Home Speech-Language Pathology Recent Dysphagia Surveys

Recent Dysphagia Surveys

by Tiffani Wallace
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(This post originally appeared on Dysphagia Ramblings)

I have often wondered what others that work in the area of dysphagia do during therapy.  I always want to know what tools they use and what books they recommend, so I made a survey.  Actually I made two.

First, I sent out 75 surveys, in the surrounding areas in Indiana (mostly central).  I received 13 of the surveys.  Ok, 12 because technically I did one as well.  Most of the surveys came back to me partially completed.  I have the results posted on Scribd.

As a whole, we had an average of 10 years of practice, with the shortest time being 2 years and the longest being 30 years or more.  Most therapists work in a SNF (Skilled Nursing Facility).  One concerning factor for me was the lack of use of a standardized bedside assessment.  In our realm of changing and more evidence-based therapy/healthcare, can we really continue to afford to use only our judgement with no real data to back up our findings??

Another concerning finding to me is that the most widely used therapy technique is diet alteration at 85%, which tied with oral exercises.  Perhaps, a new survey should be devised to determine what people consider oral exercises.  I realize that in SNF’s there will always be those patients that require a diet change and are not appropriate rehabilitation candidates, however SNF’s are also becoming widely known for rehabilitation.

Techniques that actually engage the swallowing function and tax the system to bring about an actual change, such as the Mendelsohn, the effortful swallow, etc, were only reported to be used 46-38% of the time.  I guess this would also explain why the average percentage of return to a normal diet was only 50% with most likely, spontaneous return accounting for some of the return.

Expiratory Muscle Strength Training (EMST) is an emerging therapy incorporating respiration strengthening with swallowing exercises.  Items such as The Breather were only incorporated into therapy by 1 therapist.  Of course, keep in mind, this was a very limited survey response, it still, I believe, paints a big picture of how our therapy looks.

With the limited number of surveys that were returned to me per mail, I decided to also create a survey by Survey Monkey.  This survey had a response from 44 therapists.  Again, the majority of the therapists from this survey work in a SNF.  The most widely used therapy “tool” is tongue depressors.  I’m guessing because it’s the most accessible tool we can get.  The Breather/Spirometer for EMST was still fairly low on the list with 14-17% usage and the Iowa Oral Performance Instrument (IOPI) was at 9.5%.

Again, the most popular therapy technique is diet alteration at 95%.  Some of the rehabilitative strategies we use such as the effortful swallow, Mendelsohn, etc.were used by 50% or more of the respondents.

I think that one important thing we can learn here is that diet changes, head turns, chin tucks, double swallows are not “rehabilitative”.  They create a safe swallow for the present time while we rehabilitate the swallow for a diet upgrade.  While we may have our patients on an altered diet or have them employ compensatory strategies, we also need to work the patient, use that effortful swallow, the Mendelsohn.  Work the swallow system and make it work like it should.  That is rehabiltiation.  When we bring about a change, we rehabilitate.

Most of us do recommend The Source for Dysphagia by Nancy Swigert as our favorite book.

I think the main thing we need to ask ourselves when treating our patients with dysphagia is, “Am I doing everything I can to rehabilitate my patient?”  Then ask yourself do you feel comfortable in saying yes you are.  Treat your patients as you expect to be treated.

Tiffani Wallace, MA, CCC-SLP, currently works in an acute care hospital in Indiana.  Tiffani is working to specialize in dysphagia and is working to achieve the BRS-S.  You can find Tiffani’s blog at http://apujo5.blogspot.com.

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Ashley May 12, 2011 - 12:30 am

Thanks for posting about this issue and about rehabilitation/adult population in general! I read this blog fairly regularly and would love to see more posts about the neuro/adult population. I would also like to see a shift towards more standardized dysphagia assessment and management.

Lori May 12, 2011 - 12:41 pm

Interesting findings, and thank you for sharing!

I would say that I actually use texture as a very large portion of my oral retraining. Assuming that risk is well controlled, I just don’t feel that oral exercises are going to improve mastication and bolus formation abilities without food present.

And while I do spend a fair amount of time on pharyngeal retraining by way of effortful swallow, and other techniques when I have a patient that can truly do them, again I find that controlled presentation of challenge boluses creates the most robust change.

So do you think that people are saying “diet change” when they mean using challenge textures as a retraining tool? Because you’re right – changing a diet generally doesn’t rehabilitate a swallow, it simply accommodates compromised ability.

Sonal Chitnis May 12, 2011 - 1:02 pm

I appreciate your study and heartly congratulate you.
Do you have any survey report or study on Pharyngeal stimulation used in dysphagia at any university or nursing home/ neurorehab set up? I will be happy to read and quote in our study. We are currently working and will be publishing soon our study” Efficacy of Thermal stimulation and use of swallowing maneuvers & oromotor exercises in persons with adult neurogenic swallowing disorders”. Interestingly we found significant improvement with thermal stimulation along with swallowing maneuvers & oromotor exercises in Laterla medullary syndrome with acute ischemic Stroke patients and also TBI patients. Sonal

Edgar V. Clark, M. Ed., CCC/SLP May 12, 2011 - 1:10 pm

Tiffani, I would like to make a couple of points about your survey…

First, I think the assumption that “we could be doing more for swallow rehabilitation” because diet management is a leading technique is a little misleading… I do a lot of diet changes in skilled nursing because we have lots of people that experience varying levels of ability on a daily, weekly and monthly basis. I would also submit to you that there there really isn’ t a set profile of who is a SNF resident.

Second, as you pointed out, SNF’s are becoming more well known for rehabilitation, but they also continue to serve others with no or little rehab potential that may benefit only from mangement techniques. No one would ever say a PT wasn’t doing “all they could do” if they gave a patient a cane or a walker, they are doing what the patient needs. For SLP’s (as well as other disciplines), there is a huge difference in a dementia patient that is staging to a lower ADL level and may benefit from the appropriate selection of a diet and a new stroke at the facility for 20 days of rehab services… but yet they exist in the same facility. There are tons of patients that I see that while physically able to do exercise, can’t follow directions, can’t comprehend, have severe behavioral problems, etc.,… So while your survey presents some interesting data, it needs a little refinement to really fish out what it means. Sometimes what a patient needs is “just” a diet change…

Thanks Tiffani for your blog and dedication to the profession!!!

Tiffani Wallace May 12, 2011 - 4:42 pm

Thank you all for your comments!

This survey is by no means perfect nor complete! I don’t mean to seem as if I’m cutting on the SNF’s because I’m not. I am really attempting to look at our profession as a whole, what are we doing and what we could be doing. I agree there are always those patients that are poor rehab candidates but every setting also has rehab candidates. I love oral manipulation of boluses, Lori! I agree on that! I think that for the purpose of this survey, diet changes meant merely changing the diet! You guys are all great, letting me ramble and reading my opinions! I love learning and love the positive feedback! Huge thanks for ASHASphere for publishing this!

Carol Cleary May 12, 2011 - 8:41 pm

Well, I found your article encouraging to me! I’ve been practicing for nearly 30 years, most of which I have practiced in a SNF. I continue to work in a SNF as well as PRN for home health. I do alter diets as a means to safety but as soon as I establish safety I focus on re-establishing increased ability to safely manage more challenging textures and /or consistencies. Tools: I do bolus control exercises with straws cut in half (the original exercise uses cherry whips but the saliva mixes with the red dye and stains clothing, so….), when indicated I use the Mendelsohn, Shaker exercises, forceful swallows, Masako exercises…what ever it takes. I can’t tell you the number of pureed diets in my building (it’s not huge) but I can tell you that in a building of nearly 100 residents we only have 6 on thick liquids. I always felt I should be doing something more…..I feel much better after reading your article!!!!!!!

Carol Williford May 23, 2011 - 4:32 pm

As an SLP with acquired dysphagia problems (botched surgery 20 years ago) I can attest to the ongoing need for diet change. Also I’m old enough to have been in the trenches when dysphagia evaluations and therapy were introduced to SNFs. So as a client and an SLP I can honestly say that chin tucks and head tilting were highly effective. As to regaining an actual safe swallow I think it is purely a medical issue regarding the recovery process itself – the swallow is either regained or it is not and you live with the end result. A year and a half ago I did add drinking aloe vera juice to my morning protein shake which actually improved my overall swallow and reduced GERD by 99%.

Dr. Carol Williford, CCC-SLP

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