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Position
Paper
Dysphagia: General
Disclaimer: To the best of the Speech Pathology Association of Australia Limiteds (the
Association) knowledge, this information is valid at the time of publication. The Association
makes no warranty or representation in relation to the content or accuracy of the material in this
publication. The Association expressly disclaims any and all liability (including liability for
negligence) in respect of the use of the information provided. The Association recommends you
seek independent professional advice prior to making any decision involving matters outlined in
this publication.
Contents
Speech Pathology Australia Position Statement ..................................................................... 1
1. History of the Dysphagia Position Paper.......................................................................... 2
2. Definitions ......................................................................................................................... 2
2.1 Dysphagia ................................................................................................................. 2
2.2 Service/Service Providers ......................................................................................... 2
3. Client Groups and Disorders ............................................................................................ 2
4. Changes and Trends......................................................................................................... 4
5. Client Services .................................................................................................................. 4
5.1 Service Delivery......................................................................................................... 4
5.2 Models of care .......................................................................................................... 4
6. Referral.............................................................................................................................. 5
6.1 Sources of Referral ................................................................................................... 5
6.2 Methods of Referral .................................................................................................. 5
6.3 Reasons for Referral ................................................................................................. 5
6.4 Information Required at Time of Referral.................................................................. 5
6.5 Prioritisation .............................................................................................................. 6
6.6 Urgent Referrals ........................................................................................................ 6
7. Team Work........................................................................................................................ 7
8. Assessment, Diagnosis and Management ....................................................................... 8
8.1 Background History .................................................................................................. 8
8.2 General Observation ................................................................................................. 9
8.3 Communication Status............................................................................................ 10
8.4 Clinical Oropharyngeal Assessment ....................................................................... 10
8.5 Suitability for Oral Trial ............................................................................................ 10
8.6 Oral Trial/Bedside Examination/Mealtime Observation.......................................... 11
8.7 Referral for Instrumental assessment (as appropriate)........................................... 11
8.8 Overall Impression .................................................................................................. 12
8.9 Diagnosis................................................................................................................. 12
8.10 Management Plan ................................................................................................... 12
9. Treatment........................................................................................................................ 13
9.1 Oral phase disorders............................................................................................... 15
9.2 Velopharyngeal disorders ....................................................................................... 15
9.3 Oropharyngeal transit disorders ............................................................................. 16
9.4 Pharyngeal disorders .............................................................................................. 16
9.5 Cricopharyngeal disorders...................................................................................... 17
9.6 Penetration + Aspiration ......................................................................................... 17
10. Documentation ............................................................................................................... 17
10.1 Timelines ................................................................................................................. 18
10.2 Standards ................................................................................................................ 18
10.3 Reporting requirements .......................................................................................... 18
10.4 Discharge and Resolution Planning ........................................................................ 19
10.5 Confidentiality ......................................................................................................... 19
11. Education and Counselling ............................................................................................. 19
11.1 At Referral ............................................................................................................... 19
11.2 After Clinical Assessment ....................................................................................... 19
11.3 Prior to Discharge ................................................................................................... 20
11.4 Client/Carer Education............................................................................................ 20
ii
Speech pathologists have a pivotal role to play in the assessment and management of
dysphagia (swallowing disorders). The speech pathologist may act as clinician,
consultant, team manager, educator, and/or researcher. The extent of involvement
depends on the nature of the clinical setting and population.
Safety guidelines should be followed where they exist. For this reason clinicians should
be familiar with workplace occupational health and safety policies, relevant Position
Papers from Speech Pathology Australia and other relevant legislation and guidelines.
Speech pathologists should be familiar with and follow local workplace and government
policies and procedures where available.
Speech pathologists should have knowledge of the current Speech Pathology Australia
Code of Ethics (2000) and the Principles of Practice (2001) that states that decisionmaking in dysphagia should incorporate awareness of the ethical principles of
autonomy, non-maleficence, beneficence and justice.
Speech pathologists should work within their scope of practice. Where experience or
skills are limited appropriate advice, mentoring and peer support should be sought.
Consistent, full and accurate recording and documentation of all areas of client
assessment and management should occur.
Speech pathologists should manage clients with dysphagia as part of a team where
possible to achieve the best possible outcomes.
This paper reflects available evidence, issues and current clinical practice as it presents
at this point in time.
Page 1
2. Definitions
2.1 Dysphagia
Etymologically the term dysphagia is compounded from the Greek words dys = disordered
and phagein = to eat (Winstein, 1983), meaning a swallowing disorder.
Dysphagia is not a disease in itself but is a term that refers to a condition, a disorder or a
symptom that may be genetic, developmental, acquired, functional or iatrogenic in origin. It can
be caused by structural, physiological and /or neurological impairments affecting one or more
stages of swallowing, namely the preparatory, oral, pharyngeal, and/or oesophageal stages. This
may present as a difficulty with sucking, drinking, eating, controlling saliva, protecting the airway
or swallowing. As a consequence dysphagia may lead to asphyxiation or pneumonia (Langmore,
Terpenning, Schork, Chen, Murray, Lopatin and Loesche 1998; Martin, 1994), or failure to meet
an individuals nutrition, hydration (Davalos, Ricart, Gonzalez-Huix, Soler, Marrugat, Molins, Suner
and Genis (1996); Langmore et al 1998; Martin, 1994) and social needs (Ekberg, Hamdy, Woisard,
Wuttge-Hannig & Ortega, 2002) as well as impacting on development of oral and communication
skills (Morris, 1985).
2. 2 Service/Service Providers
The term service or service provider refers to the person or organisation that is providing a
service to an individual. It incorporates all speech pathologists, including those who are
employed by organisations such as state departments of health, community service, and
education and training, non-government agencies, universities and speech pathologists in private
practice.
Page 2
The disorders listed below illustrate the diversity of clients who may experience
dysphagia but are by no means exhaustive.
Neurological
Cerebrovascular disease
Traumatic brain injury
Brain tumour
Hypoxic brain injury
Cranial nerve abnormalities
Meningitis
Dementia
Parkinsons Disease
Motor Neurone Disease
Myasthenia Gravis
Huntingtons Disease
Multiple Sclerosis
Cerebral Palsy
Developmental disability including chromosomal and congenital syndromes
Post Polio Syndrome
Mechanical
Cancer
Tracheostomy
Cricopharyngeal dysfunction
Craniofacial anomalies
Head and neck surgery including oral surgery, partial and total laryngectomy,
thyroidectomy, neck dissections
Oesophagectomy
Intubation injury
Trauma to the head and neck; for example, blow to the neck, object penetration
Inhalation burns
Metabolic
Diabetes
Thyroid dysfunction
Other
Scleroderma
Page 3
Increased research on the incidence and diversity of client groups shown to be affected
by dysphagia;
Political factors, such as pressure to reduce length of hospital stay where intervention
by speech pathologists for dysphagia is perceived as reducing the incidence of
aspiration pneumonia and the time needed for alternative nutrition;
Philosophical shift, recognising the value of intervention in improving nutrition, health
and well-being;
Medical advances which have resulted in speech pathologists treating more medically
complicated patients who are often more acutely ill and therefore more likely to be
dysphagic;
Recognition by health professionals of the role of the speech pathologist in the
management of dysphagia in neonates;
Improvement of and access to technology available for assessment and treatment;
The move to evidence based practice underpinning work practice;
The recognition that teams which include speech pathologists have better outcomes for
clients with dysphagia (Logemann, 1988).
5. Client Services
5. 1 Service Delivery
Speech pathologists assess and manage dysphagia in metropolitan, regional, rural and remote
settings.
They work with individuals across the lifespan and may be employed in hospitals or other health
services, disability services, community services, non-government agencies, education
authorities (Speech Pathology Services in Schools, 2002), residential facilities or private practice.
The speech pathology service provided will depend on the needs of the client, the location, the
policies of prioritisation and available resources.
5.2 Models of Care
Speech pathologists working with dysphagic clients may utilise a range of service delivery models
including:
A speech pathologists role need not be restricted to a single area. They may work concurrently
in:
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Provision of service delivery may at times need to be re-evaluated in line with changing needs.
These may be influenced by changes in:
6. Referral
6.1 Sources of Referral
Each facility should have a policy documenting from whom referrals can be accepted. Referral
sources may include, but are not restricted to:
Page 5
6.5 Prioritisation
Dysphagia has been implicated in the development of dehydration and malnutrition (Davalos et al
1996), chest infection and pneumonia (Langmore et al 1998; Martin, 1994). Early identification and
management is therefore critical in order to prevent or minimise such complications.
Services to clients with dysphagia should be provided in an effective, safe and timely manner.
The nature of dysphagia and its potentially serious consequences need to be reflected in
prioritisation of dysphagia services.
Prioritisation systems will vary depending upon the individual service and evidence regarding
best practice for that setting, the available resources and geographical location. Each service
should document its prioritisation process using clearly defined parameters. Prioritisation of new
referrals against the current caseload needs to be considered. Prioritisation policies should be in
accordance with the Code of Ethics (2000).
It is common practice for a benchmark to be set for response time to dysphagia referrals.
Reference to local policy and procedures and relevant national, state/territory guidelines should
be made.
6.6 Urgent Referrals
The definition of an urgent referral is multifactorial, and will depend on local policies and
procedures. Below are some of the client and clinical factors that should be considered when
determining urgency:
Acute versus chronic presentation (e.g. neonates, recent inability to tolerate oral
intake,critical care);
Medical condition (e.g. diagnosed/suspected aspiration pneumonia, documented
coughing, choking or gagging on oral intake or saliva);
Medical prognosis (e.g. palliative care) (N.B. In some cases it may be too early,
inappropriate or insufficient information may be available to provide a prognosis.);
Nutritional status (e.g. NBM, with no enteral nutrition, suspected dysphagia with
consequent malnutrition/significant weight loss/failure to thrive);
Mitigating medical factors (e.g. inability to swallow medication).
In settings where client intake/admission occurs out of regular working hours, consideration
should be given to after-hours management of dysphagia, such as in the evenings, on weekends,
or on public holidays. Services should have resources or contingency plans to meet urgent afterhours needs. This may include having in place procedures that determine the management of a
client who is admitted after hours with dysphagia. For example, clients at potential risk of
dysphagia may be kept Nil By Mouth overnight with hydration until seen by a speech pathologist,
or provision of an on-call speech pathologist on weekends or public holidays. Other team
members such as medical, nursing, and dietetics staff involved in the care of the client with
dysphagia need to be consulted in planning these procedures.
In a community/out-patient setting consideration should also be given to the availability of urgent
appointment slots.
Documentation of the prioritisation process as part of a policies and procedures manual enables
the speech pathology service to provide clients and referring agencies with a rationale for
caseload management decisions.
Page 6
7. Team Work
Clients should have access to a multidisciplinary team to ensure the provision of a holistic
service. This pertains not only to the evaluation of the swallowing problem and determination of
its aetiology, but also to its treatment and management (Logemann, 1994; Miller & Languor,
1994). The multidisciplinary team works in close cooperation with the client, their family and/or
significant others.
Multidisciplinary teams are cost-effective, and have been shown to improve clients weight and
caloric intake, reduce the risk of aspiration, have better outcomes and provide a source of
support for clients, and carers (Jones & Altschuler, 1987; Lucas & Rodgers 1998; Martens,
Cameron & Simonsen, 1990). In addition the team approach can increase staff awareness of
swallowing problems and their symptoms (Logemann, 1998).
Key team members on the dysphagia management team include:
Speech pathologists
Medical personnel - the medical team may include specialists from disciplines such as
otorhinolaryngology, gastroenterology, neurology, paediatrics, radiology, rehabilitation
medicine, respiratory medicine, general practice
Dentistry, orthodontics, dental hygienists
Nursing
Direct support workers/carers
Client/patient
Family members
Physiotherapists
Occupational therapists
Social workers
Dietitians
Pharmacist
Other team members may include, but are not limited to, radiographers, teachers,
psychologists and social workers.
Page 7
Immediate observations
Communication status
Management plan
The speech pathologist is essential to the assessment and management of the client, including
screening, clinical or bedside assessment, instrumental assessment and swallowing treatment.
Dysphagia management is a seamless process that may begin in the acute phase of medical
intervention and proceeds as the client advances through the continuum of care. Services can be
introduced at any stage of the continuum and
will terminate when the client is either nutritionally stable or able to eat at his or her highest
functional level with or without swallowing compensations (Sonies, 2000, p.101).
Information in all sections below should be applied as pertaining to the workplace. That is,
prenatal history will be relevant for those assessing paediatric clients but not for those in aged
care; similarly jaw function will be evaluated using different parameters depending on whether the
clinician is assessing chewing of solids or sucking from a bottle.
When assessing the client, ensure that any aids for communication, vision and hearing are
available for the examination. Clinicians must comply with occupational health and safety
requirements; for example, gloves, eye protection, nose mask, hand washing, current
immunisation (e.g. Hepatitis B).
Even when a client is non-compliant with the assessment, or aspects thereof, it should be
documented that assessment of these areas was attempted.
See the glossary for further information and references for the following techniques.
8. 1 Background History
Basic Competence implies the basic knowledge that would be expected from a grade one/new
graduate speech pathologist. Advanced Competence implies a greater knowledge and
understanding of how additional physical, mental and physiological factors can impact on
swallowing. These skills are expected of clinicians who operate specialist clinics, have greater
experience and or are at higher grades. These competencies should be supported by evidencebased practise and supporting research where available.
Page 8
Basic Competence
Advanced Competence
8. 2 General Observation
Basic Competence
Level of alertness/responsiveness
Posture/position
Level of activity/mobility
Presence of nasogastric tube,
tracheostomy tube (size, type),
gastrostomy tube, intravenous line,
central line
Implications of the presence of a
nasogastric tube or tracheostomy tube on
swallowing function
Ability to be positioned in optimal feeding
position and number of staff required to
obtain same
Presence of primitive and/or abnormal
reflex patterns
Respiratory function at rest and during
speech where applicable
Spontaneous swallow frequency
Presence of oral dyspraxia
Advanced Competence
Page 9
Basic Competence
Orientation
Comprehension
Hearing
Speech/vocalisation/intelligibility
Language
Voice quality
Obtain interpreter if required (refer to
workplace policy and procedures)
Advanced Competence
Assessment of need for augmentative
and alternative communication strategies
in the event of complex communication
needs
Advanced Competence
Visuoperceptual ability
Knowledge of the maturation of the
swallow
Level of alertness
Airway protection
Positioning
Fatigue
Voice quality
Advanced Competence
Page 10
Mouth opening
Lip seal/spillage
Lip closure on spoon
Sucking ability
Jaw function
Tongue function/movement
Chewing efficiency
Oral control of bolus
Efficiency of oral transfer
Oral residue post swallow
Initiation of swallow
Laryngeal elevation/hyoid movement
Cough
Swallow-respiratory coordination
Voice change
Rate/quantity of bolus given
Trial appropriate management strategies
(e.g. swallowing manoeuvres see
treatment section)
Impact/use of mealtime equipment
Impact of taste, temperature, size of bolus
on swallowing
Carer participation/skill and knowledge
Advanced Competence
Advanced Competence
Knowledge of the application, limitations and
suitability of the following assessments:
Page 11
Advanced Competence
8.9 Diagnosis
Basic Competence
Advanced Competence
Advanced Competence
Page 12
Basic Competence
Advanced Competence
9. Treatment
Treatment plans should only be formulated following the assessment of the clients swallowing
abilities. The treating speech pathologist must be able to determine and describe the presenting
symptoms, which aspect(s) of swallowing function is impaired (e.g. poor airway protection), and
the cause of dysfunction (e.g. vocal fold paresis caused by recurrent laryngeal nerve damage) to
enable the introduction of appropriate treatment.
The goals of effective dysphagia management/treatment include:
1. Increasing swallowing efficiency (through intervention)
2. Increasing swallowing safety, to minimise aspiration risk. (Whilst all care should be taken
to reduce risk it cannot be fully eliminated. Thus considered evaluation of risks and
benefits are critical in determining management.)
3. To recommend the most appropriate diet/fluid consistency and to determine when
transition from one form of nutrition to another is appropriate, such as from enteral to
oral, or puree to a soft-chopped diet
4. To determine, in conjunction with a dietitian and/or medical officer, the most appropriate
method to maintain or increase nutrition and hydration; this may include oral, or non-oral
means, or a combination of these
5. Maximising the social aspect of eating/drinking where possible
Effective management includes the ability to recognise:
1. Factors which are impeding progress and the ability to modify goals and treatment
programs accordingly
2. The need for involvement of other service providers
3. The need for involvement and support of family/carers
4. When goals have been achieved and services should cease
Page 13
Logemann (1998) reports that the key to effective dysphagia management is understanding a
clients anatomy and swallow physiology, medical diagnosis, and prognosis. Client management
will also differ according to individual client needs.
Logemann (1998) divides treatment into two general categories of management, these being
compensatory management and therapeutic strategies. Compensatory management includes the
use of techniques to compensate for loss of function. Compensatory strategies are utilised to
assist in altering the flow of the bolus in a way that compensates for compromised oropharyngeal
function, without changing the underlying physiology (e.g. head turn, chin tuck). In contrast,
therapeutic strategies are designed to improve swallow function by changing the underlying
swallow physiology and facilitating optimal functioning of available oropharyngeal structures (e.g.
improving the strength and range of movement of muscles used in swallowing). Swigert (2000)
identifies that some treatment techniques can be both compensatory and therapeutic (facilitative).
Swigert (2000) uses the example of the super-supraglottic swallow being used as a therapeutic
strategy to close the airway entrance before and during the swallow. In doing so the risk of
misdirection of food into the airway is reduced allowing oral intake. The swallow is still impaired;
however the technique allows the person to compensate sufficiently to eat.
The application of therapeutic strategies depends on several factors, including client ability,
clinical competence and the resources available at the speech pathology clinic. In some
instances other team members (e.g. nursing staff), the client and / or the clients next of kin may
be trained by the speech pathologist in compensatory or therapeutic strategies.
An outline of recognised compensatory and therapeutic strategies is listed below. The list is not
exhaustive and should be used as a guide only. For more detail on specific treatment techniques,
their use and application, clinicians should seek appropriate texts and journal publications. In
selecting suitable strategies clinicians must evaluate the suitability of the treatment based on the
clients needs, and the perceived outcome. Clinicians should also ensure that where possible the
techniques selected are underpinned by evidence and that the basis of this evidence be regularly
evaluated.
For convenience, the techniques are presented according to recognised stages of swallowing;
however, these can in no way be considered discrete as the success or failure of each stage will
have flow-on effects to other aspects of the swallow. In the management of adult clients,
strategies are defined as compensatory and rehabilitative (therapy); however, it should be noted
that any compensatory strategy that results in swallowing (either of bolus or saliva) is also
rehabilitative. In paediatric management the intervention seeks to facilitate normal developmental
stages and the refinement of oral feeding skills. In effect, both seek to establish successful oral
nutrition whilst minimising risk.
Finally:
Strategies associated with swallowing disorders with clients with tracheostomies are
not dealt with in this paper.
Techniques annotated with an * may be new and require further research and/or may
require the clinician to avail themselves of further training.
Surgical and medical procedures such as cricopharyngeal myotomy, laryngeal
diversion, botulinum toxin injection, vocal fold injection to improve airway closure or
medication designed to affect saliva are not addressed as these practices are beyond
the scope of the speech pathologist. The speech pathologist, however, should be aware
of these options and when and to whom to refer.
Biofeedback may include a number of instrumental techniques including manometry,
videofluoroscopy, cervical auscultation, respitrace and glottography.
Training in the use of Cervical Auscultation and SEMG is highly recommended before
use.
Page 14
Possible strategies
Clinical:
Compensatory:
Instrumental:
Contd. Over
Possible indicators
Possible strategies
Rehabilitation:
Possible strategies
Clinical:
Compensatory:
Instrumental:
Palatal prosthesis
Selection of specialised equipment such as
teats or straws
Texture modification of food/fluids
Rehabilitation:
Velopharyngeal exercises
Page 15
Strategies
Clinical:
Compensatory:
Instrumental:
Sounds of swallow-respiratory
incoordination on cervical auscultation
Chin tuck
Enhancing sensory input
Multiple swallows
Changing bolus size
Selection of specialised equipment such as
teats or straws
Modifying texture of food/fluids (thicker)
Modified rate of intake
Supra-glottic swallow
Rehabilitation:
SEMG/Biofeedback *
Electrical stimulation *
Possible strategies
Clinical:
Compensatory:
Instrumental:
Uncoordinated swallow
Asymmetry
Pharyngeal residue
Head rotation/tilt
Super-supraglottic swallow
Effortful swallow
Rehabilitation:
SEMG/biofeedback *
Page 16
Possible strategies
Clinical:
Compensatory:
Instrumental:
Uncoordinated swallow
Rehabilitation:
Possible strategies
Clinical:
Compensatory:
Wet voice
Throat clearing
Cough
Change in breathing pattern
Fever
Change in lung status
Instrumental:
Rehabilitation:
* may be new and require further research and or may require the clinician to avail themselves of
further training
10. Documentation
Documentation should ensure all medico-legal and accreditation requirements are met. Thorough
documentation is important and should include but not be limited to:
Page 17
Speech pathologists need to ensure that advice is recorded in writing. Verbal information, advice
or management changes should be followed up by written confirmation. The speech pathologist
should also refer to their employers departmental policy, relevant legislation and guidelines
10.1 Timelines
Documentation following client contact should occur in a timely manner as appropriate to the
requirements of the service. This should be clearly defined in each services Policy and Procedure
manual.
10.2 Standards
Standards of documentation should be specified in local organisational Policy and Procedure
manuals. The following is recommended as a minimum standard:
Care must be taken to ensure that all reports remain confidential and reports conform to the
provisions of the relevant privacy legislation.
Page 18
The service is expected to establish an appropriate system for the preparation and storage of
written documentation including assessment results, reports, client management plans,
interventional goals, progress notes and outcomes. Reference should be made to local policy.
10.4 Discharge and Resolution Planning
Once a client is discharged from Speech Pathology care, documentation regarding the rationale
for discharge and need for an ongoing treatment program should be specified in the clients
medical file or speech pathology file, whichever is applicable.
Reasons for discharge may include the following:
Goals achieved
Client reached optimal pre-morbid level of functioning
Intervention inappropriate (due to medical deterioration, lack of client/carer cooperation,
as determined by medical team)
Client discharged from hospital
Client/carer fails to attend
Client transferred to another facility/speech pathology service
Clients level of function plateaued
Client deceased
Should the client require ongoing care, with the clients permission a written care plan including
the following information should be forwarded to the client /carer and all health professionals
involved:
10.5 Confidentiality
Client documentation is to remain confidential at all times in accordance with the Code of Ethics
(Speech Pathology Australia, 2000), CBOS (Speech Pathology Australia, 2001) and relevant
privacy legislation.
The storage, duration and appropriate means of disposal of client information should be as
specified by organisational and state/territory requirements.
Page 19
Jointly obligated with the service employer to identify individual training needs and
negotiate as to the most appropriate method to achieve this (Speech Pathology
Australia, 2001, Principles of Practice);
Encouraged to share their knowledge and expertise with their colleagues (Speech
Pathology Australia, 2001, Principles of Practice);
Page 20
Support others who are expanding the knowledge base of the profession (Speech
Pathology Australia, 2001, Principles of Practice).
Infection control
Occupational Health & Safety requirements for conducting instrumental swallowing
assessments
Manual handling
Emergency evacuation
Staff requirements in Cardio-Pulmonary Resuscitation (CPR), fire training
Management of Coughing and Choking policy
Mealtime assessments in external facilities (i.e. schools)
Duty of care
Development of quality procedures should be related to evidence based best practice and any
guidelines or standards outlined by Speech Pathology Australia.
12.7.1 Measuring methods
Measurement tools are wide and varied, and range from clinical observational
measures and reports of significant others, to checklists, screening tests, and
assessments designed to measure presence of symptoms of dysphagia and
severity of dysphagia. The most frequently used outcomes tools in Australia are
the Therapy Outcome Measures Dysphagia Scale for a) Disability (TOMDD) and
b) Impairment (TOMDI) and the Royal Brisbane Hospital Outcome Measure for
Swallowing (RBHOMS) (Gupta, 1998)
Such measures may be utilised before, during and after intervention
It is important that the speech pathologist is aware of available tools and is
competent, in recognising when to use them and how to interpret them
Speech pathologists should be aware of the World Health Organization
definitions for health, disease, body structure and function, and need.
Page 21
13. Education
13.1 Clinical Education
All Australian university speech pathology courses equip students with basic skills in
dysphagia (Speech Pathology Australia, 2001, CBOS). Practical skills in the area of
dysphagia are, however, dependent upon the individual students clinical placement.
Whilst every effort is made to ensure students receive sound practical skills, individual
students experiences will vary from setting to setting.
Speech pathology students should be provided with the opportunity to observe an
experienced speech pathologist conducting a dysphagia assessment and intervention
where possible.
Speech pathology students should be provided with the opportunity to participate as
much as their skill allows in the assessment, interpretation and management of clients
with dysphagia during their clinical training where possible.
The supervising speech pathologist may provide the opportunity for students to
become clinically competent in the assessment and treatment of dysphagia however
they ultimately maintain clinical responsibility for the clients care.
Speech pathologists have an important role in contributing to the training of other health
professionals in identifying symptoms of dysphagia.
Speech pathologists may train, monitor and supervise other health professionals
involved in supporting a client with dysphagia.
Training may include provision of information, demonstration, supervision or monitoring
of practice of other staff about an individual or a group of people with dysphagia. This
training may enable other staff to carry out therapeutic manoeuvres as recommended
by the speech pathologist with an individual on a regular basis, in order to effect a
greater response to that intervention. The speech pathologist has a responsibility to
tailor the level of information to the needs and abilities of the person receiving the
training. Documentation detailing the information provided in such training sessions is
required. Any variations to these instructions must be given in writing. The speech
pathologist must document at what point they are transferring duty of care. Speech
pathologists maintain the responsibility for monitoring, supervising and altering the
treatment program.
13.3 Research
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13.3.1 Funding
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Speech pathologists should clarify the insurance situation for accidental loss, theft or damage to
resources during transport with their insurer.
14.9 Service Guidelines
It is recommended that the speech pathologist adhere to all approved guidelines of the
employing body in terms of clinical and service management.
14.10 Summary
In summary, a speech pathologist managing clients with dysphagia should:
Adhere to the Speech Pathology Australia Code of Ethics (2001) and any employing
bodys code of conduct.
Adhere to the code of conduct and all relevant policies/service guidelines of the
employing body.
Not undertake intervention that is outside their experience or expertise as a
professional.
Not overstate their expertise.
Seek advice from senior speech pathologists and/or fellow professionals as
appropriate.
Prior to treatment, obtain the client and/or parent/guardians consent to treatment.
Admission to hospital may imply global consent in some instances or a generic consent
may be obtained on admission
Keep the client and parent/guardian well informed of the intervention program.
Keep up-to-date with professional developments.
Ensure that proxies receive suitable training.
Undertake all mandatory training.
Keep accurate records.
Ensure that all advice given to the client, parent/guardian, professionals or staff is
documented.
Keep copies of all reports.
Keep up-to-date with report writing.
Ensure that the client environment is safe.
Ensure that there is adequate professional indemnity insurance cover.
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A.4 Electroglottography
The electroglottograph (EGG), also known as the Laryngograph, was initially developed as a noninvasive electrical impedence device for observing vocal fold contact during phonation
(Logemann, 1994; Perlman & Liang, 1991). It is hypothesised that the EGG could capture the
activity of the larynx as the airway closes during swallowing (Sonies, 1991). During
electroglottography an electrode is placed on either side of the neck over the thyroid cartilage.
One electrode transmits a signal, while the other receives the signal after it has been modified by
the impedance of the neck. The deflections can be used as an indicator of laryngeal elevation. It
is however subject to interference of artefact by movements of the head and tongue (Kaatzke et
al, 1996). It is not a routinely used assessment and requires additional training.
A.5 Electromyography
Electromyography describes the recording and study of the intrinsic electrical properties of
skeletal muscle (Dorland, 1982). Electromyography as it relates to swallowing assessment
describes the technique of assessing the function of the muscles involved in swallowing
(Logemann, 1994; Sonies & Baum, 1998). It provides information about the timing and relative
amplitude of muscle contraction during swallowing and the frequency of motor neurone firing.
EMG can be invasive or non-invasive. Muscles typically under investigation include the floor of
the mouth, or submental muscles, and those associated with laryngeal elevation. Additional
training will be required to use this method correctly.
A.6 Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
FEES is able to demonstrate via imaging the presence of dysphagia including laryngeal
penetration, tracheal aspiration, pharyngeal residue and bolus spillage into the pharynx prior to
the initiation of the swallow. FEES is considered to be a specialist skill requiring the speech
pathologist to undertake further training in its application.
The procedure, reported by Kidder, Langmore and Martin (1994) is an extended version of flexible
fiberoptic laryngoscopy (Langmore, Schatz & Olsen, 1988; Sonies 1991). Kidder, reported that the
technique is versatile, portable, provides immediate information and can be recorded onto
videotape for later analysis. He suggested that it complements, rather than replaces
videofluoroscopy swallowing studies and that the equipment and necessary expertise is available
in most hospitals. An advantage of the FEES is that the anatomy can be viewed directly.
It is not possible to view the total dynamics of the swallow during a FEES assessment, as the
movement of the epiglottis temporarily obscures the view during swallowing. It is possible to
detect aspiration occurring prior to a swallow, or from residue remaining in the pharynx after a
swallow. It is reported that if aspiration occurs during the swallow, residue would be visible in the
larynx and trachea once those regions return to view after the epiglottis has returned to an upright
position (Langmore et al., 1988; Sonies, 1991). FEES is able to show the direction of bolus flow
and reportedly, the appropriateness of certain treatment techniques. The technique can also be
used for review assessment to gauge improvement or decline in status.
A.7 Nuclear scintigraphy
Nuclear scintigraphy uses radionuclide scanning during the ingestion of a radioactive bolus
(usually technetium-99m) (Sonies & Baum, 1988; Sonies, 1991; Silver et al., 1991; Silver & Van
Nostrand, 1994) to track the bolus as it passes from the oropharynx to the oesophagus. The
radiopharmaceutical is not absorbed after ingestion, nor does it become attached to the
gastrointestinal mucosa (Benson & Tuchman, 1994).
Scintigraphy is an expensive, dynamic assessment of swallowing, requiring a gamma scintillation
camera, a low-energy collimator and a dedicated computer (Sonies & Baum, 1988). Measures
such as pharyngeal transit time, number of swallows required to clear pharyngeal residue and
regurgitation can be obtained. Although scintigraphy is said to offer precise quantification of
bolus volume in any area at a particular time or over time, (Fleming et al, 1990; Hamlet et al, 1989;
Humphries et al, 1987) there is much debate in the literature as to the tool's ability to detect and
quantify aspiration (Benson & Tuchman, 1994; Sonies & Baum, 1988). In the field of dysphagia,
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scintigraphy has been used primarily for the assessment of gastrointestinal reflux (Silver et al,
1991). Nuclear scintigraphy is conducted by a medical officer trained in nuclear medicine
imaging techniques.
A.8 Pharyngeal manometry
Pharyngeal manometry assesses the pressure dynamics of the pharynx and upper oesophageal
sphincter during swallowing. Pharyngeal manometry provides a means of measuring motor
activity of the pharyngeal muscles, by measuring pressure changes caused by muscle
contraction in the pharynx. It is predominantly used to investigate (a) pressure response of the
upper oesophageal sphincter (UES) to swallowing, (b) timing of pharyngeal contraction, (c) UES
relaxation and (d) the relationship between these events (Sonies, 1991). Pharyngeal manometry
requires the use of solid state pressure sensors that have a sufficiently fast response frequency to
react to rapid pressure changes that occur during the pharyngeal stage of the swallow. The
sensors are encased in a fine diameter tubing, typically 3 mm, and are passed transnasally so
that sensors are located at (a) the base of the tongue, (b) UES, and (c) cervical oesophagus
(Logemann, 1994). Other investigators, such as McConnel (1988), have an additional sensor
placed at the laryngeal inlet. Pharyngeal manometry is a procedure performed by a
gastroenterologist. Manofluorography (simultaneous manometry and fluoroscopy) is used
predominantly for research purposes. Pharyngeal manometry is frequently used where
gastroesophageal reflux is suspected.
A.9 Ultrasound
Ultrasound of swallowing is a technique that visualises the soft tissue of the oral cavity and
hypopharynx during swallowing, using a transducer placed submentally below the chin to obtain
an image. It does this by "the imaging of deep structures of the body by recording the echoes of
pulses of 1-10 megahertz ultrasound reflected by tissue planes where there is a change in
density" (Dorland, 1982, p.703). Any commercial ultrasound real-time sector or phased-array
system can be used, and the equipment and necessary expertise is available in most hospitals
and radiology services. The information is transmitted to a monitor where the image is updated
many times per second. The image represents a single 2D plane at any one time.
The physics of sound travel proves a limitation to the ultrasound technique. While sounds travels
through fluids and soft tissues, it does not travel well through fat, due to its complex tissue
structure. This limits the type of client with whom ultrasound swallowing assessment can be
used. Another limitation of the technique is that sound will not pass through bone or air. It will be
completely reflected (Benson & Tuchman, 1994). Therefore, the trachea cannot be visualised as it
is an air-filled space and thus ultrasound is unable to detect penetration or aspiration of contents
into the trachea. These factors limit its use in characterising the pharyngeal phase of the swallow,
however the oral cavity is well-visualised during ultrasound. An ultrasound assessment of
swallowing is conducted by an ultrasound technician and a speech pathologist trained in its
application.
A.10 Videofluoroscopic swallowing study
Videofluoroscopy (also known as the Modified Barium Swallow) is the so called gold-standard
against which many new dysphagia diagnostic techniques are compared for validity and reliability
purposes.
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