3 Reasons You Should Never “Fake it Till You Make it” in Dysphagia

I really don’t know where the phrase “fake it till you make it” came but it’s one phrase that absolutely makes me cringe in relationship to dysphagia.

Don’t get me wrong.  You should always go in confident in your skills.  How can you possibly be confident though in skills you don’t possess?

The scary part is, with dysphagia, if we don’t know what we are doing, but go in to diagnose and treat on the “fake it till you make it approach” we can play a key role in the person’s death.

Not necessarily that the person even chokes on something.  When we change a patient’s liquids and thicken the liquids, the person can then experience dehydration, sepsis, UTI or a multitude of other effects.

So let’s get to it.  The THREE reasons why you should never fake it till you make it in dysphagia therapy.

Reason One

It’s actually against our code of ethics provided by ASHA.

“Individuals shall not misrepresent their credentials, competence, education, training, experience, and scholarly contributions.”

When we “fake it” we are actually telling patients that we are competent in an area that we may not have a clue and misleading that patient.   Ideally, we should help that patient find a competent clinician if you do not feel that you fit that bill.

Reason Two

How can you assess and diagnose what you don’t know?

Yes, we diagnose dysphagia.  This is the reason we are Speech Language Pathologists in the US.  We are able to diagnose a range of speech and swallowing related disorders.

If you don’t understand the normal swallowing process and know the deficits, how can you possibly diagnose dysphagia?  Did you know that when a diagnose is given to a patient, that diagnosis stays with the person.

Misdiagnosis often leads to inappropriate diet changes, unnecessary therapy services and possibly secondary issues that can arise from those inappropriate diet changes.

I mean, do you really know any person that has been excited about having thickened liquids?  Have you ever had a patient comment on the amazing taste of thickened liquids?

What if you are the person responsible for the Modified Barium Swallow Study (MBSS) or Flexible Endoscopic Evaluation of Swallowing (FEES)?  Do you know how to complete the test or interpret the test.  If the answer is no, then you’ve just wasted, money, time and effort.  Accurate completion and reporting of either of these assessments is vital in diagnosing, referring or providing treatment for dysphagia.

Reason Three

Just like you can’t assess and diagnose dysphagia, how can you possibly treat dysphagia when you don’t understand it.

I mean sure, you can throw a list of exercises at a patient, you can modify the diet, but what are you doing for the patient?   What are you actually accomplishing with this patient?

This patient is relying on you to be the expert, to be honest with them and to help them with an issue that is a major roadblock in their recovery.

What can you do?

Don’t turn to social media the night before an evaluation or treatment session knowing nothing about the disease process, the assessment or the treatment protocols.

If you are interested in dysphagia but don’t feel comfortable or confident in dysphagia, find a mentor, read journal articles, shadow, read textbooks.  Learn everything you possibly can about dysphagia.

Be honest with your patient.  I am terrible with fluency.  If I have a referral for a patient with dysfluency, I will more than likely refer them out to an SLP with more experience.  It’s the right thing to do.

Hold paramount your patient’s best interest and never, ever “fake it till you make it.”

  • Tanner, D. C. (2010). Lessons from nursing home dysphagia malpractice litigation. Journal of gerontological nursing36(3), 41-46.
  • American Speech-Language-Hearing Association. (2004). Knowledge and skills needed by speech-language pathologists performing videofluoroscopic swallowing studies.
  • American Speech-Language-Hearing Association. (2002). Knowledge and skills needed by speech-language pathologists providing services to individuals with swallowing and/or feeding disorders.
  • Boaden, E., Davies, S., Storey, L., & Watkins, C. (2006). Inter professional dysphagia framework. University of Central Lancashire, Preston.
  • McAllister, L., & Rose, M. (2000). Speech-language pathology students: Learning clinical reasoning. Clinical reasoning in the health professions, 205-213.
  • Kamal, R. M., Ward, E., & Cornwell, P. (2012). Dysphagia training for speech-language pathologists: Implications for clinical practice. International journal of speech-language pathology14(6), 569-576.
  • ASHA Code of Ethics www.asha.org

The SLP and the Dining Room

dinner-table-clipart-table-clip-art-set-table-clipart-u4ostccy

I can’t even count how many times I have started work in a new building or started a new PRN job and been told meal times so that I can go sit with patients during their meals for their therapy time.  It’s easy, right.  I go sit in the dining room and “observe” 8 patients for signs and symptoms of dysphagia that I’ve already identified and remind patient A to use a chin tuck and patient b to eat at a slower pace.

This is how I learned dysphagia therapy.  What was taught to me was to sit with them during the meal to work on trials, observe those trials and remind them to use their strategies.  The reality:  I tried to do my “job” however Mrs. Smith needed more coffee, could I be a dear and run Mrs. Brooks to the bathroom?  I could never do my “job” because I was a waitress.  With no tips.

Not only could I not do my “job”, I was not doing anything for those patients!  That is not rehabilitation.  Look at it this way, if we never stress the system and remain at status quo, how will it improve?  If I’m trying to run a 5k, I’m going to push myself to keep going a little further.  If I continue to run around the block, I will never build the strength and endurance for a longer run.  If we never challenge the swallowing system with a more difficult bolus, then how will my patient upgrade their diet.

Therapy should not be in the dining room.  Just like I don’t want a physical trainer to show up in the middle of my meal, our patients don’t want us popping in at their meal time and “working” with them.

Let’s challenge our patients and stop the observation!

Supraglottic and Super-Supraglottic Swallows and Tongue Pressure-Research Review

keep-calm-and-hold-your-breath-67

Fujiwara, S, Ono, T, Minagi, Y, Fujiu-Kurachi, M, Hori, K, Maeda, Y, Boroumand, S, Nitschke, I, Ursula, V, Bohlender, J.  Effect of Supraglottic and Super-supraglottic swallows on Tongue Pressure Production against Hard Palate.  Dysphagia (2014) 29:655-662.  

The Super- and Supraglottic Swallows are maneuvers used to assist in early airway closure to prevent food or drink from being aspirated prior to the swallow.  

Participants:  19 healthy young staff members of the University of Zurich Dental School (13 females, 6 males) with an age range from 17-40.

Equipment:  Tongue pressure measurements were recorded using the Swallow Scan System using a pressure sensor that forms a “T” shape following the curve of the palate.  Participants were seated upright with their heads immobilized by  a head rest.  

Procedure:  This study looked at normal swallow, Supraglottic Swallow (ss) and Super-Supraglottic Swallow (sss).   Each participant swallowed 5 ml of water at room temperature.  For the SS, a syringe was used to inject 5 ml of water into the floor of the oral cavity with the instructions “breathe through your nose, then hold your breath lightly before and during swallowing.  Cough immediately after you finish swallowing.”  For the SSS the same procedure and instructions were given, plus the additional instruction to put the palms of their hands together in front of their chest and press them hard against each other while they held their breath.

Results:  The perimeters measured  were:  duration, maximal magnitude and integrated value of tongue pressure during swallowing.  “The duration of tongue pressure was significantly longer at the anterior-median part of the hard palate during both SS and SSS than with normal wet swallow.  The maximal magnitude increased significantly only at the posterior part of the hard palate during SS, but at all points during SSS.”  Not only do the SS and SSS increase protection of the airway prior to the swallow, they may also function to strengthen the tongue.  

Swallowing Exercise Aid (SEA)

I saw a tweet about this new Swallowing Exercise Aid yesterday.  I was extremely curious and decided to check out the article.

We’ve had some new research come out on the Chin Tuck Against Resistance (CTAR) and Jaw Opening Against Resistance (JOAR) as well as Isometric Progress Resistive Oropharyngeal Therapy (IPRO).  The common theme here is resistance.

Kraaijenga, SAC, et al.  Effects of Strengthening Exercises on Swallowing Musculature and Function in Senior Healthy Subjects:  A Prospective Effectiveness and Feasibility Study.  Dysphagia (2015) DOI:  10.1007/s00455-015-9611-8.  

This article looked at using a Swallowing Exercise Aid (SEA) in connection with 3 exercises (CTAR, JOAR and effortful swallow with resistance.)  

Ten healthy senior males with a median age of 60 were used in the study.  Inclusion criteria included absence of dysphagia or history of dysphagia.  

Exercises were completed 3x/day for 6 weeks including CTAR, JOAR and effortful swallow with resistance (swallowing with the mandible down and mouth closed).  The SEA device used was the Therabite Jaw Mobilization device with a Therabite Active Band.  The SEA device was used as resistance for all 3 exercises.  

Both CTAR and JOAR were completed isokinetically and isometrically.  For the isokinetic portion, each was completed 30 times with a 1 second muscle contraction.  For the isometric portion, each person was to complete static completion of the exercise for 60 seconds 3 times with a 60 second rest period between hold.  After an additional 60 second break, the person swallowed 10 consecutively using an effortful swallow while pushing the mandible down against the SEA and keeping the mouth closed.  Each exercise session was approximated to last 15 minutes.

Each participant was given written instructions on completion of the exercise.  They were sent 3 daily texts as reminders and used tally sheets to record exercise logs.  Participants were advised to stop exercises if they experienced pain or distress.

Outcomes were recorded prior to and 2 days after the 6 week exercise period.  Outcomes were measured by used of a dynamometer, the Iowa Oral Performance Instrument (IOPI), MRI and Videofluoroscopic Swallow Study (VFSS).  Outcomes measured included:

  • Maximum chin tuck and jaw opening strength.
  • Maximum tongue strength and endurance
  • Suprahyoid mass (Anterior Bell of the Digastric, Mylohyoid, Geniohyoid)
  • Hyoid bone displacement

Outcomes measured following 6 weeks of exercise indicated a significant increase in all of the above along with increased mouth opening and no pain.  Compliance with the program was reported at 86%.  

This program has huge implications for our patients with head and neck cancer.  I’m excited to see where this study may lead.

  

Dysphagia Tools

Here is a list of dysphagia tools that are commercially available.  Dysphagia Ramblings does not endorse any commercial tool for dysphagia.  

Thermal Stimulation

 

Vibration

 Z-Vibe

 

EMST

 

Modified Barium Swallow Chairs

 

MBSS

 Tims

 FEES

 NDOHD

 

Thickeners

 

MDTP

 Course

 

SwallowMist (Misting Device for NPO)

 

Measuring Outcomes

 SWAL-QOL and SWAL-CARE-email the author at colleen_mchorney@merck.com

 

Lingual Strengthening

 MOST

 

Modified Shaker**

 

Stimulation

 

Straws

 

Neuromuscular Electrical Stimulation**

 

Modified Utensils

 

 

Assessment Tools

 4″ by 4″ Gauze

 Handheld Mirror (I bought mine at Dollar General)

 Dum Dum Suckers

 Dysphagia Toolbox – Free assessment materials

 

Education

Swallowing and Dysphagia Rehabilitation: Translating Principles of Neural Plasticity into Clinically Oriented Evidence

I’m back to the research!  I took a brief break last month.  Since I was covering 3 buildings and transitioning into the school system, I thought blogging about research might be pushing the limits a bit.  Not to mention creating slides for a presentation in Montana.

In looking into creating some new slides for a presentation, I came across an amazing article written by several amazing researchers in the field of dysphagia.  If you have access to the ASHA journals and are looking for some great evidence base for your dysphagia therapy, this is the place to begin.

Robbins J, Butler SG, Daniels SK, Gross RD, Langmore S, Lazarus CL, Martin-Harris B, McCabe D, Musson N, Rosenbek JC.  (2008).  Swallowing and Dysphagia Rehabilitation:  Translating Principles of Neural Plasticity into Clinically Oriented Evidence.  Journal of Speech, Language, and Hearing Research, 51: S276-S300.  

This article breaks down the principles of neural plasticity.   Neural plasticity is defined as “the ability of the brain to change.”  Central Nervous System Plasticity refers to “the ability of neuronal systems to alter functino in response to changes in input, both physiological and pathophysiological.”  One thing the authors warn is that just because neural plasticity may result in a behavioral change, not all behavioral change results in neural plasticity.

There are 10 basic principles of neural plasticity.  They are:

1.) Use It or Lose It

2.) Use It and Improve It

3.) Plasticity is Experience Specific (Swallow to Improve Swallowing)

4.) Repetition Matters (How many times you repeat an exercise)

5.) Intensity Matters (Longer training does not necessarily imply more difficult training)

6.) Time Matters (Time after incident)

7.)  Salience Matters (Purposeful movement related to the behavior being trained)

8.)  Age Matters (Younger brains are more responsive, but plasticity occurs across the life span)

9.) Transference (“The ability of plasticity within one set of neural circuits to promote concurrent or subsequent plasticity” such as LSVT or EMST)

10.) Interference (“the ability of plasticity within a neural circuitry to impede the induction of new or expression of existing, plasticity within the same circuitry”)

Techniques, compensations, maneuvers and exercises we have our patients use were broken down into 4 groups.  Sensory Methods, Compensatory Methods, Motor with Swallow and Motor without Swallow.

The following is adapted from charts the authors created demonstrating behavioral vs. neural change within each group.

Sensory Methods: (From the literature)

Bolus Effects                                                                        Behavioral                                            Neural

Volume                                                                                   Yes                                                             No

Viscosity                                                                                 Yes                                                             No

Temperature                                                                        Yes                                                            No

Taste Enhancement                                                         Yes                                                             No

Stimulation

Thermal-Tactile Stimulation                                      Yes                                                              Yes

E-Stim                                                                                      Yes                                                              Yes

DPNS                                                                                         No                                                              No

Occluding Trach                                                                 Yes                                                             No

Visual Feedback                                                                 Yes                                                             No

Compensatory Methods: (From the literature)

Chin Tuck                                                                               Yes                                                             No

Head Rotation                                                                     Yes                                                              No

Head Tilt                                                                                 Yes                                                             No

Head Back                                                                               No                                                             No

Side Lying                                                                                Yes                                                             No

Breath Hold                                                                             Yes                                                           No

Bolus Consistency                                                              Yes                                                            No

Motor with Swallow:  (From the Literature)

Mendelsohn*                                                                           Yes                                                            No

Super Supraglottic                                                             Yes                                                            No

Supraglottic                                                                            Yes                                                            No

Effortful Swallow *                                                                 Yes                                                            No

Tongue Hold *                                                                          Yes                                                            No

Swallow (Frequency)                                                          Yes                                                            No

(* has the potential for plasticity)

Motor without Swallow:  (From the Literature)

ROM                                                                                               Yes                                                          No

Strengthening-Tongue*                                                      Yes                                                          No

Strengthening-Respiratory *                                            Yes                                                          No

Tongue Control                                                                       Yes                                                            No

Shaker *                                                                                        Yes                                                             No

LSVT  *                                                                                           Yes                                                              No

Pharyngeal Exercises*                                                           No                                                               No

Gargling                                                                                         No                                                               No

Vocal Exercises                                                                           No                                                               No

Velar Elevation                                                                            No                                                               No

Airway Closure/Breath Hold                                              Yes                                                               No

So, some of the techniques, compensations and exercises we use do create a behavioral change, including increased airway protection to reduce or eliminate penetration/aspiration, better control of the bolus, etc.  Few cause an actual neural change.

Looking at each principle and each category the authors created a great table which I will summarize.  Looking at 5 categories 1.) Sensory Methods Bolus Effects 2.) Sensory Methods Stimulation 3.) Compensatory 4.) Motor with Swallow  5.) Motor without Swallow:

1.) Meets all 10 principles, with a question on Time Matters

2.)  Meets all 10 principles with a question on Time Matters

3.)  Meets all 10 Principles, however questioning interference.

4.)  Meets all 10 principles except interference

5.)  Meets all 10 principles except Salience Matters

There are many areas that continue to warrant research in the field of dysphagia.  One thing we need to keep in mind that the authors point out:  “the primary role of swallowing rehabilitation is to effect change (i.e. improved strength, duration and timing of movement) in the physiologic components of swallowing, which will have a direct influence on bolus flow kinematics through the aerodigestive tract.”  Also “The immediate lesson for the swallowing clinician, however, is that training-even the training of a patient who is aspirating and at high risk for pulmonary or other health consequences-appears preferable to merely observing and documenting.”

Whether we’re using dry swallows or bolus swallows with our patient, we need to keep them swallowing.

I absolutely think this article is a MUST read for any dysphagia therapist.

Of course, after writing this article, I realized, I already blogged about it!   Talk about needing some plasticity for memory skills!!!  So, I will also post the original blog here as well!

Neural plasticity refers to the ability of the brain to change.

The 10 principles of plasticity are 1.) Use it or lose it, 2.) Use it and improve it, 3.) Plasticity is experience specific, 4.) Repetition Matters, 5.) Intensity matters, 6.) Time matters, 7.) Salience matters, 8.) Age matters, 9.) Transference and 10.)Interference.

For principle 1, Use it or Lose it, the simple act of swallowing will not improve the swallow in a person with dysphagia. They need to use the function with increasing competence. The question remains what are the best treatment strategies for swallowing. It makes sense that those patients that are NPO and have not swallowed in years will “lose” their swallow function. Simple saliva swallowing drills can help a person return to oral feedings.

Principle 2, Use it and improve it, there are many different treatment techniques including expiratory muscle strength training, lingual strengthening, Shaker, Mendelsohn, Masako and effortful swallow. Keep your patients swallowing to strengthen those muscles, but as they swallow, challenge the patient and challenge the swallow system. To merely sit and observe as a patient eats a meal is by no means therapeutic. To feed a patient during a meal is by no means therapeutic. Building the competence of a system is imperative, not just allowing a patient to complete the simple act of swallowing.

Principle 3, Plasticity is experience specific, to focus and rehab the swallow may or may not affect other aspects, such as dysarthria or voice deficits and vice versa. Does simply completing OME with patients improve the swallow?? If we have the patient complete voice exercises, that do not involve the swallow, how will that improve the swallow function. It’s a different function to complete the exercises without a bolus than it is with a bolus. 

Principle 4, Repetition matters, number of repetitions of an exercise will affect the neural changes made by that exercise. Many of the effective exercises involve systematic repetition such as LSVT, isometric lingual exercises and the Shaker. Simply completing a movement or an exercise 10 times 3 times a day may not cut it. The Shaker uses 90 repetitions and 3 repetitions of holding the head up and seems far more effective than simple OME alone. 

Principle 5, Intensity matters, there is building evidence that intensity is critical for swallowing therapy. Evidence is still pending for particular dosage recommendations that are therapeutic for the swallow. If you are training for a fight, to run, to lift weights, etc, how can you improve without an intense workout. We’re working with a muscular system with swallowing and should apply the same exercise science rules to swallowing as we do to any other training.

Principle 6, time matters involves the length of your session. A person is going to benefit more from a longer session, 30-60 minutes then they will a 15 minute session. 

Principle 7, Salience matters, therapy has to be purposeful for swallowing. You can’t have the person stick out their tongues 15 times and expect their swalow to improve. Simple, repetitive movements and strength training are likely not going to improve swallow function.

Principle 8, Age matters, although neural plasticity does occur throughout the lifespan, a younger system will be more responsive to the changes. This may imply that older adults need a more strenuous or a program with a greater length of time.

Principle 9, transference defined as “the ability of plasticity within one set of neural circuits to promote concurrent or subsequent plasticity.” Evidence from NMES (neuro muscular electrical stimulation) applies to this principle. This continues to be a principle that needs further investigation for implications to the swallowing system.

Principle 10, interference results from inappropriate use of E-stim. E-stim can either facilitate or inhibit the corticobulbar excitability. A simple change in Hz can change the excitability which is why there is extensive study out there now on NMES.

These principles can and should be incorporated into therapy. The more a therapist understands the swallowing system, exercise physiology and neural plasticity, the better prepared they are to treat a dysphagic patient.

Bonnie Martin-Harris and colleagues found 14 physiologic components in the swallowing system,
~lip closure
~hold position/tongue control
~bolus preparation/mastication
~bolus transport/lingual motion
~initiation of pharyngeal swallow
~soft palate elevation and retraction
~laryngeal elevation
~anterior hyoid excursion
~laryngeal closure
~pharyngeal stripping wave
~pharyngeal contraction
~pharyngoesophageal segment opening
~tongue base retraction
~esophageal clearance

Our role as a therapist is to improve the strength, duration and timing of the swallowing movements, with regards to the above components.

We have different options with different interventions including bolus effects by altering volume, viscosity, thermal, taste, tactile or temperature. We can use e-stim. Compensatory strategies including the chin tuck, head rotation, head tilt, head back and side lying positions. We can use maneuvers such as the Mendelsohn, Supraglottic swallow, Super Supraglottic swallow, effortful swallow, double swallow or the Masako. We also use lingual exercises and the Shaker. 

The Mendelsohn can alter the extent and duration UES opening as well as aiding in hyolaryngeal excursion.

The supraglottic and super supraglottic swallows facilitate the timing and extent of laryngeal closure at specific levels of the larynx.

The effortful swallow help to increase base-of-tongue retraction and results in increased tongue propulsive force, increased oral pressure, duration and extent of hyoid movement and laryngeal vestibule closure, longer duration of pharyngeal pressure and UES relaxation.

The tongue hold maneuver increases anterior motion of the posterior pharyngeal wall at the level of the tongue base.

You can find increased tongue base-pharyngeal wall pressure and contact duration when performing the effortful swallow, tongue-hold, Mendelsohn and super supraglottic swallow.

Robbins and her group demonstrated that lingual muscles have a propensity for increasing strength and mass and that as a result of non-swallowing exercises, improvement in swallowing pressures on liquid boluses occurred, penetraion Aspiration Scores were reduced and dysphagia-specific quality of life improved. 

The Shaker exercise increases swallowing function through decreased aspiration following the swallow. 

There is still a need for research from this article including looking at variables of repetition, intensity and time for rehabilitation and finding the appropriate site, stimulation frequency, amplitude, phase duration, optimal frequency and length of an individual stimulation treatment including potential effects.

When presented with a patient with dysphagia, research the disorder. If you are requesting an MBSS ask that the therapist look at muscle movement rather than just the absence or presence of aspiration/penetration. Treat the system as a whole and as a muscular system. We can actually learn much from our PT and OT friends on exercise physiology and use that to design our dysphagia therapy programs to better serve our patients.

Article and references can be found at: http://jslhr.asha.org/cgi/content/full/51/1/S276.

Usual Care in Dysphagia Rehabilitation

I am so excited to be a part of the journal article blogging group! Of course, my articles reviewed will be regarding dysphagia.

My first article, I found very interesting:

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 respondants 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

Shaker Exercise

Hyolaryngeal Elevation (Mendelsohn)

Effortful Swallow

Oromotor Exercises

Tongue-Based Retraction

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!