Posted by Title: The Intensive Dysphagia Rehabilitation Approach Applied to Patients with Neurogenic Dysphagia: A Case Series Design Study
Authors: Malandraki, Rajappa, Kantarcigil, Wagner, Ivey, & Youse
Journal: Archives of Physical Medicine
Year of Publication: 2016
Design Type: Retrospective interventional Case Series
Purpose: “To examine the effects of the Intensive Dysphagia Rehabilitation approach on physiological & functional swallowing outcomes in adults with neurogenic dysphagia”
Population: 10 adult outpatients diagnosed with neurologic injury/disease and confirmed dysphagia via diagnostic imaging
Inclusion criteria: 1) adult-onset neurogenic etiology of dysphagia (per neurologist); 2) diagnosis of oropharyngeal dysphagia per >1 of either: a PAS score >3, ASHA NOMS dysphagia score <4, and/or endoscopic evidence; 3) willingness/cognitively competent to participate (informally assessed); 4) medical stability; 5) willing caregiver to participate
Exclusion criteria: inability to provide consent; inability to elicit swallow response or open UES; history of HNC or surgery/radiation; currently receiving speech/swallowing services
Sometimes when people describe things as “intense,” one of two emotions emerge for me:
- Intriguing curiosity if I am capable of being a triumphant Rocky💪
- Scared out of my mind that the intensity will be too much to handle and all my efforts won’t be enough (never again P90X😫)
However, if there is something I am capable of completing that also ensures pretty good results because of its tested and true foundation, then I’d probably be cutting my way to the front of the line to sign up. The authors share their innovative approach with methods that’ll surely make even your saliva sweat!😄
So buckle up, because it’s about to get INTENSE up in here!!😎
The authors easily lay out their case for more comprehensive and intensive treatment options when it comes to moderate-severe dysphagia, even calling us clinicians out citing the 2013 study that found 200+ SLPs used more than 4 swallowing exercises each session with great variability, essentially throwing everything including the kitchen sink in treatment plans in order to try to make the most improvement given our often limited reimbursed timeframes. Truth be told, I’ve never felt more SEEN while being guilty at the same time😬.
Luckily, they put their efforts into a solution to this all-too-common “when all you have is a hammer, everything looks like a nail” method. By including adult patients in their study with confirmed dysphagia from neurologic etiologies from 2 different outpatient specialty clinics across a 3 year timespan, they were able to assess certain aspects of swallow function and impact before and after their prescribed intervention plan.
typical numbers for these non-rookies
Yes, obviously having the same amount of participants as the number of fingers on your hands isn’t ideal. You know it. I know it. And the authors surely know it pointing out this limitation:
“Case series designs can provide important information when testing new treatment models and determining their safety and effectiveness; however, their results may not generalize to the larger population.” p.7
Now that we can accept that, we can move on to delight in how those participants were fairly representative to many we see every hour across settings:
- Stroke, TBI, peripheral nerve virus, progressive neuromuscular disease
- Acute (neuro event <6 mo before protocol)
- Chronic dysphagias (diagnosis >6mo before protocol) who had no improvement with prior treatments
- Originally 5 NPO, 3 partial PO intake (I’m left to assume this leaves 2 with full oral intake?🤨)
The study really utilized a wide-range of measurement tools:
- Airway invasion: PAS
- primary outcome
- Physiological tongue pressures: IOPI (isometric for anterior/posterior)
- 2 sets of data for each location
- Patient-reported QOL outcome: EAT-10
- Functional level of oral intake: ASHA NOMS
- rated by 3 certified, blinded SLPs (>3 yrs dysphagia experience) who weren’t involved in the treatment phase
If that wasn’t enough, they also followed up again for QOL and any adverse effects via online survey 4 weeks posttreatment.
It’s important to keep in mind that the PAS primary outcome was utilized via FEES vs VFSS. Why? Since the authors didn’t really give a rhyme or reason, I can’t say🤔, but I’ll just assume that was either all they had or there might be something they know that I don’t (which is always a good possibility😅).
However, they did redeem themselves by describing their specific bolus administration which included 2 trials of each of the following:
- 5 mL thin liquid
- 10 mL thin liquid
- thin liquid via self-administered straw sip
- 5 cm3 of pudding
Alas, I couldn’t help feeling slightly disappointed by not knowing why these specific presentations were selected (straw vs cup?) or why more weren’t added because these are the things that’ll keep a curiously questioning SLP up at night😅! While there was a single patient that had only the two 5mL boluses presented due to apparent gross aspiration, at least there was some optimal blinding happening by having the recorded and de-identified evaluations scored across 2 different reviewers (blinded to the treatment and time of assessment), along with a small 10% sample also judged by the overseeing investigator, Dr. Malandraki.
Now on to what we all really wanna know more about…
That intense intervention!!🤩🤩
[For a detailed picture of what the protocol looks like, checkout the initial post, Phew!😓 Intensifying Approaches for Dysphagia Management]Otherwise, here’s a glimpse at the Intensive Dysphagia Rehabilitation protocol, a 4-week treatment approach based on 3 components:
- High intensity structured training across 2 different oropharyngeal-targeted, evidence-based regimens for each patient
- each regimen targets different muscle groups (tongue, pharyngeal, suprahyoid) or neuromuscular goals (strength vs ROM etc.)
- 2 regimens were practiced on alternating days
- weekly/biweekly gradual increase in # of reps per set or duration of certain exercises
- High intensity targeted swallowing practice
- single swallows determined by safety on FEES
- 60 swallows per day (20 sets x3 daily)
- Emphasis on saliency, support, and short duration
- preferred food items, caregiver participation, binder for homework completion
Some more details on that “targeted swallow practice:” Yes, it is very closely linked to not only the McNeill Dysphagia Training Program (MDTP), but also many other foundational principles like “use-it-or-lose-it” and “training specificity.“
“Advancement or downgrading of materials during targeted swallowing practice was determined by patient performance. This refers to clinical observations relating to: duration of oral preparation time, approximate timing of the initiation of the swallow, potential expectoration of the material, overt clinical signs of aspiration, observed oral or oropharyngeal residue after each swallow, overall duration of each swallow, and respiratory function as monitored with pulse oximetry.” p.4
And if you thought researchers are always a ‘no ifs, ands, or buts’ bunch in their studies, think again:
“In general, if consistent difficulties (across multiple trials) were observed in any 3 of the following parameters (ie, signs of aspiration, expectoration, respiratory function), then we would consider downgrading materials. This was, however, very infrequent.” p.4
Finally, oral care was a must throughout and after the protocol, along with the help of having a stable medical status as well🙂.
Let’s get right to those results so we can start thinking if we wanna put this intense treatment to the test:
Penetration Aspiration Scale (PAS)
- Statistically significant decrease in average pre-posttreatment scores and maximum PAS scores for the 7 patients who were able to complete both pre/post treatment FEES.
“The Intensive Dysphagia Rehabilitation approach appeared to be effective in significantly improving airway safety in 4 weeks without the need of daily in-clinic therapy. This is likely because of the cumulative effect of the Intensive Dysphagia Rehabilitation components, including the individualized and systematic combination of evidence-based exercises, the functional targeted swallowing practice enhancing training specificity, and the inclusion of adherence-inducing features absent from existing regimens.” p.6
Before taking this to heart, it can be important and beneficial to remember the classification of what the PAS is and consider Steele & Grace-Martin’s 2017 proposed revisions to the scale. For example, which should be regarded as “worse:” deeper airway invasion but with an effective swallow/cough to clear OR less airway invasion but no sensation or ability to clear???🤔🤔 These are the kinds of constant questions clinicans and researchers are thinking about as we self-analyze our own swallows! Lucky for us, the results in this study show we don’t need to be as worried about this issue at least for this study…
Iowa Oral Performance Instrument (IOPI)
This measure is interesting because while all participants had baseline pre/posttreatment lingual measures, not every participant’s IDR regimens specifically targeted lingual strengthening (e.g. some needed pharyngeal strengthening+Mendelsohn, etc.):
“All but 1 patient increased in both anterior and posterior tongue pressures…increased lingual pressures were noted post intervention in 9 of the 10 patients. For patients completing (n=4), lingual strengthening, lingual pressure gains were pronounced (25-225%) and are consistent with or higher than those reported previously in patients poststroke.”
“For patients who were not completing lingual strengthening…the small strength gains (8.5-29%) in these patients may be explained by the shared musculature (lingual and suprahyoid) that is stimulated with these exercises and is known to contribute to these pressures.” p.5-6
So here we have results from some who actively worked on this issue as well as others who didn’t, yet almost all patients had lingual improvements! While unfortunately, we can’t say these changes were statistically significant, clinically that does show progress and meaningful change in the clinical sense😉
EAT-10
“Nine participants had improved EAT-10 scores post intervention. However, these improvements were not statistically significant. At the 4-week follow-up, patients reported further improved QOL compared with baseline, which was significant. This may suggest a carryover effect associated with generalization of behaviors through daily use (ie, swallowing). One patient had a higher/worse total EAT-10 score immediately posttreatment, but continued to report improved scores at follow-up.” p.6-7
So while just about everyone subjectively felt better about their swallowing abilities immediately following treatment and 4 weeks after, nobody’s perception changed enough to a “normal” swallowing-related quality of life which the authors fully accept and ponder “may indicate that the duration of IDR approach is insufficient to return patients with severe dysphagia to fully normative QOL.”😕
ASHA NOMS
“NOMS levels were improved for 8 of the 10 participants and remained unchanged in 2 participants…Remarkably, of the 5 patients who were NPO at baseline, only 1 remained NPO (with pleasure trials orally) posttreatment. This patient was diagnosed with a brainstem stroke (3y postonset) and was unable to consistently trigger a swallow at baseline. After the implementation of the Intensive Dysphagia Rehabilitation approach, the patient gained the ability to more consistently initiate a swallow and manage his secretions and started accepting some soft foods by mouth (pleasure feedings).”
“Two of the 5 patients started receiving their nutrition fully by mouth, and 1 patient started receiving most of his nutrition (>50%) by mouth. These findings indicate significantly improved functional swallowing outcomes as a result of the Intensive Dysphagia Rehabilitation approach.” p.7
I’d say those changes are pretty clinically significant🤩!! While the authors do explain the 2 participants’ lack of change was deemed due to chronic progressive condition as well as the lowest adherence rates and another’s newly 3-month-old unspecified diagnosis, nonetheless, the overall impact and functional change to most of the participants can certainly be something to brag about👍
Now that we know a lot more about IDR, what it does, and what it actually does as far as the outcomes, we can start asking ourselves, “Is this right for my patient?”
In doing so we also need to think about reasons why this might not be appropriate and consider some obvious limitations.
For example, like with any intense training program–be it for biceps or the pharynx–motivation and adherence are required. The authors acknowledge they only tracked this by the use of homework logs and recommend future home visits or tele-sessions be implemented. In the future, I’d also love to see some type of rating for “ease of intervention” tracked (because while I might go to my workout classes, I still might have to always rush to get there or put a lot more work in!)
As mentioned before, the use of FEES vs VFSS obviously limits visualization of certain physiological swallowing aspects like hyolaryngeal excursion, which the authors also suggest in the future (I personally was also a bit bummed to not have as many specific physiological measurements as well besides IOPI😕).
It also seems if we lived in an ideal world where funding and time weren’t an issue, the participants would’ve been able to be completely re-evaluated in person. Also, not forgetting that while most patients did have an improved QOL from the short EAT-10 survey following treatment and lasted weeks after, no significant improvements “back to normal” were made and texture restrictions still remained for all. Does that mean more improvement could’ve been made if the protocol continued longer? We’ll never know🤷♀️ (until another study finds this out for us🤓!!)
And if you’re sitting there asking yourself, “What about if my patient has a different type of diagnosis or etiology for dysphagia?” The authors of course would love to know if the IDR approach works better for some versus others, however, we’ll have to keep hanging around for that too:
“we acknowledge that recovery and responsiveness to intensive therapy may be different across different diagnoses and across different durations of neurologic deficit. This is why the Intensive Dysphagia Rehabilitation approach addresses each patient with an individualized plan of care, but intensity and frequency remain the same…Furthermore, the personalized nature of this approach, with the inclusion of different combination of exercises, complicates the interpretation of the findings.” p.7
So that really does leave it up to us clinicians at this time. Maybe trialing it with a motivated, stable post-stroke acute rehab patient might be beneficial🤔? Maybe implementing it in a home health setting with all the education and training but extending the duration might be more appropriate??🤷♀️
I don’t have all the answers, neither do the researchers (yet!). So it’s up to each of us to put on our clinical thinking caps, weigh the benefits and risks, inform and educate our patients, and make the best of what we’ve got!
Curious what other options there are for intense interventions? Stay tuned for Part 2: MD Anderson’s Swallow Boot Camp!!!
Articles Referenced:
- Malandraki, G., Rajappa, A., Kantarcigil, C., Wagner, E., Ivey, C., & Youse, K. (2016). The Intensive Dysphagia Rehabilitation Approach Applied to Patients With Neurogenic Dysphagia: A Case Series Design Study. Archives Of Physical Medicine And Rehabilitation, 97(4), 567-574. doi: 10.1016/j.apmr.2015.11.019
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