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C
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D
Figure 10–2. continued C. Patient’s risk factors are noted. D. Information from fluoro-
scopic swallow study. continues
224
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225
E
Figure 10–2. continued E. Information from multiple studies can be compared.
a chest x-ray that helped document
aspiration pneumonia also provides
evidence of lung recovery. Endoscopy
of the pharynx, larynx (see Chapter4),
and/or the esophagus (see Chapter9)
is another imaging tool that can be
used to monitor a patient’s progress
with behavioral, medical, or surgical
interventions. Laboratory studies are frequently a part of treatment assessment.
For example, a CBC (complete blood
count) can establish or rule out an infec-
tious or inflammatory disease, and a
nutritional evaluation may include the
determination of serum protein and
albumin levels (see Chapter 13) important to improved nutrition. Special
studies include pH testing to monitor
the effects of medication or surgery on
reflux events (see Chapter 18) and scintigraphy, used to determine percent of
bolus material aspirated.
Many other criteria can be included
in assessing outcomes. Clinical evidence
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
of a patient’s ability to move from nonoral to oral feeding and of reductions
in time required for oral feeding or
in restrictions necessary for oral eating are examples of extremely useful
variables to consider in assessment.
Stable weight or weight gain, normal
temperatures, and improved ability
to manage saliva are similarly useful as signs of a patient’s improving
condition. Measures that incorporate
patients’ own appraisals of their eating or swallowing abilities are increasingly recognized as important. These
might be classified as self-assessment
tools. One that was developed at our
institution and is used routinely is
the EAT-10 (Belafsky et al., 2008). The
American Speech-Language-Hearing
Association has developed the NOMS
(National Outcomes Measurement
System), which includes a section on
dysphagia and assesses patients’ functional progress and satisfaction with
their progress (ASHA, http://www.
asha.org). Two additional survey tools
that have undergone extensive development are the SWALQOL (swallowing
quality of life) and SWAL-CARE (swallowing quality of care) (McHorney,
Bricker, Kramer, et al., 2000; McHorney,
Bricker, Robbins, Kramer, Rosenbek, et
al., 2000; McHorney et al., 2002). These
instruments are designed for patients
with oropharyngeal dysphagia and
involve the completion of a set of questions pertinent to social, psychological,
and cultural domains of swallowing/
eating function and to patients’ perceptions of the quality of care received for
their dysphagia. In a study (McHorney
et al., 2006), associations between the
two survey tools and results of videofluoroscopy studies were examined in
386 patients. The Penetration-Aspiration Scale previously referenced was
used to evaluate the fluoroscopy studies. Interestingly, though not surprising
to clinicians, relationships between the
surveys and the Penetration-Aspiration
Scale were generally weak. The authors
suggest that this reflects evidence of
not only a generally recognized lack of
covariance between patient-based measures of function and clinician-based
measures but also the need to consider
both in evaluating treatment effects.
This is a point well taken, in our opinion. No single test, study, or opinion
is likely to adequately and accurately
assess changes with time or treatment.
THE TEAM APPROACH
Nowhere is the advantage of a multidisciplinary approach to dysphagia assessment more obvious than in the teamdeveloped treatment plan. Etiologies
of dysphagia cross many disease and
disorder categories. The bodily systems
that contribute to, or are affected by,
dysphagia are extensive in number and
are complex. Potential treatments range
from behavioral, to medical, to surgical.
And the implications of dysphagia for
an individual’s physical, mental, and
social well-being can be enormous. An
effective treatment plan must reflect this
understanding of the dysphagia gestalt,
and this requires, in our opinion, as
many relevant and thoughtful specialty
resources as we can bring to bear. The
likelihood of failing to recognize salient
features of either the patient or the disorder is minimized, and the likelihood
of developing an appropriate model for
treatment is maximized. To some extent,
of course, the effectiveness of a team is
determined by the relative strengths of
each member and by the interprofessional dynamics present in team activities. But the opportunity to share exper-
10. THE TREATMENT PLAN: BEHAVIORAL APPROACHES
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tise, to formulate objectives for treatment
that reflect each specialist’s concerns and
knowledge base, and to then collectively
prioritize the components of the plan is
well worth the effort required to establish a team and to maintain whatever
diligence is necessary to ensure that it
functions effectively as a team.
STUDY QUESTIONS
1. What factors, beyond the results of
instrumental evaluations, should
be considered in making treatment
recommendations for a patient?
2. What are some of the indications for
recommending exercises designed
to improve strength or mobility of
structures?
3. Would respiratory exercises ever
be considered appropriate for a patient with dysphagia? Under what
circumstances?
4. What is the IOPI? The Shaker exercise? What are they designed to do?
Is there evidence to support their
effectiveness?
5. How might electrical stimulation
affect a muscle? What is meant by
“selective stimulation”?
6. What characteristics of a bolus
might be manipulated to facilitate
swallow?
7. What are “postural compensations,” and how might they facilitate swallow?
8. Do “facilitative maneuvers” require
more from a patient than other
strategies? Why? What are some of
these maneuvers, and why/when
would each be implemented?
9. What behavioral recommendations
to patients are typically included in
reflux management?
10. What might be useful treatments in
managing xerostomia?
Which of the following might ben-
11.
efit from a behavioral approach?
Oral closure defects
a.
b.
Velopharyngeal valve failure
c.
Reduced pharyngoeseophageal
opening size
Esophageal stricture
d.
12.
What types of assessment tools
might be useful in determining the
effects of time or treatment?
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