Dysphagia: Diagnosis, Management and Outcome Measures

‘Dysphagia’ is the medical term for a difficulty in swallowing, further described as any complication passing food or drink from the mouth to the stomach (Logemann, 1998). It occurs in three phases: the oral phase, the pharyngeal phase and the esophageal phase. Speech and language therapists (SLT) specialize in identifying, assessing and managing Feeding, Eating, Drinking and Swallowing disorders (FEDS) (IASLT, 2018) located in the oral and pharyngeal stages of swallowing, called oropharyngeal dysphagia. Ill-management of dysphagia can have detrimental consequences for the patient such as aspiration, malnutrition, dehydration and depression impacting pulmonary, nutritional and psychological well-being (Helldén, Bergström & Karlsson, 2018; Tanner, 2006).

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The International Classification of Functioning, Disability and Health framework (ICF) put forward by the World Health Organisation (WHO, 2001) is used in the broader assessment of dysphagia to provide intervention that fulfills ethical tenets of autonomy and beneficence (Threats, 2007). The ICF boasts a ‘biopsychosocial’ design whereby aspects of the medical and social models of functioning are integrated to provide a dynamic, holistic picture of the person with dysphagia (Cichero & Murdoch, 2006). Dysphagia is described using three categories: Body Functions and Structures, Activities and Participation, and Environment and Personal factors.

Outcome measures are the used in the management of dysphagia to assist clinicians and researchers in making informed decisions regarding the most accurate intervention pathway and comparative effectiveness of dysphagia strategies (Patel et al., 2017). Dysphagia outcomes measures, however, rarely focus on the effect on the patient’s life, concentrating mainly on the direct ill-health effects of the symptom (Threats, 2007). Martino et al. (2009) support this viewpoint as while patients consider psychosocial obstacles as a direct result of their dysphagia to outweigh biomedical consequences, both clinicians and caregivers value biomedical, pulmonary and nutritional health to be of greater importance in recovery of dysphagia. The WHO’s ICF therefore, seeks to expand the SLT’s view on dysphagia and offer outcome measures that capture the patient’s experience (Penderson, Wilson, McColl, Carding & Patterson, 2016). Patient related outcome measures (PRO) provide substantial evidence directly related to the social importance of dysphagia treatment, advocating for an increased quality of life (Patel et al., 2017). This paper seeks to critically discuss available outcome measures in the management of dysphagia and how they relate to the ICF in terms of three domains.

The Clinical Bedside Examination (CBE) is often the SLT’s first step towards providing critical information relevant to the diagnostic and therapeutic processes as it is quick and readily available at bedside (Lenord & Kendall, 2008). The CBE involves gathering relevant case history from the client, medical team and carers, collation of comprehensive oro-motor assessment to examine sensory and motor aspects of the oral mechanism and clinical observation during swallow trials at bedside. Despite providing a general yet limited overview of the pharyngeal phase of the swallow, the CBE gauges the patient’s cognitive-behavioral abilities, baseline of orofacial functioning, helps determine the optimum positioning for feeding and explores of feeding options such as diet alterations or compensatory strategies (Ward & Morgan, 2009). The three ICF domains are broadly addressed during this initial assessment of the patient whereby Body Structures and Function impairments are hypothesized based on clinical impression, Activities and Participation limitations are indicated by the patients case history, and Environmental and Personal factors are observed by the clinician are reported by patient and caregivers (McAllister, Kruger, Doeltgen & Tyler-Boltrek, 2016). Moreover, the CBE results determine whether instrumental assessment is warranted (Lenoard & Kendall, 2008).

Objective, instrumental assessment techniques are used as outcome measures in dysphagia. The Video Fluoroscopic Swallowing Study (VFSS) and Fiberoptic Endoscopic Evaluation of Swallowing (FEES) are typically considered the ‘gold standard’ of dysphagia assessment, although they are not always readily available in clinical practice. VFSS, more commonly known as ‘videofluoroscopy’, is an imaging technique widely used to detect oropharyngeal dysphagia (Tomita et al., 2018). Videofluoroscopy provides a detailed, objective view of the internal anatomical structures involved in the swallow and its physiology during this process. The procedure is regarded as ‘gold standard’ as the presence or absence of aspiration can be immediately confirmed or denied, and prevented in order to avoid chronic aspiration, malnutrition and lengthy mealtimes (McNair & Reilly, 2003). VFSS is invasive as it requires food and fluid trails to be mixed with a radioactive chemical, called barium, which highlights boluses on x-ray as they travel from mouth to stomach. Patient’s mobility also has to be taken into consideration when deciding on whether VFSS is a suitable outcome measure as assessments take place the radiology department, away from the bedside.

According to the IASLT (2018), Fiberoptic Endoscopic Evaluation of Swallowing (FEES) involves the insertion of a fibreoptic nasendoscope transnasally to the level of the pharynx allowing optimum evaluation of laryngopharyngeal anatomy and physiology. Images are recorded as the patient manages his/her own secretions, and swallows’ food and fluid (IASLT, 2018). Studies have indicated that FEES achieves good intra- and inter-rater reliability considering it to be ‘gold standard’ practice (Kelly, Drinnan, Leslie, 2007; Kelly, Leslie, Beale, Payten, & Drinnan, 2006; Colondy, 2002). However, lack of validated and standardised rating scales, variable image quality and experience of endoscopist/assessing clinician, contribute to reliability of the FEES instrument (Kelly et al., 2007; Cichero & Murdoch, 2006).

VFSS and FEES assessments account solely for the Body Structures and Functions category of the ICF. Dysphagia evaluation and management, based strictly on the results from these instrumental assessments may lead to recommendations with limited relevance or practicality for the patient. Therefore, cautious interpretation of assessment findings along with evaluation from other categories of the ICF allows for more client-centered, relevant and practical recommendations (Threats, 2007).

The Penetration-Aspiration Scale (PAS) is a clinician-rated scale used in conjunction with fluoroscopy studies, such as the VFSS and FEES (Leonard & Kendall, 2008). The objective of the scale is to quantify ‘whether or not material enters the airway, the level to which the material descends to and whether or not the swallower responds to penetration or aspiration’ (Cichero & Murdoch, 2006, p.549). The Dysphagia Outcome Severity Scale (DOSS), is second a clinician-rated scale which measures the severity of dysphagia based on videofluoroscopy and makes recommendations based on nutritional level, diet and independence (Zarkarda & Regan, 2018). The psychometric properties of these scales provide information on the Body Structures and Functions domain only. The Functional Oral Intake Scale (FOIS) documents the patient’s current level of functional oral intake and considers functional changes that have occurred due to dysphagia adhering to Body Structures and Functions, and Activity and Participation psychometric domains (McMicken, Muzzy & Calahan, 2010).

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Outcome measures that incorporate a patient’s own opinions of their eating or swallowing abilities and difficulties are addressed in the Activity and Participation category of the ICF framework. The SWAL-QOL is a patient-centered outcome measure that assesses the ‘physical, social, psychological and cultural experiences associated with eating’ and drinking (Keage, Delatycki, Corben & Vogel, 2015). Probing for descriptions of behaviours that may influence food and liquid manipulation, such as couching with oral intake, is accounted for in the SWAL-QOL which falls under Body Functions and Structure. Moreover, anxieties linked to dysphagia are reported and are considered psychological impairments of the disease again categorized as Body Function (Keage et al., 2015). Activities and participation behaviours are reported whereby patients admits limiting or restricting themselves socially as a consequence of their dysphagia (Threats, 2007). The SWAL-QOL is therefore considered ‘holistic’ as evidenced by the inclusion of all elements of the ICF (Keagle, 2015). The EAT-10 is a patient-administered, symptom specific outcome measure for dysphagia (Wilmskoetter et al., 2017). Body Structures and Functions are predominantly outlined with only two items referring to impact on Activity, failing to meet social and emotional circumstances (Keagle et al., 2015).

Other available outcome measures involve the SWAL-CARE and MD Anderson Dysphagia Inventory (MDADI). The SWAL-CARE is tool commonly used in partnership with the SWAL-QOL as it provides Environmental information regarding interaction between the patient and clinician, quality of care and patient satisfaction (Keagle et al., 2015; Threats, 2007). The MDADI is a self-administered survey that looks globally at a patient’s difficulty in swallowing and how it affects their life overall, rather than specifically about modified diets (Khan et al., 2015).

(Cichero)In clinical practice, SLT’s are influenced by what outcome measures to use based on one’s philosophy of evaluation and treatment. Clinicians dedicated to biomechanics are more likely to use instrumental assessment with the underlining belief that with biomechanical improvements comes improvements in other domains, such as increased quality of life. A second factor that influences a SLT’s choice of outcome measure for a patient is the amalgamation of what the patient wants and what the clinician believes is appropriate and achievable. However, the foundations for choosing outcome goals are influenced by reliability and validity. There is a current paucity of reliable and valid outcome measures available that address body structures and functions, activity and participation, environmental and personal factors, all of which contribute to the ICF. Continuous growth and expansion of such measures will allow clinicians to learn more of persons with swallowing difficulties. The more that is known, the more efficiently one works.

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