As a medical speech-language pathologist, I’m the expert in dysphagia on my interdisciplinary team, but I’m no expert within the field of dysphagia. However, in my role as a developer of therapy apps, I’ve had the opportunity to work closely with three talented clinicians who are experts in swallowing disorders. Through collaboration with them, this aphasia specialist learned some exciting new things about dysphagia.
Yvette McCoy, MS, CCC-SLP, BCS-S, Tiffani Wallace, MA, CCC-SLP, BCS-S, and Rinki Varindani Desai, MS, CCC-SLP, all speech-language pathologists with (or pursuing) board-certified specialization in swallowing disorders, saw a need for an app to help clinicians navigate dysphagia treatment options.
In the process of creating a new app called Dysphagia Therapy, there were many engaging debates, impassioned discussions, and long emails about some surprising things. These clinicians are passionate about what they do, keep up with all the dysphagia courses, mediate discussions on social media, and commonly present to other professionals, so it was fascinating to listen in as they deliberated on the finer points of dysphagia therapy. Here are 5 concepts I learned about dysphagia:
1) The important difference between an impairment and an observation
There are many things that can go wrong with swallowing: sometimes we see the actual physical impairment, and sometimes we observe only the effects of the underlying problem. Focusing on these observations can leave us feeling lost when determining a treatment plan, given that many impairments can cause them.
We pay a lot of attention to the behavior of the bolus and where it goes (e.g. aspiration, penetration, and residue) in our assessments, but we treat impairments – not the bolus. The behavior of the bolus will change if we can improve the impairments. Vallecular residue may be caused by decreased tongue base retraction, delayed initiation of the swallow, impaired hyolaryngeal excursion, or impaired pharyngeal contraction. The therapy for each of these may look different, so we need to figure out which are the actual impairments to treat in order to resolve this problem of residue.
In designing how the app can point people to the best therapy options, we had to decide if observations should even be included in the search, since it’s the impairments that matter most. Knowing that some clinicians do not have access to the diagnostic imaging they need, receive incomplete reports from other facilities, or may be unaware of the difference between observations and impairments, including both types of problems (but marking them as different) allows everyone to find what they’re looking for. Savvy clinicians will focus on the impairments.
Take-home message: Figure out what the underlying impairments are and let those guide your treatment.
2) What we can and cannot determine at bedside
Of all the anatomy and physiology we need to evaluate in our dysphagia patients, only a few aspects can truly be assessed by a clinical (or bedside) assessment. Most of the swallowing components require an instrumental assessment – either FEES or VFSS/MBS – to visualize, measure, or diagnose an impairment.
I was surprised that when the Dysphagia Therapy app filters the list of impairments and observations for what can be assessed clinically, hyolaryngeal excursion isn’t on the list. It’s a critical part of the swallow, but it turns out we can’t accurately gauge impairment from just palpating the larynx. While our subjective tactile judgments can tell us if there is movement or not, whether that movement is adequate to deflect the epiglottis and open the upper esophageal sphincter can only be determined with an instrumental exam. This information is essential to identify whether there is truly an impairment that requires therapy to address it.
More than just assessment, video fluoroscopy and FEES can also help us know which therapy techniques and strategies are working. Many people who think they’re doing a swallowing maneuver correctly, such as the Mendelsohn, actually aren’t. It can be very effective to train patients on a technique at bedside, then verify the success during your instrumental assessment.
Take-home message: Use instrumental assessments whenever possible for the most accurate diagnosis and treatment planning (and if you don’t have access – advocate!).
3) We have more options than we realize
There are so many options for how to manage dysphagia, it is both exciting to know we have choices, and overwhelming to decide where to start. Unfortunately the most common management technique in use still seems to be diet texture modification. There are certainly occasions to do this, but it is almost always the patient’s least favorite option.
When the authors of the app put together a list of therapy options, I was shocked to see over 45 different techniques – and not one of them involved taking away someone’s toast. These options fall into 5 categories: rehabilitative exercises, sensory stimulation techniques, compensatory strategies, swallowing maneuvers, and treatment protocols.
Many patients are able to participate in active rehab, so exercises and maneuvers are a great place to start. For those less able to follow directions, sensory techniques or feeding strategies involving positioning or cuing may be the right approach. There are also several therapy protocols, most of which require training and/or certification, such as MDTP or NMES, with evidence that must be carefully evaluated.
Take-home message: Do right by your patients and be sure to consider all the treatment options available.
4) Apps can’t make decisions for us
In dysphagia management, there are so many factors to consider. What are the patient’s goals? What is their (and your) risk tolerance? How likely is the patient to carry out a daily exercise plan? To remember to use a strategy? To stick to your recommendations?
While an app can gather all the information in one place, make it easily searchable, and match impairments to treatments, an app cannot make a clinical decision. Ideally, a dysphagia therapy app would take in impairments A, B, and C; do some computing; spit out recommended treatments 1, 2, and 3; and off you’d go. Realistically, there are just too many factors involved.
No app, flowchart, or book can ever tell you what the best plan is for your patient. The best it can do is help you focus on the right things and provide the information you need to think critically and make decisions. You need to use your educated brain, along with your clinical experience, human empathy, and patient relationship to make the best call.
Take-home message: Use apps as tools to help guide your decision-making process, to gather information, and to make your job easier – only YOU can make the best decision for your patient.
5) It’s a great time to be a dysphagia clinician
I’ve noticed that there are several exciting trends developing in the dysphagia world lately. The evidence has been growing, access to instrumental assessments has become more widespread, and restorative therapy is in focus. Critical thinking, accurate diagnostics, and patient-centered treatment plans are emerging as the norm.
While we still fight the advocacy battle to educate our patients that speech-language pathologists are involved in swallowing and cognition too (“But I talk just fine!”), our medical colleagues and administrators increasingly value our role in dysphagia to improve patient outcomes. Now if only they’d approve our request for a new biofeedback device…
Take-home message: You do amazing work in exciting times. Keep it up!
- There are many, many references for each treatment technique included in the Dysphagia Therapy app. Here are a few references to support the information included in this post:
- Azola, A. M., Greene, L. R., Taylor-Kamara, I., Macrae, P., Anderson, C., & Humbert, I. A. (2015). The relationship between submental surface electromyography and hyo-laryngeal kinematic measures of Mendelsohn Maneuver duration. Journal of Speech, Language, and Hearing Research. http://jslhr.pubs.asha.org/article.aspx?articleid=2451343
- Coyle, J. L., Davis, L. A., Easterling, C., Graner, D. E., Langmore, S., Leder, S. B., & Steele, C. M. (2009). Oropharyngeal dysphagia assessment and treatment efficacy: setting the record straight (response to Campbell-Taylor). Journal of the American Medical Directors Association, 10(1), 62-66.
- Daniels, S. K., & Huckabee, M. L. (2014). Dysphagia following stroke. Plural Publishing.