consult should be directed to the SLP because we have the expertise needed to assist the patient in the recovery of their swallowing disorder.
Links of Interest
- MedBridge courses by Dr. Groher
- Clinical Management of Dysphagia in Adults and Children
- Introduction to Adult Swallowing Disorders
- Dysphagia: Diagnosis and Management
- Japanese Society of Dysphagia Rehabilitation
- Dysphagia Research Society
Miller RM, Groher ME. (1993). Speech-language pathology and dysphagia: A brief historical perspective. Dysphagia 8:3, 180-184.