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OUR SERIES AIMS TO DEVELOP YOUR SKILLS FOR CRITICAL APPRAISAL MAKING DECISIONS EVIDENCE BASED PRACTICE

This House Believes

Oropharyngeal dysphagia is the term used to describe swallow impairment. Swallowing difficulty can arise from nerve, muscle or structural damage to the oropharyngeal tract including the oral cavity, pharynx and upper oesophageal sphincter. Speech and language therapists have a primary role in the assessment and treatment of oropharyngeal dysphagia. International and national organisations agree that both non-instrumental and instrumental procedures are within the speech and language therapists scope of practice and require a specific level of training (ASHA , 2002; NCCAC, 2006; RCSLT, 2006) . The clinical swallowing evaluation usually includes reviewing medical history, patient and carer interviewing, completion of the oro-facial sensory motor examination, and observing the patient during trial swallows. The instrumental examination typically includes videofluoroscopy or fibreoptic endoscopy. The primary goals of dysphagia assessment include: a. determining the presence or absence of a disorder b. describing its nature and cause c. evaluating impacts on quality of life d. designing an effective treatment plan. There is broad agreement on the goals but how we achieve these has historically been the source of controversy (Splaingard et al., 1988). There are mixed opinions as to the need and use for both the non-instrumental and instrumental procedures. Many clinicians view the clinical swallowing evaluation as a starting point for gathering information to determine the need for an instrumental examination. Others have shunned the subjectivity and methodological inconsistencies of noninstrumental procedures, concluding that the instrumental examination is essential in all cases. A recent prospective study showed marked variability in clinical decision making and in conducting non-instrumental procedures (Pettigrew & O'Toole, 2007). These findings were comparable to previous studies showing high variability in clinical practice and clinical decision making (Mathers-Schmidt & Kurlinski, 2003; Bateman et al., 2007).

Samantha Procaccini and Paula Leslie weigh up the evidence for offe endoscopy to all people referred with acute dysphagia, but find the s
practice raises concerns for methodological efficacy and ultimately patient care. In response to the growing expectation of consistent evidence based practice, our debate considers the evidence for and against a requirement for instrumental procedures on all acute patients referred for a swallowing evaluation.

This House Believes explained

In her teaching, Paula Leslie uses a debating idea from the British Medical Journal to get her students to critically review a controversial subject. By understanding the strengths and weaknesses of the arguments on both sides, the students are better prepared to develop their own views. Students are strictly limited in word count and number of references to foster concise and relevant writing. Their work is now being adapted for Speech & Language Therapy in Practice. The debating format means: the Proposition is required to prove its case, while the Opposition aims to show why the Proposition is wrong either side can interrupt with a point of information while the other side is speaking our authors reach a conclusion based on the evidence and readers can continue the floor debate via the Critical Friends process see www. speechmag.com/About/Friends.

Background

Samantha

Paula

The proposition case is that clinicians should complete an instrumental exam on all acute care patients referred for swallow evaluation. Swallowing is a complex process involving the coordination of several covert physiological systems. Clinicians wishing to achieve objective clinical methods for detecting swallowing dysfunction have been plagued by the complexity of the physiology. One of the problems that dysphagia clinicians face is the difficulty of identifying aspiration. A false negative exam (when a patient is incorrectly identified as having no problem) may lead to potentially devastating outcomes in the medical course of a patient. Dehydration, malnutrition, and aspiration pneumonia are reported complications for those suffering from dysphagia. A recent study showed that the negative predictive value of aspiration or penetration was 64 per cent when a tracheostomised patient passed the clinical swallowing evaluation. This meant that over one third of the patients who passed later failed the instrumental examination (fibreoptic endoscopic evaluation of swallowing) (Hales et al., 2008). This study also concluded that fibreoptic evaluation of swallowing is highly valuable in routine assessment of swallowing. POINT OF INFORMATION The Hales paper clearly states that for those patients identified as having a problem on clinical evaluation the use of further instrumental assessment is unnecessary simply to identify if there is a problem. This supports the view that requiring instrumental examinations on all acute patients is unwarranted unless the instrumental exam is used to define the nature of the swallow impairment. The clinical swallowing evaluation is often used as the standard measure for assessing dysphagia in medical settings. The accuracy of such methods for detecting aspiration is widely scrutinised amongst clinicians and researchers. The clinical swallowing evaluation has been

The proposition case: external evidence increases clinical efficacy

Samantha Procaccini is a speechlanguage pathologist at the University of Pittsburgh Medical Center-Passavant in Pittsburgh, USA, and a clinical fellow in the medical speech language pathology clinical doctoral program at the University of Pittsburgh, USA, email sjp52@pitt. edu. Paula Leslie is Associate Professor, Communication Science and Disorders at the University of Pittsburgh, USA, email pleslie@pitt.edu. Paula is also a specialist advisor in swallowing disorders for the Royal College of Speech & Language Therapists.

Defining the topic

Dysphagia assessment procedures must be clear, consistent and evidence based. An accurate dysphagia assessment is paramount to providing effective treatments for patients. Inappropriate or inaccurate assessments can put patients at risk of malnutrition, dehydration, anxiety, respiratory infection and even death (Hudson et al., 2000). Variability in any type of clinical

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s in instrumental assessment
criticised for its inability to define pharyngeal phase abnormalities and silent aspiration. Additionally, use of the clinical swallowing evaluation alone has been criticised for being unreliable in guiding dietary management and treatment recommendations of patients with dysphagia. Leder & Espinosa (2002) reported reliance on non-instrumental measures alone for diagnosing and treating dysphagia led to underestimation in patients with aspiration and overestimation in patients who did not aspirate. McCullough et al. (2001) confirmed more efficacy data is needed if the clinical swallowing evaluation is used to predict aspiration on videofluoroscopy. POINT OF INFORMATION: Dr Leder has subsequently changed his position and advocates the use of a simple 3oz water swallow test as being sufficient: Importantly, for the first time it has been shown that if the 3-ounce water swallow test is passed, diet recommendations can be made without further objective dysphagia testing. (Suiter & Leder, 2008) Even if the clinical swallowing evaluation accurately detects aspiration, the clinician is unable to judge either the amount or whether compensatory strategies or manoeuvres reduce aspiration risk. To adequately address the cause of a swallow impairment we must be able to evaluate the physiology, and this requires instrumental imaging.

ering instrumental assessment in the form of videofluoroscopy or fibreoptic scales tip to a more patient-centred, needs-led approach. Summing up the case for the proposition

There is a drive to increase evidence based practice in clinical decision making. Universally implementing instrumental examinations on all patients referred for a swallow evaluation would provide the external evidence needed to achieve the highest quality patient care. Video documentation would serve as a vehicle to substantiate diagnostic and treatment recommendations. A department better equipped to perform evidence based practices and cutting edge dysphagia services is more likely to gain transdisciplinary respect, and potentially more referrals. Based on the results of instrumental assessments, treatment recommendations and dietary management can be made with greater clinical efficacy.

POINT OF INFORMATION: Acute care patients may have different impairments and therefore requirements to rehabilitation patients. By the time patients get to rehabilitation they should have already had the instrumental exams and so the cause of the swallow impairment would be known.

Danger of test focus

A false positive exam (when a patient is incorrectly identified as having a problem) can also lead to potentially negative effects on a patient's quality of life, independence, and life satisfaction. Patients may be placed on a diet modification following a clinical swallowing evaluation when there is no need. Although it is documented that patients can be adequately hydrated with thickened liquids (Sharpe et al., 2007), there is a high risk of dehydration for patients receiving thickened liquids. This is related to reduced intake of liquids from refusing thickened liquids (Finestone et al., 2001). Colodny (2005) surveyed 63 patients with dysphagia who were considered to be "noncompliant" with the speech and language therapists recommendations. The second most common response for justifying noncompliance was dissatisfaction with diet modifications. Determining the need for diet modification should be justified by evidence and the use of instrumental imaging could help patients understand why recommendations are being made.

Diet modification

Instrumental evaluations of swallowing are not required for all acute care patients referred for a swallow evaluation. Detecting aspiration is not the sole or even primary objective of the clinical swallowing evaluation. McCullough et al. (2005) pointed out that it serves a wide range of purposes including 1. documentation of feeding position 2. amount of oral intake 3. eating efficiency and 4. overall pleasure derived. The clinical swallowing evaluation quite importantly aims to establish the need to conduct an instrumental examination. During the clinical swallowing evaluation it should become clear if the factors are more or less oropharyngeal related, for example the patient who had a stroke a year ago but the event precipitating the referral was vomiting whilst asleep and subsequent chest problems. Factors such as simple fatigue may be the primary reason for the swallow impairment. Westergren et al. (2002) investigated eating difficulties in a group of hospital rehabilitation residents aged 65+ years. The most common eating difficulties were low food consumption, manipulation of food on the plate and variable speed of eating. The primary characteristic of eating difficulties overall and in non-assisted patients was low energy - people simply didnt have enough energy to finish their meal. Low energy is an insidious problem and often not identified in patients who dont receive assistance. This is a serious issue as low energy had the strongest correlation with malnutrition.

The opposition case: clinical judgement is needed

Videofluoroscopy and fibreoptic endoscopic evaluations of swallowing have historically been considered gold standard instrumental measures for evaluating dysphagia. There is a danger that we focus too much on one test and forget the complexity of physical and psychological issues involved in maintaining adequate nutrition and hydration and the non-physiological aspects of eating and drinking. Some experts advocate for 100 per cent requirement of videofluoroscopy using the threat of litigation as pressure, without regard to the many other factors involved (Tanner, 2006.) Psychosocial factors are equally important. People with eating difficulties may feel embarrassed and fear socialising over a meal. Leow et al. (2009) showed that dysphagia carried a high level of burden for those with Parkinson's disease. The burden of having dysphagia may lead to a loss of appetite, social isolation and embarrassment, raising the potential for depression and anxiety (Eckberg et al., 2002; Westergren et al., 2002).

Summing up the opposition case

The use of instrumental assessment must be deemed appropriate and this requires clinical judgment. Pollens (2004) pointed out using instrumental testing would be inappropriate if i. the results were not going to change clinical management ii. the patient was too medically fragile or iii. the patient refused. Evidence based practice standards require that medical practitioners use their best clinical judgement and adhere to a patient-centred care model. Take the scenario where a speech and language therapist receives a swallowing referral for a patient just recently placed on palliative care for end stage lung cancer. The patient and carer make an informed choice to refuse an altered diet and participation in instrumental testing measures. In this clinical case, ordering an instrumental exam would be a pure act of paternalism and violation of the ethical principles of autonomy and informed consent.

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Judgement: Motion defeated

Instrumental testing serves an integral role in dysphagia diagnosis and treatment. Clinicians must recognise the potential dangers and impracticalities of over-using instrumental measures. Technological advances have made equipment more accessible. We must provide fair and equitable treatment to all according to the medical ethical principle of justice. A requirement for all acute care patients to have an instrumental exam has consequences in terms of budget and staff availability. Acute care facilities often have a large volume of patients referred for swallow evaluations. Completing unnecessary testing would result in increased hospital costs and lengthier hospitalisations. There is very little robust evidence linking dysphagia assessment and intervention with long-term or global health outcomes. We practise in a culture that is increasingly risk averse, but without evidence supporting our fears. Many patients are still restricted in their diets based on observation of aspiration during a videofluoroscopy sometimes without any other evidence. Yet we have evidence that thickened drinks result in dehydration (Finestone et al., 2001), a major health risk factor. Universal use of instrumental measures in swallow evaluation is not always appropriate. Instrumental exams are an essential tool but, even when we know there is a problem from the clinical evaluation, we might not recommend a further instrumental. The evidence from Hales et al. (2008) shows we are good at identifying that there is a problem. What we do then will vary - for some patients it will be to consider 100 per cent non-oral supplementation, for others it will be to try consistencies that they can cope with, and for others it will be to analyse it further through an instrumental examination. The clinical swallowing evaluation assesses much more than just aspiration or physiology and so the informed clinician can make a judgement regarding the nature of the swallow impairment. This allows for prioritisation for subsequent evaluation which may include instrumental testing. Clinicians should not use the lack of resources as an excuse for not requiring instrumental testing. Services should be requested based on patient need rather than what service is available. Clinicians need to be evidence based thinkers and practitioners, aware of what a full dysphagia evaluation requires and what the instrumental exam can tell us as a part of it. We propose that instrumental exams are NOT required for all acute patients. Equally, the clinical swallowing evaluation should be comprehensive, so we do not support Leders position on the use of a simple water test. Further recommendations after the clinical swallowing evaluation should be based on patient need and understanding of the consequences of our recommendations. This position applies to all evaluations of patients with dysphagia in all settings, not just the acute wards.

American Speech-Language-Hearing Association. (2002). Roles of Speech-Language Pathologists in Swallowing and Feeding Disorders [Position Statement]. Available from www.asha.org/policy. Bateman, C., Leslie, P. & Drinnan, M.J. (2007) 'Adult dysphagia assessment in the UK and Ireland: are SLTs assessing the same factors?', Dysphagia 22(3), pp.174-86. Colodny, N. (2005) 'Dysphagic independent feeders' justifications for noncompliance with recommendations by a speech-language pathologist', Am J Speech Lang Pathol 14(1), pp.61-70. Eckberg, L.A., Hamm, L.J. & Soltis, J.A. (2002) 'Breaking free of restraints', Provider 28(7), pp.57-60, 62. Finestone, H.M., Foley, N.C., Woodbury, M.G. & Greene-Finestone, L. (2001) 'Quantifying fluid intake in dysphagic stroke patients: a preliminary comparison of oral and nonoral strategies', Arch Phys Med Rehabil 82(12), pp.1744-6. Hales, P.A., Drinnan, M.J. & Wilson, J.A. (2008) 'The added value of fibreoptic endoscopic evaluation of swallowing in tracheostomy weaning', Clin Otolaryngol 33(4), pp.319-24. Hudson, H.M., Daubert, C.R. & Mills, R.H. (2000) 'The interdependency of protein-energy malnutrition, aging, and dysphagia', Dysphagia 15(1), pp.31-8. Leder, S.B. & Espinosa, J.F. (2002) 'Aspiration risk after acute stroke: comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing', Dysphagia 17(3), pp.214-8. Leow, L.P., Huckabee, M-L, Anderson, T. & Beckert, L. (2009) 'The Impact of Dysphagia on Quality of Life in Ageing and Parkinson's Disease as Measured by the Swallowing Quality of Life (SWALQOL) Questionnaire', Dysphagia [online]. DOI 10.1007/s00455-009-9245-9. Mathers-Schmidt, B.A. & Kurlinski, M. (2003) 'Dysphagia evaluation practices: inconsistencies in clinical assessment and instrumental examination decision-making', Dysphagia 18(2), pp.114-25. McCullough, G. H., Rosenbek, J.C., Wertz, R.T., McCoy, S. & Mann, G. (2005) 'Utility of clinical swallowing examination measures for detecting aspiration post-stroke', J Speech Lang Hear Res 48(6), pp.1280-93. McCullough, G.H., Wertz, R.T. & Rosenbek, J.C. (2001) 'Sensitivity and specificity of clinical/ bedside examination signs for detecting aspiration in adults subsequent to stroke', J Commun Disord 34(1-2), pp.55-72. National Collaborating Centre for Acute Care (2006) Nutrition Support in Adults. Oral nutrition support, enteral tube feeding and parenteral nutrition. London: National Collaborating Centre for Acute Care. Pettigrew, C. M. & O'Toole, C. (2007) 'Dysphagia evaluation practices of speech and language therapists in Ireland: clinical assessment and instrumental examination decision-making', Dysphagia 22(3), pp.235-44. Pollens, R. (2004) 'Role of the speech-language pathologist in palliative hospice care', J Palliat Med 7(5), pp.694-702. Royal College of Speech & Language Therapists (2006) Communicating Quality 3. London: RCSLT. Sharpe, K., Ward, L., Cichero, J., Sopade, P. & Halley, P. (2007) 'Thickened fluids and water absorption in rats and humans', Dysphagia 22, pp.193-203. Splaingard, M. L., Hutchins, B., Sulton, L.D. & Chaudhuri, G. (1988) 'Aspiration in rehabilitation patients: videofluoroscopy vs bedside clinical assessment', Arch Phys Med Rehabil 69(8), pp.637-40. Suiter, D. M. & Leder, S.B. (2008) 'Clinical utility of the 3-ounce water swallow test', Dysphagia 23(3), pp.244-50. Tanner, D. (2006, February 07) 'The Forensic Aspects of Dysphagia: Investigating Medical Malpractice. The ASHA Leader [online]. Westergren, A., Ohlsson, O. & Hallberg, I.R. (2002) 'Eating difficulties in relation to gender, length of stay, and discharge to institutional care, among patients in stroke rehabilitation', Disabil Rehabil 24(10), pp.523-33.

References

Resources
The Socialeyes pack from the National Autistic Society is designed to help people with autism become more confident in social situations. www.autism.org.uk/socialeyes 3D Anatomy software is now available for speech and language therapy clinicians and lecturers, and includes a client education section. www.primalpictures.com/speech_language_ pathology.aspx The national advice and information service for additional support for learning in Scotland. www.enquire.org.uk/pcp/index.php Looking Up is a monthly international newsletter devoted to autism. www.lookingupautism.org/subscribe.html Nottingham Rehab Supplies has a 48 page brochure of equipment which may help people with dementia. Email info@nrs-uk.co.uk for a copy. The Assessment of Mental Capacity Audit Tool (AMCAT) is an online resource for staff and carers. www.amcat.org.uk/ The May 2010 Stroke Matters includes articles about involving clients and carers in research. www.stroke.org.uk/professionals/information_ and_resources/stroke_matters.html Preview NDP3 Speech Builder software for creating therapy tools based on the 700 images in the Nuffield Centre Dyspraxia Programme. www.ndp3.org/speechbuilder.html Users of Clicker and ClozePro software can now choose from three different symbol sets Widgit, Mayer-Johnson PCS and SymbolStix. www.cricksoft.com A Voice Fit for Teaching is a 24 page booklet by voice coach Caroline Cornish to give guidance to teachers on voice care and use. www.southgatepublishers.co.uk/ A simplified computer aimed at older people has just six buttons for basic tasks such as email. SimplicITy costs start at 435.99. www.discount-age.co.uk/simplicity_computers/ Source = MND Cheshire newsletter A central resource for advice on developing Personal Communication Passports. www.communicationpassports.org.uk/Home/ The National Literacy Trust has overhauled its website to include a Wiki of good practice, policy and campaigns and expert blogs. www.literacytrust.org.uk/

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