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Clinical Swallow Examination (CSE): Can We Talk?

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Abstract

The clinical swallow examination (CSE) is widely used by clinicians evaluating patients with dysphagia, yet this method remains controversial among many. The composition and purpose of the CSE are highly variable by region, facility, age group and individual clinician. This article will review literature on the topic and present clinical practice suggestions to further its usefulness and ongoing investigation.
Clinical Swallow Examination (CSE): Can We Talk?
Luis F. Riquelme
Department of Speech-Language Pathology, New York Medical College
Valhalla, NY
Barrique SLP at Center for Swallowing & Speech-Language Pathology, New York Methodist Hospital
Brooklyn, NY
Financial Disclosure: Luis F. Riquelme is an associate professor at New York Medical College and
director of Barrique SLP at Center for Swallowing & Speech-Language Pathology at New York
Methodist Hospital.
Nonfinancial Disclosure: Luis F. Riquelme has previously published in the subject area.
Abstract
The clinical swallow examination (CSE) is widely used by clinicians evaluating patients
with dysphagia, yet this method remains controversial among many. The composition and
purpose of the CSE are highly variable by region, facility, age group and individual clinician.
This article will review literature on the topic and present clinical practice suggestions to
further its usefulness and ongoing investigation.
To complete a clinical swallow examination or not to complete a clinical swallow examination...
Is that the question? The answer depends on the individual speech-language pathologist (SLP).
For many clinicians, it is not a question. Many, not all, SLPs that practice in the area of dysphagia
do conduct a clinical swallow examination (CSE) prior to completing an instrumental examination,
if warranted.
The CSE is largely considered a bedside or office procedure that involves review of the
patients history, via chart review and/or interview, and a direct physical exam. As stated by
Carnaby (2012), the CSE should be viewed as an assessment method. This should not be confused
with a dysphagia screening, which is designed as a minimally invasive and quick procedure to be
administered by a variety of healthcare professionals and is usually reported as pass/fail. Confusion
over these two procedures is not new. As far back as 1997, published articles on this topic use terms
such as clinical screening assessmentsin the abstract, yet the body of the article continually
refers to a clinical swallow assessment(Daniels, McAdam, Brailey, & Foundas, 1997). Five years
ago, greater confusion was created by the introduction of requirements for dysphagia screenings
in patients who present to emergency rooms around the country with signs and symptoms of
stroke. The pressure for SLPs began in 2006, when The Joint Commission (then Joint Commission
on Accreditation of Healthcare Organizations [JCAHO]) required a swallowing screenfor all
patients arriving at emergency rooms with signs/symptoms of stroke (Swigert, Riquelme, & Steele,
2007). While this standard was rescinded in 2010, many state departments of health have
continued its requirement (e.g., American Heart Association, n.d.). Popular dysphagia screening
protocols include: the Yale Swallow Protocol, previously known as the 3-ounce water swallow test
(Leder & Suiter, 2014; Suiter & Leder, 2008), the Toronto Bedside Swallowing Screening Test,
TOR-BSST (Martino et al., 2009) and the Modified Mann Assessment of Swallowing Ability, MASA
(Nader et al., 2010). The purpose of these screening tools, as per the definition of a screening, is
to identify which patients require further assessment. There is no consensus on which screening
approach or tool is best at the present time. Daniels and colleagues (2012) conducted a systematic
review for valid items for screening dysphagia risk in patients with stroke. They concluded that
numerous swallowing and non-swallowing behaviors were found to be associated with aspiration
and that the best combination of these for screening purposes remains unclear (Daniels, Anderson,
& Wilson, 2012). The assessment that may follow the failure of a dysphagia screen may be a
CSE or an instrumental examination, depending on the protocols followed by the SLP.
Perspectives on Swallowing and Swallowing Disorders (Dysphagia)
Volume 24, February 2015, Copyright © 2015 American Speech-Language-Hearing Association
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Searching for Evidence
In this era of searching for evidence-based clinical procedures, the argument over the benefits
of the clinical swallow examination (CSE) remains in the forefront. A survey of over 300 SLPs from
the American Speech-Language-Hearing Associations Special Interest Group 13, Perspectives
on Swallowing & Swallowing Disorders (Dysphagia), identified that the most common form of
swallowing examination used by clinicians was an informal checklist of swallowing features
(Harrenberg & Carnaby-Mann, 2011). Less than 20% of those surveyed used their clinical
examination as a measure of follow-up evaluation of patient progress. The authors conclude:
Given the simplicity and relative utility of the clinical bedside exam, this data seems
counterintuitive. Possible reasons for this lack of clinical measurement may include lack of
confidence in current clinical assessment methods, lack of education in clinical assessment
techniques, use of the clinical exam as a screenonly, limited knowledge of value and
availability of valid clinical exams, lack of resources to invest in assessment training of staff,
or an overreliance on expensive instrumental evaluation methods.
Several authors have noted that the conduct and interpretation of the CSE relies heavily
on the knowledge and experience of the examiner/clinician (Harrenberg & Carnaby-Mann, 2011,
p. 148; McCullough, Wertz, Rosenbek, & Dinneen, 1999).
Arguments over the benefits of the CSE are not new in the dysphagia literature. In 1997,
Daniels reported on six clinical features that were identified as being indicative of risk of aspiration
in acute stroke patients (reported later in Daniels, Ballo, Mahoney, & Foundas, 2000). She and
colleagues stated that the presence of two or more of these six clinical features provided an objective
clinical indicator of stroke patients at risk for aspiration: dysphonia, dysarthria, abnormal
volitional cough, abnormal gag reflex, cough after swallow, and voice change after swallow. In
1999, McCullough and colleagues looked at clinician preferences in conducting the CSE and
videofluoroscopic swallow studies/examinations (VFSS). They found that 85% of the methods and
measures surveyed showed a wide range in preference ratings among clinicians in their sample.
McCullough, Wertz, and Rosenbek (2001) later reported on the sensitivity and specificity of the
CSE for detecting aspiration in adults subsequent to stroke. Martino, Pron, and Diamant (2000)
reviewed the literature on CSEs extensively, evaluating 154 sources, 89 of which were original
articles. Data, when available, were collapsed and reanalyzed for sensitivity, specificity, and
likelihood ratio. Their results suggested that few data are currently available to support the concept
that clinicians are able to detect abnormal swallow physiology with a clinical examination, and
they suggested that large, well-designed trials are needed for more conclusive evidence of screening
benefit(Martino et al., 2000, p. 19). The concerns expressed by Martino and her colleagues are
understandable given some of the individual clinical signs reported in the literature. As cited in
Martino et al. (2000), the presence of an abnormal, volitional cough (Daniels et al., 1998; Gordon,
Hewer, & Wade, 1987; Horner, Brazer, & Massey,1993; Horner, Massey, & Brazer, 1990) and
the absence of a pharyngeal gag reflex (Daniels et al., 1998; Gordon et al., 1987; Horner, Massey,
Riski, Lathrop, & Chase, 1988; Linden & Siebens, 1983; Logemann, Veis, & Colangelo, 1999) have
been identified by some researchers as signs of aspiration in stroke patients. Others have found
no relationship between an abnormal, volitional cough or the lack of a pharyngeal gag reflex and
aspiration (Leder, 1997; Linden, Kuhlemeier, & Patterson, 1993).
The studies that have looked at the sensitivity and specificity of the CSE correlate it with
VFSS or fiberoptic endoscopic evaluation of swallowing. This correlation is most often based on
one item from the CSE (wet voice or cough), and one from the instrumental examination (presence
or absence of aspiration). This is limiting for the clinician, as the CSE is not only completed for
the purpose of identifying patients at risk for aspiration, but also to assess the other array of
neuromuscular, behavioral, and environmental factors involved in successful swallowing and
eating. Furthermore, a large part of the literature is based on participants post stroke, therefore,
results do not always apply to other patient populations.
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A few studies have looked at other components of the CSE, however, continue to maintain
the focus on presence or absence of aspiration and aspiration risk. McCullough et al. (2005)
published an investigation conducted to determine the utility of the CSE for detecting aspiration
by VFSS in patients post-stroke. They concluded that some CSE measures serve some purposes,
which need to be better defined. They found that if aspiration was suspected on the CSE, it was
10 times more likely that aspiration would be seen on VFSS. They noted that even if aspiration
was suspected on the CSE, how much aspiration could not be estimated without the instrumental
assessment. In 2009, Leder, Suiter, and Warner investigated the difference in odds for aspiration
based upon answering orientation questions correctly. In a retrospective sample of 4,070 patients
referred for evaluation, the odds of liquid aspiration were 31% greater for persons not oriented
to person, place, or time. Moreover, the utility of the oral mechanism examination for the CSE
has also been investigated by Leder, Suiter, Murray, and Rademaker in 2013. In their sample of
3,919 referred patients, they found that when lingual range of motion and facial symmetry are
incomplete, the clinician should be alerted to potential increased odds of aspiration during
subsequent instrumental dysphagia testing.The use of pulse oximetry to detect aspiration has
also been investigated (Colodny, 2001; Leder, 2000). In 2012, Carnaby wrote on the utility of the
cranial nerve/clinical examination for dysphagia. She summarized that, the clinical dysphagia
assessment, though still requiring further integration and standardization in general practice,
can offer the dysphagia professional a multifaceted and effective tool for both evaluation and
intervention.
Clinical Practice
While many clinicians accept the fact that the CSE does not provide information on presence
or absence of aspiration, nor does it accurately represent the biomechanics of the swallow in the
patient, many SLPs employ it for other reasons. A complete analysis of all the factors and information
gathered during the CSE and its use in clinical decision-making has not been rigorously studied.
One of the difficulties in conducting such an analysis is clinician preference for items to include in
the CSE (Mathers-Schmidt & Kurlinski, 2003), as well as the need to control for clinician experience
(knowledge and skills). We must define what is to be included in a CSE, if we are to reliably support
its widespread use. Others may argue, however, that completing a CSE based on the standards
created at each facility or by each clinician would suffice. This approach, which is more in line with
current practice, does not allow us for a systematic and controlled approach to its study. In 1999,
McCullough and colleagues found the following four sections to be generally included in the CSE
protocol by SLPs surveyed: history, oral/motor praxis, voice, and trial swallows. While many
dysphagia textbooks dedicate chapters to this topic, few research studies have defined the
parameters and overall protocol for each section. Identifying which items in the history are clinical
indicators of possible dysphagia, which parts of the oral mechanism examination are relevant to
swallowing, what tasks should be included in the voice screening, or how to conduct trial swallows
during the CSE, should be a focus of study in our research endeavors. New clinicians would
benefit from more evidence-based guidance to this clinical examination and decisions made after
its completion.
Defining the purpose of the CSE is also needed. Clinicians may use it as a screening tool or
as an actual assessment method. It is known that in some settings, and for some specific groups
of patients, the CSE suffices as an assessment tool without the need for further instrumental
assessment. The reason for referral to the SLP for a swallow assessment should also play a major
role in its applicability. In acute care settings, if the CSE is employed as an initial assessment at
bedside, percentages of how many patients subsequently undergo an instrumental examination
vary across the country and between institutions. This is usually based on clinician and facility
preference. The overall case mix at each facility, of course, also plays a role in this process as well.
In long-term care settings, the percentage of patients referred for an instrumental examination
declines greatly after completion of a CSE. While this may also be influenced by clinician preference,
other factors to consider in this decision-making process include the overall case mix, reimbursement
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limitations for instrumental exams, and if prior diagnostic work-up suffices to commence a
treatment/management program for the patient.
Communicating Findings
In this discussion on the utility of the CSE, a commentary on communication and
documentation is of essence. Much variety exists on how SLPs document results of the CSE and
instrumental exams. While the writing style may be specific to each clinician and facility, it does
not always allow for accurate or compete interpretation by a colleague at another facility. The
advent of electronic documentation, and the variety of companies providing this service, have
further complicated this issue. Sharing results of our exams is essential for good patient care,
which includes the decision-making process to be undertaken by physician colleagues, nurses,
dietitians, and/or the clinician at the receiving facility, upon patient transfer. However, if the
documentation is incomplete or unspecific, it is of no benefit to anyone. If the documentation is a
simple checklist with a listing of broad categories, how is the professional reading the report to
interpret those results? Another example may be that of statements that are incomplete due to
insufficient qualifying information—“(+) cough for semi-solidsis a statement that requires
further clarification: What semi-solid was administered? When did the patient cough (before, during,
after)? How much bolus volume was administered? On how many of how many trials was the cough
elicited? All these questions could be answered by simply providing the basic information of what
took place at the time of the CSE. These are some of the specifics we require of our researchers,
so as to allow for proper duplication of results, so why not also make this a requirement for our
clinical documentation? Similar problems are noted for reporting results of instrumental exams,
where penetration or aspiration are not differentiated, amount of trials presented for each
consistency are not reported, etc. The latter is beyond the scope of this article. In addition, while
there may be many subjective practices included by some in the CSE, these may contribute to the
overall picture of the patient. For example, reporting on laryngeal palpation or cervical auscultation
remain highly debated, yet used and reported often.
Creating a Standard of Care
Clinicians sometimes wonder if there should be uniformity on clinical approaches to the
care of the patient with dysphagia. As mentioned earlier, the need to systematically study several
aspects of the CSE is of essence. However, in the more immediate future, ensuring that at least
groups of clinicians at each facility agree on how to conduct and interpret the CSE, if it is to be
used, is also relevant. Reaching agreement among several colleagues may be difficult, as per the
fine balance needed between different levels of evidence. As has been shown, clinician preferences
vary for what to include in the CSE (McCullough et al., 1999). Agreement on how to conduct and
interpret the CSE is important, especially by facility. It would not be appropriate to have Patient A
seen by SLP 1 and Patient B seen by SLP 2 each undergo a different examination with different
interpretation. Imagine if Patient A coughs X1 on thin and nectar liquids and is placed on honey
thick liquids based only on the CSE; whereas Patient B presents a similar pattern and is allowed
water and is not placed on thickened liquids. To make this situation worse, imagine if Patient A
and Patient B share a room at the hospital! This scenario should serve to illustrate why it is
important for some basic agreement on clinical procedures and practices among clinicians at the
same facility. In addition to patient care, imagine the confusion this creates for the physician,
dietary, and nursing staff following both patients. This suggested facility-wide practice pattern
can be achieved by collaborative discussions, case presentations, journal reviews, etc. among
the SLP team. Incorporating the development of a practice pattern could be incorporated into a
performance improvement project for the department. Very often, this process allows for clinicians
with all levels of experience to share and grow professionally for the benefit of the patient and the
institution.
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Summary
The clinician evaluating persons with dysphagia is advised to consider the benefits and
limitations of the CSE and interpret results wisely. While more research is needed to further clarify
the content and interpretation of the CSE, each clinician needs to define its use, if relevant, and
purpose. It should be understood that this varies by facility and by setting. For some of us, the
CSE is a great tool, as long as we understand its limitations, as well as its utility. The CSE should
serve as an estimate of swallow ability, not disability(Harrenberg & Carnaby-Mann, 2011).
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History:
Received September 28, 2014
Revised December 1, 2014
Accepted December 9, 2014
doi:10.1044/sasd24.1.34
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... This assessment is necessary as it allows SLTs to make decisions regarding oral intake and consistency, additional compensations and ultimately the need for instrumental assessments (Namasivayam-MacDonald & Riquelme, 2019;Virvidaki, Nasios, Kosmidou, Giannopoulos, & Milionis, 2018). There is significant controversy regarding the utility of the CSE as a stand-alone assessment to guide dysphagia management (Doeltgen, McAllister, Murray, Ward, & Pretz, 2018;Riquelme, 2015), given its reliance on perceptual information and varied practice patterns (Riquelme, 2015). However, the CSE is still the most commonly used form of dysphagia assessment (Virvidaki et al., 2018). ...
... This assessment is necessary as it allows SLTs to make decisions regarding oral intake and consistency, additional compensations and ultimately the need for instrumental assessments (Namasivayam-MacDonald & Riquelme, 2019;Virvidaki, Nasios, Kosmidou, Giannopoulos, & Milionis, 2018). There is significant controversy regarding the utility of the CSE as a stand-alone assessment to guide dysphagia management (Doeltgen, McAllister, Murray, Ward, & Pretz, 2018;Riquelme, 2015), given its reliance on perceptual information and varied practice patterns (Riquelme, 2015). However, the CSE is still the most commonly used form of dysphagia assessment (Virvidaki et al., 2018). ...
... However, the CSE is still the most commonly used form of dysphagia assessment (Virvidaki et al., 2018). It is regarded as a time efficient, cost-effective and non-invasive assessment, which allows therapists to understand a patient's dysphagia in relation to their medical history and displayed symptoms (Carnaby-Mann & Lenius, 2008;Riquelme, 2015;Virvidaki et al., 2018). ...
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Background: This study explored the available literature on the phenomenon of clinical reasoning and described its influence on the clinical swallow evaluation. By exploring the relationship between clinical reasoning and the clinical swallow evaluation, it is possible to modernise the approach to dysphagia assessment. Objectives: This study aimed to contextualise the available literature on clinical reasoning and the CSE to low-middle income contexts through the use of a scoping review and expert consultation. Method: A scoping review was performed based on the PRISMA-ScR framework. The data was analysed using thematic analysis. Articles were considered if they discussed the clinical swallow evaluation and clinical reasoning, and were published in the last 49 years. Results: Through rigorous electronic and manual searching, 12 articles were identified. This review made an argument for the value of clinical reasoning within the clinical swallow evaluation. The results of the study revealed three core themes related to the acquisition, variability and positive impact of clinical reasoning in the clinical swallow evaluation. Conclusion: The results of this review showed that the clinical swallow evaluation is a complex process with significant levels of variability usually linked to the impact of context. This demonstrates that in order to deliver effective and relevant services, despite challenging conditions, healthcare practitioners must depend on clinical reasoning to make appropriate modifications to the assessment process that considers these salient factors.
... Clinical practice is the procedure or protocol that is followed by all health professionals who manage adults with stroke (Davis & Taylor-Vaisey, 1997;Heinemann et al., 2003;Van Peppen, Hendriks, Meeteren, Helders & Kwakkel, 2007). This knowledge-theory relationship gives rise to evidencebased practice which is an effective and high-quality practice that is driven by knowledge from the latest research (American Speech-Language-Hearing Association, 2005) as well as by the speech-language therapist's competency, experience and preference for practice (Riquelme, 2015). Evidence-based practice is a crucial part of health care delivery as it contributes towards improving health outcomes for those with neurogenic dysphagia due to acute stroke (Straus, Tetroe & Graham, 2009). ...
... A limited amount of literature was available. All 12 studies included in the study showed that most clinical swallow evaluations comprise four main subsections: history, oral motor examination, voice and trial swallows; however, more specific elements still differ among speech-language therapists and have not been officially or extensively outlined by the literature (Riquelme, 2015). Key findings showed that clinical components utilised by more than 90% of speech-language therapists ranged between 24% and 63% across five studies, and the consistency of clinical component utilisation varied between 32% and 58% across three studies. ...
... Experience results in increased levels of confidence and influences practice. Clinical competency and expertise, and preference and attitude towards practice also play a role in practice patterns (Riquelme, 2015). Practice in South Africa is based on experience at an undergraduate level and in the working world as well as from the opinions of experienced colleagues, thus not being evidence-based (Steele et al., 2007). ...
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Background: Speech-language therapists are specifically trained in clinically evaluating swallowing in adults with acute stroke. Incidence of dysphagia following acute stroke is high in South Africa, and health implications can be fatal, making optimal management of this patient population crucial. However, despite training and guidelines for best practice in clinically evaluating swallowing in adults with acute stroke, there are low levels of consistency in these practice patterns. Objective: The aim was to explore the clinical practice activities of speech-language therapists in the clinical evaluation of swallowing in adults with acute stroke. Practice activities reviewed included the use and consistency of clinical components and resources utilised. Clinical components were the individual elements evaluated in the clinical evaluation of swallowing (e.g. lip seal, vocal quality, etc.)Methods: The questionnaire used in the study was replicated and adapted from a study increasing content- and criterion-related validity. A narrative literature review determined what practice patterns existed in the clinical evaluation of swallowing in adults. A pilot study was conducted to increase validity and reliability. Purposive sampling was used by sending a self-administered, electronic questionnaire to members of the South African Speech-Language-Hearing Association. Thirty-eight participants took part in the study. Descriptive statistics were used to analyse the data and the small qualitative component was subjected to textual analysis. Results: There was high frequency of use of 41% of the clinical components in more than 90% of participants (n = 38). Less than 50% of participants frequently assessed sensory function and gag reflex and used pulse oximetry, cervical auscultation and indirect laryngoscopy. Approximately a third of participants showed high (30.8%), moderate (35.9%) and poor (33.3%) consistency of practice each. Nurses, food and liquids and medical consumables were used usually and always by more than 90% of participants. Conclusion: Infrequent use of clinical components and high variability in clinical practice among speech-language therapists calls for uniform curricula in the clinical evaluation of swallowing at South African universities and for continued professional development post-graduation. Different contexts and patient symptoms contribute towards varied practice; however, there is still a need to improve consistency of practice for quality health care delivery. A research-based policy for the clinical swallowing evaluation for a resource-limited context is also needed.
... Many clinicians accept the fact that the CSE does not provide information on presence or absence of aspiration, nor does it accurately represent the biomechanics of the swallow in the patient, however, they employ it for other reasons. Rationales for use of the CSE range from reduced access to instrumental examinations to the need to create a hypothesis of the problem prior to further testing [64]. The preference of our team is to conduct a CSE so as to obtain all pertinent history, address the person's complaint and evaluate any additional factors that may influence swallow physiology. ...
... Recommendations should include food and liquid consistency, strategies required/suggested and safe eating/feeding recommendations. Riquelme, 2015, suggested that the examiner conducting a CSE must be aware of its utility, as well as its limitations [64]. This is in line with the information presented above. ...
... Recommendations should include food and liquid consistency, strategies required/suggested and safe eating/feeding recommendations. Riquelme, 2015, suggested that the examiner conducting a CSE must be aware of its utility, as well as its limitations [64]. This is in line with the information presented above. ...
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Persons with intellectual disability (ID) have received little attention in systematic studies of healthcare and quality of life. Less attention has been provided to specific disorders, such as those impacting the swallowing mechanism. In comparison to the general population, persons with ID experience noticeably greater healthcare inequalities and despite greater life expectancy, it is still lower than the general population. This paper serves as an introduction to healthcare colleagues regarding the risks involved in choking and swallowing disorders in persons with ID, how to evaluate these potential risks and possible treatments. Associated etiologies are presented. A discussion on feeding disorders versus swallowing disorders is also introduced. The inadequacy of swallowing assessment services to persons with ID may be related to the lack of professionals with specialized training in working with this population, reduced funding for research to explore options for improved nutrition and reduced risk of choking and minimal research on changes in feeding skills and/or swallow physiology in this select group of individuals.
... These reflections on the inconsistencies in clinical practice have been detailed before. Luis Riquelme, PhD, CCC-SLP, BCS-S summarized relevant literature on the topic and reviewed how the composition and purpose of the CSE are highly variable by region, facility, age group, and individual clinician (Riquelme, 2015). Mathers-Schmidt and Kurlinski (2003) evaluated dysphagia practices via a survey of 150 SLPs in terms of (a) the components of the clinical examination most commonly used, (b) consistency of clinical examination practices across clinicians, and (c) consistency of clinical decision making given specific patient scenarios. ...
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Purpose Dysphagia management in COVID-19 patients during the New York City spring surge in early 2020 was challenging for many speech-language pathologists, as instrumental swallow evaluations were unavailable. Renewed attention was brought to the value of the clinical swallow evaluation. Conclusion While consistently utilized, the experience also brought back into light the inconsistences in which the clinical swallow evaluation is executed.
... • PPE training/review (e.g., Canada, 2020); and • review of available evidence for clinical swallowing evaluations (e.g., Daniels et al., 1997;Rangarathnam & McCullough, 2016;Riquelme, 2015), consequences of aspiration (e.g., Nativ-Zeltzer et al., 2018), and predictors of aspiration (e.g., Langmore et al., 1998) to improve decision making at the bedside. 1.7 ...
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Dysphagia with aspiration is prevalent in acute stroke; however, noninvasive clinical screening assessments to identify patients at risk of developing aspiration are limited. This study was undertaken to determine whether risk factors detected in the clinical examination approximated the videofluoroscopic swallow study (VSS) in identification of dysphagia severity. Six clinical features - dysphonia, dysarthria, abnormal volitional cough, abnormal gag reflex, cough after swallow, and voice change after swallow - were assessed by means of an oropharyngeal evaluation and a clinical swallowing examination. Clinical assessments and VSS were completed on consecutive stroke patients (n = 59) within 5 days of hospital admission, the VSS was scored on a scale of 0 to 4 (0 = normal, 1 = mild, 2 = moderate, 3 = moderate-severe, 4 = severe dysphagia). Results showed that the presence of at least 2 of the 6 clinical features consistently distinguished patients with moderate to severe dysphagia from patients with mild dysphagia/normal swallowing. These data demonstrate that this clinical dysphagia screening tool can provide objective criteria for the need for VSS in acute stroke patients.
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BACKGROUND: Although many dysphagia screening protocols have been introduced in recent years, no validated, physician-administered dysphagia screening tool exists for acute stroke that can be performed at the bedside. Based on the psychometrically validated Mann Assessment of Swallowing Ability (MASA), we developed the Modified MASA (MMASA) as a physician-administered screening tool for dysphagia in acute stroke. OBJECTIVE: The purpose of this study was to complete initial validation of this new screening tool for dysphagia in acute ischemic stroke. METHODS: Two stroke neurologists independently performed the MMASA on 150 patients with ischemic stroke. Speech-language pathologists performed the standard MASA on all patients. All examiners were blinded to the results of the other assessments. Interjudge reliability was evaluated between the neurologists. Validity between the screening tool (MMASA) and the clinical evaluation (MASA) was assessed with sensitivity/specificity and predictive value assessment. RESULTS: Interobserver agreement between the neurologists using the MMASA was good (k=0.76; SE=0.082). Based on the comprehensive clinical evaluation (MASA), 36.2% of patients demonstrated dysphagia. Screening results from the neurologists (N1 and N2) identified 38% and 36.7% prevalence of dysphagia, respectively. Sensitivity (N1: 92%, N2: 87%), specificity (N1: 86.3%, N2: 84.2%), positive predictive value (N1: 79.4%, N2: 75.8%), and negative predictive value (N1: 95.3%, N2: 92%) were high between the screen and the comprehensive clinical evaluation. CONCLUSIONS: This preliminary study suggests that the MMASA is a potentially valid and reliable physician-administered screening tool for dysphagia in acute ischemic stroke. Use of this tool may facilitate earlier identification of dysphagia in patients with stroke prompting more rapid comprehensive evaluation and intervention.
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Use of an oral mechanism examination is ubiquitous and long-standing despite a paucity of research supporting its clinical utility in dysphagia diagnostics. The purpose of this study was to investigate whether components of an oral mechanism examination, i.e., binary judgments (complete/incomplete) of labial closure, lingual range of motion, and facial symmetry, were associated with increased odds of aspiration as confirmed by subsequent instrumental testing. Study design was a single-group consecutively referred case series with a single judge. A total of 4,102 consecutive inpatients from a large, urban, tertiary-care teaching hospital were accrued, with 3,919 meeting the inclusion criterion of adequate cognitive ability to participate in an oral mechanism examination followed immediately by a fiberoptic endoscopic evaluation of swallowing. Stepwise multiple logistic regression analysis indicated that participants with incomplete lingual range of motion had an odds of aspiration that was 2.72 times the odds of aspiration of those with complete lingual range of motion (95 % confidence interval [CI] = 1.96-3.79, p < 0.0001), and incomplete lingual range of motion was an independent risk factor for aspiration regardless of labial closure and facial symmetry. Participants with incomplete facial symmetry had an odds of aspiration that was 0.76 times the odds of aspiration of those with complete facial symmetry (95% CI = 0.61-0.95, p = 0.017). Isolated incomplete labial closure did not affect the odds of aspiration (p > 0.05). New and clinically relevant information was found for lingual range of motion and facial symmetry, i.e., when incomplete, the clinician should be alerted to potential increased odds of aspiration during subsequent instrumental dysphagia testing.
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There is no evaluation of the evidence for the screening of oropharyngeal dysphagia in stroke. We reviewed the literature on clinical screening for oropharyngeal dysphagia in adults with stroke to determine (a) the accuracy of different screening tests used to detect dysphagia defined by abnormal oropharyngeal physiology on videofluoroscopy and (b) the health outcomes reported and whether screening alters those outcomes. Peer-reviewed English-language and human studies were sought through Medline (from 1966 to July 1997) by using the key words cerebrovascular disorders and deglutition disorders, relevant Internet addresses, and extensive hand searching of bibliographies of identified articles. Of the 154 sources identified, 89 articles were original, peer-reviewed, and focused on oropharyngeal dysphagia in stroke patients. To evaluate the evidence, the next selection identified 10 articles on the comparison of screening and videofluoroscopic findings and three articles on screening and health outcomes. Evidence was rated according to the level of study design by using the values of the Canadian Task Force on Periodic Health Examination. From the identified screening tests, most of the screenings were related to laryngeal signs (63%) and most of the outcomes were related to physiology (74%). Evidence for screening accuracy was limited because of poor study design and the predominant use of aspiration as the diagnostic reference. Only two screening tests were identified as accurate: failure on the 50-ml water test (likelihood ratio = 5.7, 95% confidence interval = 2.5–12.9) and impaired pharyngeal sensation (likelihood ratio = 2.5, 95% confidence interval = 1.7–3.7). Limited evidence for screening benefit suggested a reduction in pneumonia, length of hospital stay, personnel costs, and patient charges. In conclusion, screening accuracy needs to be assessed by using both abnormal physiology and aspiration as diagnostic markers for dysphagia. Large well-designed trials are needed for more conclusive evidence of screening benefit.
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The Yale Swallow Protocol is an evidence-based protocol that is the only screening instrument that both identifies aspiration risk and, when passed, is able to recommend specific oral diets without the need for further instrumental dysphagia testing. Based upon research by Drs. Steven B. Leder and Debra M. Suiter, an easily administered, reliable and validated swallow screening protocol was developed and can be used by speech-language pathologists, nurses, otolaryngologists, oncologists, neurologists, intensivists and physicians assistants. In addition, the protocol can be used in a variety of environments, including acute care, rehabilitation and nursing homes. The Yale Swallow Protocol meets all of the criteria necessary for a successful screening test, including being simple to administer, cross-disciplinary, cost effective, acceptable to patients and able to identify the target attribute by giving a positive finding when aspiration risk is present and a negative finding when aspiration risk is absent. Additionally, early and accurate identification of aspiration risk can significantly reduce health-care costs associated with recognized prandial aspiration. © Springer International Publishing Switzerland 2014. All rights are reserved.
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The clinical dysphagia examination is the mainstay of evaluation methods for the working speech-language pathologist (SLP). It is cheap, accessible, simple to deliver, and consumes few resources (Carnaby-Mann & Lenius, 2008). Though it has often been criticized for its validity in comparison to the more costly videofluoroscopic assessment, it remains the “working SLP’s” best friend when initially confronted with a patient’s complaint of difficulty swallowing. This article will review the misconceptions related to the value of the clinical dysphagia assessment, and the role of the cranial nerve review component in the examination and, more broadly, in patient evaluation, care, and treatment planning.
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Screening for dysphagia is essential to the implementation of preventive therapies for patients with stroke. A systematic review was undertaken to determine the evidence-based validity of dysphagia screening items using instrumental evaluation as the reference standard. Four databases from 1985 through March 2011 were searched using the terms cerebrovascular disease, stroke deglutition disorders, and dysphagia. Eligibility criteria were: homogeneous stroke population, comparison to instrumental examination, clinical examination without equipment, outcome measures of dysphagia or aspiration, and validity of screening items reported or able to be calculated. Articles meeting inclusion criteria were evaluated for methodological rigor. Sensitivity, specificity, and predictive capabilities were calculated for each item. Total source documents numbered 832; 86 were reviewed in full and 16 met inclusion criteria. Study quality was variable. Testing swallowing, generally with water, was the most commonly administered item across studies. Both swallowing and nonswallowing items were identified as predictive of aspiration. Neither swallowing protocols nor validity were consistent across studies. Numerous behaviors were found to be associated with aspiration. The best combination of nonswallowing and swallowing items as well as the best swallowing protocol remains unclear. Findings of this review will assist in development of valid clinical screening instruments.
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Although many dysphagia screening protocols have been introduced in recent years, no validated, physician-administered dysphagia screening tool exists for acute stroke that can be performed at the bedside. Based on the psychometrically validated Mann Assessment of Swallowing Ability (MASA), we developed the Modified MASA (MMASA) as a physician-administered screening tool for dysphagia in acute stroke. The purpose of this study was to complete initial validation of this new screening tool for dysphagia in acute ischemic stroke. Two stroke neurologists independently performed the MMASA on 150 patients with ischemic stroke. Speech-language pathologists performed the standard MASA on all patients. All examiners were blinded to the results of the other assessments. Interjudge reliability was evaluated between the neurologists. Validity between the screening tool (MMASA) and the clinical evaluation (MASA) was assessed with sensitivity/specificity and predictive value assessment. Interobserver agreement between the neurologists using the MMASA was good (k=0.76; SE=0.082). Based on the comprehensive clinical evaluation (MASA), 36.2% of patients demonstrated dysphagia. Screening results from the neurologists (N1 and N2) identified 38% and 36.7% prevalence of dysphagia, respectively. Sensitivity (N1: 92%, N2: 87%), specificity (N1: 86.3%, N2: 84.2%), positive predictive value (N1: 79.4%, N2: 75.8%), and negative predictive value (N1: 95.3%, N2: 92%) were high between the screen and the comprehensive clinical evaluation. This preliminary study suggests that the MMASA is a potentially valid and reliable physician-administered screening tool for dysphagia in acute ischemic stroke. Use of this tool may facilitate earlier identification of dysphagia in patients with stroke prompting more rapid comprehensive evaluation and intervention.
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In the acute-care setting patients with altered mental status as a result of such diverse etiologies as stroke, traumatic brain injury, degenerative neurologic impairments, dementia, or alcohol/drug abuse are routinely referred for dysphagia testing. A protocol for dysphagia testing was developed that began with verbal stimuli to determine patient orientation status and ability to follow single-step verbal commands. Although unknown, it would be beneficial to ascertain if this information on mental status was predictive of aspiration risk. The purpose of this investigation was to determine if there was a difference in odds for aspiration based upon correctly answering specific orientation questions, i.e., 1. What is your name? 2. Where are you right now? and 3. What year is it?, and following specific single-step verbal commands, i.e., 1. Open your mouth. 2. Stick out your tongue. and 3. Smile. In a consecutive retrospective manner data from 4070 referred patients accrued between 1 December 1999 and 1 January 2007 were analyzed. The odds of liquid aspiration were 31% greater for patients not oriented to person, place, and time (odds ratio [OR] = 1.305, 95% CI = 1.134-1.501). The odds of liquid aspiration (OR = 1.566, 95% CI = 1.307-1.876), puree aspiration (OR = 1.484, 95% CI = 1.202-1.831), and being deemed unsafe for any oral intake (OR = 1.688, 95% CI = 1.387-2.054) were, respectively, 57, 48, and 69% greater for patients unable to follow single-step verbal commands. Being able to answer orientation questions and follow single-step verbal commands provides information on odds of aspiration for liquid and puree food consistencies as well as overall eating status prior to dysphagia testing. Knowledge of potential increased odds of aspiration allows for individualization of dysphagia testing thereby optimizing swallowing success.