What is the ‘‘usual care’’ in dysphagia rehabilitation

I have been really trying to stay out of Facebook forums this week but sometimes I get tagged (thanks Dan) and I have to interject. There was a long post today concerning the practice of therapy in SNFS and I want to make my position clear. First, I understand that there are times when an alteration of diets makes sense, and it is appropriate, if the patient and/or caregiver determines this is the best way to improve quality of life. However, it is my contention that this is consistently over utilized and poorly understood. We are not given courses in nutrition yet we are often guilty of going around changing diets like Oprah on Christmas. Little thought is given to the real impact of these decisions. The first issue is we, as a profession, are under educated when it comes to dysphagia. If you want to understand the scope of the problem I encourage you to read “What is ‘‘usual care’’ in dysphagia rehabilitation: A survey of USA dysphagia practice patterns” Carnaby 2013. Dr. Carnaby conducted a survey, only including those who have a special interest in dysphagia. What she found was that 55% of the time therapists are literally making up assessments, 44% of the time therapists are completely making up a treatment. Only 3.9% of the respondents could identify physiology and 58% of the interventions recommended for a posted MBSS did not correspond to the pathophysiology. There is much more, go read it. None of it is good news for the future of our participation in treating dysphagia. Then I read posts encouraging diet changes and compensatory strategies as a standard of care and my head spins and I spit green vomit. If you have to have a notebook to keep up with all the people on altered diets you may want to rethink what you are doing and examine if you are actually helping.

Steele 2015 published a systematic review of literature concerning modifying diets. We do not know much:• This systematic review identified major gaps in the understanding of the impact of liquid consistency and food texture on swallowing physiology, both in healthy and disordered populations.

• With respect to objective measures that might be used to guide the classification of thickened liquids and texture modified foods, the review identified an absence of convention, particularly in terms of the shear rates that are used for reporting apparent viscosity.

• Exceptionally limited information is available for objective measurement of texture-modified foods.

A 2005 study by Wright evaluated dietary intake over the course of a day in hospitalized patients older than 60 years comparing intake in patients consuming a regular diet to those consuming a texture modified diet

• Patients on the modified diet had a significantly lower nutritional intake in terms of energy and protein.

• 54% of patients on a texture modified diet were recommended a nutritional supplement, compared with 24% of patients on a regular diet.

Viganó (2011) simply studied the nutritional value of various diets. Compared with the normal diet the puréed and liquid diets were the ones with the most reduced:• energy (reduced 31.4% and 39.9%, respectively),• protein ( reduced 45.4% and 79.8%, respectively)• lipids ( reduced 41.0% and 76.0%, respectively)

Here is some information concerning thickened liquids:

• Despite the lack of evidence to support first-line use of thickened liquids, many clinicians continue to believe they are an effective intervention. (Wang 2016)

• In a 2005 survey of speech-language pathologists, respondents prescribed thickened liquids to 25% to 75% of patients with dysphagia. (Garcia 2005)

• “Qualitative synthesis revealed two key trends with respect to the impact of thickening liquids on swallowing: Thicker liquids reduce the risk of penetration– aspiration, but also increase the risk of post-swallow residue in the pharynx.” (Steele 2015)

• “No strong evidence is available supporting the use of thickened liquids as an intervention for patients with dysphagia.” Sura et al. 2012

• Dehydration occurred to a significant degree in the presence of thickened liquids. Logemann 2003

Dehydration in the elderly can lead to:• Hypotension• Falls• Constipation• UTI• Confusion• Delirium• Poor recovery from illness

Complications that may arise from thickeners:• Slow gastric emptying• Increase risk of reflux• Reduce appetite

“The generally accepted clinical notion that manipulation of thicker (more viscous) substances reduces occurrence of aspiration, or modifies other bolus flow characteristics in dysphagic persons that produce an “improved swallow,” has little support, other than anecdotal, in the literature. Despite the paucity of data, the manipulation of thickness in the diet has become a cornerstone of dysphagia management practice.” Robbin 2002

“Use of thickened liquids reduces videofluoroscopic evidence of aspiration in older adults with dementia but does not reduce the 3-month risk of pneumonia in the same population.” Wang 2016

It is pretty clear that changing diets is not a benign decision. There are significant negative consequences. This should not be a permanent solution. Dysphagia is not a problem with the food. We need to stop treating diets. Dysphagia is a problem with swallow physiology and it is the responsibility of the SLP to work on swallowing. Let’s get out of the dining room and into the therapy room and figure out what we need to be doing to treat dysphagia.

So go ahead and call me whatever name you wish, but it does not negate the facts.

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