What is “Usual Care” in Dysphagia Rehabilitation: A Survey of USA Dysphagia Practice Patterns by Giselle D. Carnaby and Lindsay Harenberg.
This article was found on the Dysphagia Journal website DOI 10.1007/s00455-013-9467-8.
This article surveyed members of ASHA SIG 13. They were questioned on experience, work setting, schooling and treatment options given a scenario of a patient. There were 254 responses.
As a whole, we are moving away from use of compensation and maneuvers and working more towards exercise-based programs including Expiratory Muscle Strength Training (EMST) and the McNeill Dysphagia Therapy Program (MDTP).
This article defines evidence based as ” effectively combines clinical expertise, scientific research, and patient values to ensure that a client receives research-supported care that is tailored to his or her individual needs.”
60% of respondents routinely conduct an MBSS prior to therapy, but only 40% conduct and MBSS post-therapy.
55% of SLPs reported using self-developed assessment or outcome measures, 44% use facility-developed, 37% use published peer-reviewed tools and 29% use published tools with statistically confirmed validity.
Typical length of therapy is 30 minutes with 54% providing treatment daily. Of therapy techniques, 92% were derived from CEU courses, 70% were learned from colleagues and 44% were self-developed or 20% from journal articles.
37% reported that their patients were tube-dependent prior to treatment with 49% reporting patients at a FOIS level 5. Post-therapy, 48% reported their patients at a FOIS level 5. 19% reported return to a full oral diet without restriction. Only 54% responded that patients returned to their pre-injury diet.
With review of the patient scenario, 91% stated they would commence swallowing therapy. 52% would start with ice chips.
Seven swallowing techniques were suggested on whole:
Neuromuscular Electrical Stimulation
Hyolaryngeal Elevation (Mendelsohn)
Super Supraglottic Swallow
More than 47 different therapy techniques were recommended for this patient (only 3.9% of respondents indicated they derived their recommendations from a specific physiologic abnormality from provided data. 96 different combinations of therapy techniques were recommended with no single combination exactly repeated. More than 58% of the techniques recommended did not match the patient’s specific dysphagic symptoms. 13% of techniques were exercise-based interventions and 19% reported using an exercise-based intervention as their primary method.
This study is vital in looking at what we as dysphagia specialists do in our treatments. Although recent literature is showing us that it is vital to use exercise-based treatments for dysphagia, only 13% recommended exercise based therapy techniques.
No 2 people recommended the same exercise combination of techniques. Basically, from this large sample, there is no “usual” care and few are using valid tools to measure and assess. Only 19% reported patients returning to their prior-level diet!!
As a whole we should be rehabilitating the swallow. This article shows that we may not be doing what we are claiming. We have no “usual” care. We often decide on a variety of exercises, with no 2 clinicians using the same set of exercises. For dysphagia, we have no standardization.
Protocols such as MDTP and EMST give us the intensity, frequency and resistance we should be adding to our therapy sessions. Our goal is to rehabilitate the patient to their pre-dysphagia level and we have to work to the best of our abilities to get our patients there!
Carnaby, G. D., & Harenberg, L. (2013). What is “usual care” in dysphagia rehabilitation: a survey of USA dysphagia practice patterns. Dysphagia, 28(4), 567-574.