Evidence-Based Systematic Review: Oropharyngeal Dysphagia Behavioral Treatments. Part III-Impact of Dysphagia Treatments on Populations with Neurological Disorders
Ashford, John, McCabe, Daniel, Wheeler-Hegland, Karen, Frymark, Tobi, Mullen, Robert, Musson, Nan, Schooling, Tracy, Hammond, Carol Smith, Journal of Rehabilitation Research & Development
Speech-language pathologists (SLPs) trained in dysphagia management have an integral role in evaluating and treating swallowing disorders for adults with neurologically induced dysphagia. Cerebrovascular accidents (CVAs), head injuries, and degenerative diseases are often associated with oropharyngeal dysphagia and can lead to serious and life-threatening consequences, such as aspiration pneumonia, malnutrition, and immunocompromised health. Data from the Agency of Health Care Policy and Research report an estimated 300,000 to 600,000 individuals each year exhibit some form of dysphagia because of neurological illnesses or injuries . Moreover, findings from the American Speech-Language-Hearing Association's (ASHA's) National Outcomes Measurement System (NOMS) indicate swallowing as the most commonly treated disorder for individuals with neurogenic diagnoses . NOMS data reveal that 47.6 percent of patients receiving SLP intervention in healthcare settings are being treated for dysphagia secondary to neurogenic diagnoses; the majority of whom (66.8%) improve swallow function after SLP services .
The primary aim of SLP intervention is to reduce the risk of aspiration and improve swallow function for safe and efficient oral intake . To do this, clinicians employ a number of behavioral therapeutic approaches, including the use of compensatory swallowing postures and maneuvers. Pioneered by Larsen in the early 1970s, "neck-flexed postures" and "breath-holding maneuvers" were first introduced to reduce the risk of aspiration and improve deglutition . Others expanded on this early work and further investigated specific compensatory postures of the head and neck as a means to protect the airway, while additional studies examined swallow maneuvers to alter specific aspects of swallow physiology [5-7]. To date, little is known about the effectiveness of these interventions for populations with neurogenic diagnosis.
Recently, ASHA's National Center for Evidence-Based Practice in Communication Disorders (N-CEP) partnered with the Department of Veterans Affairs (VA) to conduct a series of evidence-based systematic reviews (EBSRs) examining the current state of the evidence on compensatory swallowing postures and maneuvers. EBSRs employ specific and transparent procedures to evaluate the scientific research , providing an invaluable resource to SLPs seeking evidence. This current review is part of a series of EBSRs targeting the impact of behavioral swallowing treatments, including head and neck postures and swallowing maneuvers for individuals with neurologically induced dysphagia. Other reviews in this series focus on behavioral swallowing treatments of populations with no disorders (Wheeler-Hegland et al., this issue, Part II, p. 185) and populations with structural disorders (McCabe et al., this issue, Part IV, p. 205).
Clinical questions were identified targeting seven behavioral swallowing treatments (postures and maneuvers) for individuals with neurologically induced dysphagia. Operationally defined in Part I (Frymark et al., this issue, p. 175), the goal of postural treatments is to alter the flow of the bolus by repositioning the body, head, and/or neck before the onset of the pharyngeal phase of the swallow, with the position maintained until the swallow is completed. Postures included side lying, chin tuck, and head rotation. Maneuvers were defined as volitional movements of the oral, pharyngeal, or laryngeal structures before or during the pharyngeal phase of the swallow that are intended to increase swallow force or alter airway protection mechanisms. Maneuvers studied included the effortful swallow, Mendelsohn, supraglottic, and super-supraglottic. In constructing the clinical questions, we also considered various outcomes. Outcomes were classified as those effects on swallow physiology (e.g., timing, efficiency, pressure, and elimination of aspiration), functional swallow ability (e. …