“True wisdom is knowing what you don’t know”― Confucius
Flashback to 2011
I had just graduated from one of the topmost M.S. programs in Speech-Language Pathology in the country; armed with a specialization in medical SLP, five adult-based clinical rotations behind me, two graduate courses in dysphagia, a pocketful of swallowing knowledge and a smile on my face, all set to revolutionize patient lives. Shortly after, I landed a CFY position at a coveted long-term acute care (LTAC) hospital in Dallas, Texas, surrounded by patients with trachs and vents, complex medical diagnoses, critical illnesses and all kinds of dysphagia cases one can imagine. It was all a dream come true!
It didn’t take long however, for the bubble to burst and for me to realize how much I didn’t know. Having an off-site clinical supervisor didn’t make the job any easier. Patients were not as simple as the case studies in school. Bedside exams were not as straightforward. Treatments didn’t always work. There seemed to be no black and white in the ‘real’ world of dysphagia; just endless shades of grey.
By the end of CFY, I found myself grappling; grappling to become a competent dysphagia clinician, to make better judgements, to keep up with evidence and the ever changing landscape of healthcare reforms, to meet productivity requirements, to advocate for instrumental evaluations, to provide ethical care, to request treatment materials, to maximize outcomes… the to-do list seemed endless. The struggle was real and it felt like I was facing it alone.
The fortunate and unfortunate part of this story is that thousands of SLPs experience it all the time. Watching them voice similar concerns over and over on social media groups made me realize how easy it is to get burnt out, especially as dysphagia clinicians today; sometimes even before our careers have really begun.
Fast-forward to 2016
Five years later, a lot has changed for the better; not just in terms of my skills, competence and dysphagia knowledge, but most importantly in my attitude. Five years later, the powerful words of Confucius changed the trajectory of my career.
“True wisdom is knowing what you don’t know”
It takes courage to accept this and to then make every effort you can to fill in the missing gaps of knowledge. It often seems easier to settle in our comfort zones and complain about all the training we didn’t get and all the demands placed on us and the struggles we have to face each day as budding dysphagia clinicians, rather than to go above and beyond our basic clinical responsibilities to advance our skills and provide our patients with the best care possible.
This post was intended to be about the Dysphagia Research Society and my top takeaways from the recent 2016 meeting in Tucson. But as I started writing it, it became more than that… it became about a universal issue I see SLPs struggling with every day. I hope reading this post encourages everyday clinicians to step out of their comfort zones, face the fear of the unknown and to make dedicated efforts to grow and contribute to the field of dysphagia.
DRS: What, When, Why?
The Dysphagia Research Society (DRS) was founded almost 25 years ago to advance the science and care of patients with swallowing disorders in a multidisciplinary fashion. This year, the 24th Annual DRS Meeting was held from February 24-27 at the Westin La Paloma Resort and Spa, nestled amidst the foothills of the Santa Catalina Mountains in sunny Tucson, Arizona. It was focused on evidence-based best practices for research and care delivery.
The DRS meeting was attended by almost 500 attendees from multidisciplinary fields, representing over 20 countries from around the world. The Post-Graduate course titled ‘Something You Can Chew On: Evidence-based Dysphagia Clinical Care’ provided a unique opportunity for clinicians to gain an understanding of the scientific basis for the evaluation and treatment of patients with dysphagia and to learn from a team of experts including SLPs, Radiologists, ENTs, Gastroenterologists etc. This was followed by 3 full days of informative, stimulating and thought-provoking sessions; some more research-based than others and many with direct applications to clinical practice.
Hundreds of papers were presented via posters and oral sessions over a span of 4 days. It would be impossible to encapsulate all those findings in one post. You can follow tweets from the event by looking up the hashtag #DRS2016 on Twitter, read updates on the DRS Facebook page or listen to a bunch of us discussing our post-DRS musings in the popular Swallowing Podcast ‘Down The Hatch’.
Here’s what Dr. Ianessa Humbert, creator of the DTH podcast, co-director of the Swallowing Systems Core Lab and Chair of the WCPRC DRS Committee had to say:
“DRS is a place where swallowing clinicians can go to expand their thinking and their professional social network. It is a place where you can go to meet and learn from the founders and leaders who enabled SLPs and other clinicians to manage dysphagia decades ago. You will also see that many of these important people are retiring and that YOU are the future of this field and sub-discipline!”
Top Takeaways from DRS 2016
Clinical Bedside Swallow Evaluation (CBSE): Advantages with Limitations
Dr. Giselle Carnaby inaugurated the Post-Graduate course at DRS with an enlightening talk on ‘Promoting Evidence and Standards in Clinical Assessment’. She stressed that the CBSE should be differentiated from a ‘screen’. It should be more that an observational checklist of symptoms. There is huge variability in the administration and interpretation of CBSE among clinicians today, with too much focus on ‘aspiration’ as an outcome. The CBSE should primarily be used to determine need for further instrumental examination and formulation of a preliminary treatment plan. It has some advantages in providing information about overall dysphagia severity; however it should not be used to make judgements about swallow physiology and pharyngeal events of the swallow or replace the need for more objective instrumental exams.
Takeaway: The CBSE has definite advantages and is more than a screening tool. However, we must realize its limitations when using it to guide treatment decisions.
Videofluoroscopic Swallowing Study (VFSS): All That Glitters Is Not Gold
- Following Dr. Carnaby’s power packed session was a thought-provoking talk by Dr. Julie Barkmeier-Kraemer on the VFSS. The VFSS/MBSS continues to be the ‘gold standard’ test for swallowing assessment. However, it has a number of problems, which need resolutions. VFSS administration and analysis methods vary greatly. There are many evolving protocols, but no standard mandatory protocol for performing and interpreting VFS studies between clinicians. There is no consensus on the most effective sampling rate for performing the procedure. Research has shown that interpretation of VFS studies change when sampling rate was changed from 15 pps to 30 pps. Images generated using frame rates of 30 fps are likely to capture impairment most efficiently, requiring the smallest number of swallows to reveal the problem. We should partner with Radiology to reach a consensus on technical specifications required for conducting the safest and most effective VFSS.
- Catriona Steele and colleagues from the Swallowing Rehabilitation Research Laboratory in Toronto presented findings from their study, which aimed to establish normative values for timing and kinematic measures of functional swallowing in adults across a range of bolus consistencies. Their goal is to provide normative data to serve as a reference for clinicians analyzing VFS studies, so as to enable them to accurately determine the nature of the pathophysiologies contributing to aspiration or residue in patients with dysphagia. Their ultimate aim is to make VFSS interpretations more reliable and standardized.
Takeaway: Improving the accuracy of swallowing evaluations/VFSS is essential to increasing treatment efficacy. Swallowing should not lie in the eye of the beholder.
Strengthening Exercises: Does Progressive Resistance Make Perfect?
- A novel pilot study done by Laurie Slovarp et al at the University of Montana provided evidence that the unassisted tongue pull back (TPB) exercise may not be any more helpful in improving tongue base retraction than normal swallowing. Adding resistance to the TPB by holding the tongue with gauze may be an effective alternative. The study also demonstrated proof-of-concept for creating a device that attaches to the tongue to provide progressive resistance during the TPB for improving tongue base retraction.
- Nicole Rogus-Pulia and colleagues presented multi-site outcomes from the Swallow STRONG clinic, which supported the positive influence of progressive resistance training of oropharyngeal musculature on lingual strength, quality of life (QOL) and overall health for dysphagic patients with various medical etiologies.
Takeaway: Strengthening exercises have a place in dysphagia rehabilitation. Various parameters for exercise-based interventions need to be further explored to better inform therapeutic guidelines for clinical application.
Head And Neck Cancer (HNC) Treatment: Do Exercises Help?
- A RCT done by Barbara Messing et al examined the efficacy of prophylactic swallow exercises in the HNC population undergoing chemoradiation. Findings of their trial provide some evidence for positive early effects on swallow physiology and function; however long term benefits of prophylactic exercises were not supported.
- Elissa Greco, Rosemary Martino et al presented a poster about a systematic literature review they conducted to assess the efficacy of exercise (regardless of timing) in HNC patients on swallow physiology, function and QOL. They concluded that there is no high level evidence to date, suggesting that exercise therapy benefits swallow physiology or function in HNC patients with dysphagia due to RT/CRT. In contrast, limited evidence suggests some benefits to QOL.
Takeaway: Future RCTs with good methodological designs are needed to identify the most effective dysphagia interventions that benefit HNC patients.
Role of the Esophagus: Looking Beyond the Pharynx
- Amy Litwack et al presented a very informative poster to discuss the prevalence of esophageal disorders in adult patients who are referred for oropharyngeal dysphagia. They concluded that esophageal dysphagia was found more frequently than aspiration (46% vs 36%) in a large cohort of the patients they studied (10,357 patients) over the age of 60 years. Structural/anatomical abnormalities (CP bar, diverticuli, obstruction) occurred in 11% of patients while functional dysmotility occurred with three times the frequency (35%). These findings emphasize the critical need for esophageal evaluation in this population.
- The PG course sessions by Radiologist Dr. Cheri Canon and Gastroenterologist Dr. Arash Babei also discussed the impact of esophageal disorders on oropharyngeal function and the consequences of missed esophageal diagnoses.
Takeaway: Deglutition is a multidisciplinary team effort. SLPs must start thinking and looking beyond the pharynx.
Post-Extubation Dysphagia Evaluation: Does Timing Matter?
- Stevie Marvin and group from the University of Wisconsin, Madison presented important findings from their research, which attempted to study if the timing of evaluation matters in post-extubation dysphagia. They wanted to assess if there are differences in swallow function between FEES performed the day of extubation (2-4 hours post) v/s 24 hours after extubation. They concluded that while majority of their patients were found to be safe for oral diet at 2-4 hours post extubation, swallow function improved at the later time point. This suggested that while patients might be capable of tolerating a diet soon after extubation, they may have fewer restrictions and a safer swallow function 24 hours later.
Takeaway: Further research is needed to determine optimal timing for evaluation in post-extubation dysphagia. Timing does seem to matter and should help guide treatment decisions and diet recommendations.
Dysphagia Education and Competency: Less Is NOT More
- My co-investigator Yvette McCoy and I presented a poster on the findings of our survey, which was conducted to determine the adequacy of dysphagia graduate preparation in the United States. Results indicated that 61% of 715 respondents felt incompetent in the practice area of dysphagia upon graduation. Recommendations to improve dysphagia graduate training included more hands-on training with swallowing assessments, increasing the number of core dysphagia graduate courses and offering a specialized track for medical vs educational SLPs among others.
- Alicia Vose and Ianessa Humbert completed a nationwide survey to examine clinical accuracy in identifying swallowing pathophysiologies on VFSS images. Findings presented in their poster demonstrated poor to modest accuracy in identifying swallowing disorders and frequent false positives. This suggested that additional training in both normal and disordered swallowing is needed to increase accurate diagnosis of dysphagia among practicing clinicians.
- A poster presented by Susan Brady and group suggested that incorporating technology into graduate medical education yielded significant gains compared to traditional lectures, with respect to the ability of medical residents to accurately interpret FEES. Findings support the need for more classroom time focusing on the hands-on component of FEES. This has important application in dysphagia graduate education as well.
Takeaway: A lot needs to change at the graduate level in order to improve the adequacy of dysphagia training and competency. Less is NOT more in this case.
Clinicians and Researchers: When Our Powers Combine
I have immense gratitude and appreciation for all the presenters who flew down to Tucson to share their research and expertise at DRS 2016. However, my top takeaway from DRS was not from a particular study or session. It was something much greater than that. It was the understanding and realization that the assessment and treatment of dysphagia NEEDS to be a multidisciplinary team effort. It doesn’t have to be us (the community or hospital based SLP) v/s them (Researchers, ENTs, Pulmonologists, Radiologists etc.). We can all work together with our unique skill sets, towards asking the same questions and finding common answers that will ultimately improve our patient’s lives.
Attending DRS 2016 allowed me to put myself in the researcher’s shoes for once and view evidence differently. It helped me improve my understanding of WHY we do what we do. It not only helped me appreciate the limitations of our treatments, but also made me realize how I can utilize my clinical expertise and critical thinking skills to fill in the missing gaps.
“True wisdom is knowing what you don’t know”…
and then doing what you can to change that!
Quoting Dr. Gary McCullough (DRS 2016 President-Elect):
“The DRS Annual Meeting is the adrenaline shot that will last you all year long. I can’t tell you the number of times I’ve heard people tell me that they come to DRS, realize they are not doing enough for the profession, and leave inspired to do more. It’s because the quality of the work presented is just phenomenal. And, more importantly, it’s translational science at its best. Whether you do research yourself or see patients in the evidence-based manner current practice dictates, attending DRS ups your game. It’s like Lays potato chips. You can’t have just one. You will be back for more”
Couldn’t have said it better myself! I know I will surely be going back for more. See you all in Portland, Oregon at DRS 2017.