Dysphagia Grand Rounds 6

One of the major issues with the management of people with dysphagia is the discontent and in many cases, the refusal to adhere to diets composed of thickened fluids. Given that modified diets raise serious clinical management problems with respect to hydration and quality of life; and in the absence of conclusive scientific evidence, numerous facilities have adopted policies allowing patients free access to water. However, this is not a uniform policy with minimal documented evidence to reflect the practice.  

Dysphagia Grand Rounds 6 reviews a randomized-control prospective study that investigates the effects of oral intake of water in people with dysphagia with previously identified aspiration. Read the article below before watching the DGR 6 webinar to maximize your learning experience.  

Article: Effects of oral intake of water in patients with oropharyngeal dysphagia
Authors: Martha Karagiannis, Leonie Chivers and Tom Karagiannis
Journal: BMC Geriatrics. 2011;11:9 

Read DGR 6 article herehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3053239/ 

Download DGR 6 webinar here: http://dysphagiagrandrounds.yondo.com/playlist/dgr-6-june-2017/365

Abstract: 
BACKGROUND
Dysphagia is associated with numerous medical conditions and the major intervention to avoid aspiration in people with dysphagia involves modifying the diet to thickened fluids. This is associated with issues related to patient quality of life and in many cases non-compliance leading to dehydration. Given these concerns and in the absence of conclusive scientific evidence, we designed a study, to further investigate the effects of oral intake of water in people with dysphagia. 

METHODS
We monitored lung related complications, hydration levels and assessed quality of life in two groups of people with dysphagia. The control group was allowed only thickened fluids and patients in the intervention group were allowed access to water for a period of five days. 

RESULTS
Our findings indicate a significantly increased risk in the development lung complications in patients given access to water (6/42; 14.3%) compared to the control group (0/34; no cases). We have further defined patients at highest risk, namely those with degenerative neurologic dysfunction who are immobile or have low mobility. Our results indicate increased total fluid intake in the patients allowed access to water, and the quality of life surveys, albeit from a limited number of patients (24% of patients), suggest the dissatisfaction of patients to diets composed of only thickened fluids. 

CONCLUSIONS
On the basis of these findings we recommend that acute patients, patients with severe neurological dysfunction and immobility should be strongly encouraged to adhere to a thickened fluid or modified solid consistency diet. We recommend that subacute patients with relatively good mobility should have choice after being well-informed of the relative risk.

Dysphagia Grand Rounds 5

May is Stroke Awareness Month. More than 50% of the 665 thousand stroke survivors experience dysphagia acutely, of which approximately 80,000 experience persistent dysphagia at 6 months. Early treatment of dysphagia aims to reduce secondary complications such as dehydration, malnutrition and pneumonia and allows for spontaneous recovery of swallowing function. For those with dysphagia persisting beyond the acute phase, it is crucial to continue treatment that, in addition to reducing secondary complications, targets the physiologic deficits caused by the stroke with the goal of improving swallowing function or compensating for lost function (Vose et al., 2014).

Dysphagia Grand Rounds 5 reviews a recent research study that compares two tongue-pressure resistance training protocols for post-stroke dysphagia. Read the article below before watching the DGR 5 webinar to maximize your learning experience. 

Article
A Randomized Trial Comparing Two Tongue-Pressure Resistance Training Protocols for Post-Stroke Dysphagia
Authors: Catriona M. Steele, Mark T. Bayley, Melanie Peladeau-Pigeon, Ahmed Nagy, Ashwini M. Namasivayam, Shauna L. Stokely, and Talia Wolkin
Journal: Dysphagia. 2016;31(3):452-461

Download DGR 5 article here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4871779/

Download DGR 5 webinar here: http://dysphagiagrandrounds.yondo.com/playlist/dgr-5-may-2017/305

Abstract
The objective of this study was to compare the outcomes of two tongue resistance training protocols. One protocol (“Tongue-Pressure Profile Training”) emphasized the pressure-timing patterns that are typically seen in healthy swallows by focusing on gradual pressure release and saliva swallowing tasks. The second protocol (“Tongue-Pressure Strength and Accuracy Training”) emphasized strength and accuracy in tongue-palate pressure generation and did not include swallowing tasks. A prospective, randomized, parallel allocation trial was conducted. Of 26 participants who were screened for eligibility, 14 received up to 24 sessions of treatment. Outcome measures of posterior tongue strength, oral bolus control, penetration-aspiration and vallecular residue were made based on videofluoroscopy analysis by blinded raters. Complete data were available for 11 participants. Significant improvements were seen in tongue strength and post-swallow vallecular residue with thin liquids, regardless of treatment condition. Stage Transition Duration (a measure of the duration of bolus presence in the pharynx prior to swallow initiation, which had been chosen to capture impairments in oral bolus control) showed no significant differences. Similarly, significant improvements were not seen in median scores on the Penetration-Aspiration Scale. This trial suggests that tongue strength can be improved with resistance training for individuals with tongue weakness following stroke. We conclude that improved penetration-aspiration does not necessarily accompany improvements in tongue strength, however tongue-pressure resistance training does appear to be effective for reducing thin liquid vallecular residue.