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REVIEW
Living with oropharyngeal dysphagia: effects of bolus
modification on health-related quality of life—a systematic review
Katina Swan
1
•Rene
´e Speyer
1,2
•Bas J. Heijnen
2
•
Bethany Wagg
1
•Reinie Cordier
1,3
Accepted: 7 April 2015
Springer International Publishing Switzerland 2015
Abstract
Purpose Difficulty swallowing, oropharyngeal dyspha-
gia, is widespread among many patient populations (such
as stroke and cancer groups) and aged community-dwelling
individuals. It is commonly managed with bolus modifi-
cation: altering food (usually cutting, mashing or pure
´eing)
or fluids (typically thickening) to make them easier or safer
to swallow. Although this treatment is ubiquitous, anec-
dotal evidence suggests patients dislike this management,
and this may affect compliance and well-being. This re-
view aimed to examine the impact of bolus modification on
health-related quality of life.
Methods A systematic review of the literature was con-
ducted by speech pathologists with experience in oropha-
ryngeal dysphagia. The literature search was completed with
electronic databases, PubMed and Embase, and all available
exclusion dates up to September 2012 were used. The search
was limited to English-language publications which were
full text and appeared in peer-reviewed journals.
Results Eight studies met the inclusion criteria. Gener-
ally, bolus modification was typically associated with
worse quality of life. Modifications to foods appeared to be
more detrimental than modifications to fluids, but this may
be due to the increased severity of dysfunction that is im-
plied by the necessity for significant alterations to foods.
The number of studies retrieved was quite small. The di-
verse nature of methodologies, terminologies and assess-
ment procedures found in the studies makes the results
difficult to generalise.
Conclusion Overall, even though the severity of dys-
phagia may have been a confounding factor, the impact of
bolus modification on health-related quality of life in pa-
tients with oropharyngeal dysphagia appears to be nega-
tive, with increased modification of food and fluids often
correlating to a decreased quality of life. Further, associ-
ated disease factors, such as decreased life expectancy,
may also have affected health-related quality of life. More
research is needed.
Keywords Systematic review Oropharyngeal
dysphagia Deglutition Bolus modification
Health-related quality of life
Introduction
Oropharyngeal dysphagia (OD) is a disorder of swallowing
that may affect mastication, sucking, saliva management,
bolus passage and control through the oral cavity, pharynx
or oesophagus entrance and impair protection of the air-
way. It affects individuals across the lifespan, may be
transient or chronic and may arise from congenital abnor-
malities, acquired neurologic or physical dysfunction,
progressive degeneration and psychiatric disorders [1–5].
Prevalence of OD varies depending on aetiology and age;
among a typical cross section of community-dwelling
&Katina Swan
katina.swan@my.jcu.edu.au
Rene
´e Speyer
renee.speyer@jcu.edu.au
1
Discipline of Speech Pathology, School of Public Health,
Tropical Medicine and Rehabilitation Sciences, James Cook
University, Townsville, QLD 4811, Australia
2
Department of Otorhinolaryngology and Head and Neck
Surgery, Leiden University Medical Center, Leiden,
The Netherlands
3
School of Occupational Therapy and Social Work, Curtin
University, Perth, WA, Australia
123
Qual Life Res
DOI 10.1007/s11136-015-0990-y
individuals aged 65 years and over, it has been reported to
be between 11 and 15 % [6–8]. Between 7 and 44 % of the
normal individuals over the age of 50 have identified
having difficulty swallowing at some point [9]. A range of
conditions which commonly affect the general population
are associated with a drastic increase in frequency; in
stroke, OD occurs in up to 80 % of patients following bi-
lateral brainstem lesions [10]. The prevalence of OD is also
high in Parkinson’s disease, head and neck cancer, and
other neurodegenerative diseases [4,11–16]. Patients with
OD secondary to psychiatric disorders are 43 times more
likely to choke to death compared to the general populace
[5].
The effects of OD are varied and range from complete
incapacitation of the individual’s swallowing system and
airway integrity to mild discomfort or dysfunction when
swallowing. The consequences include difficulty meeting
nutrition and hydration requirements, asphyxiation, pneu-
monia, depression and social isolation [17–20]. Data from
North American acute hospitals indicate the economic
impact of dysphagia is $USD547 million per year [21].
A common management strategy for OD is the modifi-
cation of boluses, that is, altering food or fluids in some
way to make them safe and easier for the person with OD
to swallow [22]. Typically, fluids are thickened. Thicken-
ing acts to decrease aspiration risk through a number of
mechanisms, one of which is compensating for delayed or
discoordinated swallows by slowing the rate of fluid transit
and subsequently increasing time for the larynx to be
shielded by the epiglottis and vocal folds. Thickening fluids
may also increase airway closure intervals and cricopha-
ryngeal sphincter opening duration [23,24]. Acidity or pH,
dairy content, temperature and carbonation of fluids may
also be altered to decrease delays in swallowing and dis-
courage mucous production [25,26]. Food modification
may include softening, chopping, mincing or pure
´eing of
meals, and restriction to foodstuffs or textures deemed safe
[26]. Bolus modification ranges from mild adjustments
(such as avoiding foods that are difficult to chew) to sig-
nificant alterations which affect the taste and appearance of
the food or fluid (such as pure
´eing all meals and thickening
water to the consistency of pudding). Selection of the grade
of bolus modification required is based on the severity of
OD, specific dysfunctions affecting deglutition and masti-
cation, and the goals of management. The ability of the
patient to safely tolerate a food or fluid texture with
minimal risk of aspiration or choking usually drives bolus
texture choices.
Although bolus modification is a ubiquitous compen-
satory strategy, a number of issues regarding this practice
have been identified. There is an association between de-
hydration and thickened fluids. This is likely due to de-
creased fluid intake, rather than any inherent dehydrating
properties of the thick fluids. The bioavailability of water
from thickened and normal liquids does not differ sig-
nificantly, and among patients with OD restricted to thick
liquids, grossly inadequate fluid intake has been reported
[27,28]. Dehydration has significant impact on health.
Mild dehydration among healthy young participants is
linked to increased fatigue, anxiety and headaches, poorer
concentration, and memory [29,30]. Among the elderly
and medically fragile, the adverse consequences become
more severe. Profound dehydration may result in throm-
boembolic complications, kidney dysfunction, hyperten-
sion and delirium [31]. Dehydration is also a predisposing
factor for recurrent stroke [32] and may exacerbate effects
of motor neurone disease [16]. Patients who are restricted
to texture-modified foods are also at risk of health com-
plications. Much lower energy (63 %) and protein (66 %)
intake is found among this population contrasted with
comparable hospitalised patients receiving normal diets
[33]. A Cochrane review in 2000 [34] also raised questions
about the nutritional adequacy of bolus modification. A
2013 systematic review [35] found evidence for thickened
fluids reducing aspiration pneumonia in the acute setting
but not for preventing it in chronic dysphagia. There was
insufficient evidence to determine whether texture-mod-
ified foods or fluids improved hydration or nutrition. As the
evidence for advantages of modified boluses proved weak,
the authors strongly suggested patients should have influ-
ence in clinicians’ diet and fluid prescription decisions.
Patients choosing not to comply with prescriptions for
modified boluses is anecdotally a common issue, with
many expressing a strong dislike of the altered textures [36,
37]. The taste of a variety of thickening agents has been
found unpalatable in some research [38,39]. One study
found very few patients were actually using their pre-
scribed fluids and noted that for the majority of par-
ticipants, the benefits of using thickener (i.e. not
coughing/choking or developing aspiration pneumonia) did
not outweigh the positives of drinking normal fluids. These
authors further suggested patient satisfaction with modified
fluids was important to promote both compliance and
quality of life [39].
The term quality of life refers to how the individual
perceives their life in the framework of their own culture
and ideals and the way in which they live as related to their
goals, expectations of life and standards of living. Quality
of life does not refer only to physical health, but also to
psychological health, social relationships and environment
combined with the individuals’ underlying value system
[40]. Health-related quality of life is a more personal
measure, focussed on the way the disease or disorder af-
fects the individual. Measurement is not completed via
assessment of population health, life expectancy and aeti-
ology of mortality but instead seeks to examine the impact
Qual Life Res
123
of health status on quality of life. It has been suggested that
with understanding of the impact of a disorder in quality of
life, the clinicians’ and clients’ interactions alter. Patients
are more likely to receive comprehensive health care, while
clinicians take more fulfilment in their work [41].
In the context of the clinician working day to day with
dysphagic populations, a better understanding of the impact
of bolus modification on our patients’ health-related quality
of life may enable us to understand the impact of our
treatment choices on the patients’ overall well-being as
well as provide impetus for us to look for creative solutions
which are a better fit for the patient and their family. Thus
far, the question of the effects of bolus modification on
health-related quality of life (HRQoL) in OD has been
largely unexplored.
This article presents a systematic review on the effects
of bolus modification on HRQoL among individuals with
OD.
Methods
To address the question of the effect of bolus modification
on HRQoL in OD, an electronic database search was car-
ried out using PubMed and Embase and all available in-
clusion dates up to September 2012. Search strategies
including free text and database-specific subject headings
(such as Thesaurus and Mesh Terms) used for these
searches are detailed in Table 1.
This resulted in 115 abstracts, excluding duplicates.
Abstracts were then appraised by two reviewers indepen-
dently and accepted for full-text retrieval if, based on re-
viewer consensus, they met the following criteria: (1)
included bolus modification, (2) reported on participants
with OD, (3) reported on HRQoL, (4) were published in
peer-reviewed journals, (5) were written in English, (6)
available in full text. Exclusion criteria were (1) if par-
ticipants had oesophageal dysphagia or oesophageal dys-
phagia mixed with OD, (2) QoL measures were unrelated
to bolus modification and (3) published information was
insufficient to extract data meaningful to the scope of this
study.
The full-text articles were then appraised by both re-
viewers and accepted for inclusion in this systematic re-
view if they were found to continue to meet all inclusion
criteria and not fulfil exclusion criteria on closer ex-
amination. Citations of retrieved articles were also checked
for further references. See Fig. 1for further details on re-
viewing process.
The methodological quality of the included studies was
evaluated by the summarised information of study design
(randomisation, use of comparison or control group, par-
ticipant attrition) and then classified according to the evi-
dence ranking scale by Siwek et al. [42]. Level A refers to
high-quality randomised controlled trials, level B to non-
randomised clinical trials and level C to expert opinions or
consensus articles.
Definitions varied, and some terms were used inter-
changeably in the literature. The following definitions were
agreed upon for the purposes of this study:
•OD refers to a disorder of deglutition. The definition
encompasses abnormalities within the oral and pharyn-
geal phases of swallowing which result in difficulty or
discomfort [43].
•Bolus modification refers to alteration of the viscosity,
particle size, cohesiveness, volume, temperature and/or
pH of food or fluids to be consumed [22].
Table 1 Search strategies in electronic databases
Database Search strategies
PubMed (‘‘Deglutition Disorders’’[Mesh:NoExp] OR ‘‘deglutition disorders’’[All Fields] OR ‘‘oropharyngeal dysphagia’’[All Fields] OR
((‘‘deglutition’’[MeSH Terms] OR ‘‘deglutition’’[All Fields] OR ‘‘swallowing’’[All Fields]) AND (‘‘dysfunction’’[All Fields] OR
‘‘pain’’[MeSH Terms] OR ‘‘pain’’[All Fields] OR ‘‘problem’’[All Fields] OR ‘‘problems’’[All Fields] OR ‘‘disease’’[MeSH Terms]
OR ‘‘disease’’[All Fields] OR ‘‘disorder’’[All Fields] OR ‘‘disease’’[All Fields] OR ‘‘disorders’’[All Fields]))) AND
(((‘‘food’’[MeSH Terms] OR ‘‘food’’[All Fields]) AND (substance[All Fields] OR intake[All Fields] OR ‘‘administration’’[All
Fields] OR consistency[All Fields] OR preparation[All Fields] OR thickener[All Fields] OR thickeners[All Fields] OR
fortification[All Fields])) OR ‘‘amylase-resistant’’[all fields] OR ‘‘viscosity’’[MeSH Terms] OR ‘‘viscosity’’[All Fields] OR
mashed[all fields] OR ‘‘texture modification’’[all fields] OR ‘‘modified texture’’[all fields] OR ‘‘fluid’’[All Fields] OR liquid[all
fields]) AND (‘‘Quality of Life’’[Mesh] OR ‘‘Quality of Life’’[all fields] OR ‘‘health related quality of life’’[all fields] OR
HRQL[All Fields] OR HRQoL[All Fields] OR QoL[all fields])
Embase (*dysphagia/OR ‘‘deglutition disorders’’.ti. OR ‘‘oropharyngeal dysphagia’’.ti. OR ((*swallowing/OR ‘‘deglutition’’.ti. OR
‘‘swallowing’’.ti.) AND (‘‘dysfunction’’.ti. OR *pain/OR ‘‘pain*’’.ti. OR ‘‘problem*’’.ti. OR *diseases/OR ‘‘disease*’’.ti. OR
‘‘disorder*’’.ti.))) AND (exp ‘‘quality of life’’/OR ‘‘Quality of Life’’.mp. OR ‘‘health related quality of life’’.mp. OR HRQL.mp. OR
HRQoL.mp. OR QoL.mp.) AND (((food/OR ‘‘food’’.mp.) AND (substance.mp. OR intake.mp. OR ‘‘administration’’.mp. OR
consistency.mp. OR preparation.mp. OR exp thickening agent/OR thickener*.mp. OR fortification.mp.)) OR ‘‘amylase-
resistant’’.mp. OR exp viscosity/OR ‘‘viscosity’’.mp. OR mashed.mp. OR exp food texture/OR ‘‘texture modification’’.mp. OR
‘‘modified texture’’.mp. OR ‘‘fluid’’.mp. OR liquid.mp. OR liquid/)
Qual Life Res
123
•Quality of life (QoL): ‘a state of complete physical,
mental and social well-being, not merely the absence of
disease or infirmity’ [44].
•HRQoL: the impact of health, illness and treatment on
quality of life [45].
Results
One hundred and thirty-three abstracts were found via
PubMed and Embase. A total of 18 duplicates were found,
resulting in a total of 115 articles, eight of which met the
inclusion criteria. A meta-analysis of the data was not
practicable due to the heterogeneity of the populations,
study designs, assessment tools and lack of standardisation
of terminology used in a relatively small pool of research.
Data that related to the topic of HRQoL and bolus
modification were extracted from the eight accepted arti-
cles, collated and presented descriptively. Table 2provides
an overview of the accepted articles. The studies are listed
alphabetically by lead author (second column). The first
column of the table ranks the level of evidence according
to the ABC level of evidence rating scale devised by Siwek
et al. [41]. The following columns list the number of par-
ticipants, aetiology of OD, the QoL tool(s) used, groups,
treatments (if applicable) and finally the authors’ key
findings.
The final number of studies accepted in this review was
two randomised controlled trials (level A) and six well-
designed non-randomised clinical trials (level B). All au-
thors performed statistical analysis to evaluate the effects
of differing bolus modifications on HRQoL.
The studies in this review altered only textures, that is,
viscosity of fluids and moisture and cohesiveness of foods.
There is a wide variety of terminologies for different grades
of bolus modification in the literature, and it is beyond the
scope of this review to comment on suitable terms; therefore,
the original authors’ terminology for bolus modifications is
retained in their respective columns. However, a hierarchy of
modification from least altered to most altered textures can
generally be determined (i.e. ‘liquid food only’ denotes
greater modification than ‘some solid food’).
Due to the heterogeneity of tools and participant groups,
it is difficult to make a comprehensive statement about
results. Studies that used the same tools still differed on the
subscales which appeared affected by bolus modification
[14,46,49–53], suggesting individual differences between
patient experiences, even when similar dysphagia severity
or management is present. Generally, participants receiving
less modified textures (i.e. normal or nearly unmodified
food/drinks) had considerably better HRQoL than those
receiving more modified textures. Another theme that
emerged was modifications to food textures may have a
more substantial impact to HRQoL than modifications to
fluids; both McHorney et al. [51] and Vanderwegen et al.
[52] compared participant groups receiving modified fluids
and diets. Groups with modified foods showed worse
HRQoL than the modified fluids groups in these studies.
Discussion
A total of eight studies met the inclusion criteria. Consid-
ering the widespread use of bolus modification, this dearth
of research is unfortunate. Therefore, it is timely to ask:
Electronic data base search of
Pubmed and Embase
115 abstracts retrieved.
Abstracts appraised by two
reviewers independently.
Abstracts were rejected:
if there was no indication of OD among any participants (N = 0),
if dysphagia was of esophageal aetiology or all or a majority of the
participants had esophageal dysphagia instead of OD (N=15),
if there was no evidence of a QoL tool used or QoL measures
appeared unrelated to bolus modification (N=28),
if there was no evidence of bolus modification (N= 49).
Reviewers met to determine consensus for
abstract acceptance: 23 abstracts accepted and
the full text articles of the abstracts were
attempted to be retrieved.
Reviewers met to determine consensus for abstract
acceptance: did not include bolus modification or information
provided was insufficient to extract meaningful data about
bolus modification (N=2), no QoL assessment was used (N=
1), participants did not have OD, had OD mixed with
oesophageal dysphagia or data of groups without OD was not
clearly separated from those with OD (N=2).
13 full text articles retrieved, 8 articles
accepted for inclusion in the review.
References of 13 retrieved articles searched by
reviewers for additional relevant studies.
2 references accepted for abstract retrieval. 0 abstracts
accepted for full text article retrieval.
Final inclusion: 8 articles
10 full text
articles were
unable to be
retrieveda
Fig. 1 Methodology: effect of bolus modification on HRQoL in
participants with OD.
a
Articles not in English or full text not available
(texts were abstracts only, posters or conference proceedings)
Qual Life Res
123
Table 2 Effect of bolus modification on HRQoL in individuals with OD
Level of
evidence
Reference Number of participants with
OD (plus aetiology)
a
(HR)QoL assessments Treatment(s)/Groups
b
Authors’ conclusions/key findings
A
(Randomised
controlled trial)
Carlaw et al.
[46]
N=15
Diverse aetiologies (CVA,
spinal cord injury,
traumatic brain injury, head
and neck cancer)
SWAL-QOL
c
: selected subscales
(symptom, burden mental health,
fear and fatigue), composite
scale (comprising all selected
subscales)
The GF Strong Water Protocol (GFSWP):
Participants received thin water (after
oral care) between meals. Liquids with
meals and taken with medications were
thickened
Group I (N =9): GFSWP (14 days).
Thickened fluids and water
Group II (N =6): Standard care (14 days,
control phase). Only thickened fluids
There was a statistically significant difference in
the composite scores, with Group I showing
improved HRQoL and Group II worsened
HRQoL
No statistically significant differences were present
in pre- and post-intervention change in burden,
mental health, or fatigue domains between group
Karagiannis
et al. [47]
N=18
Diverse aetiologies (CVA,
neurologic disease, cancer
or TB)
Four questions (related to QoL):
How have you been feeling? Are
you happy with the drinks? Have
you been feeling thirsty? How
clean does your mouth feel?
Response options: 1–6 faces rating
chart (Wong and Baker, [48])
Group I (N =13): Thickened fluids and
free access to thin water access (5 days)
Group II (N =5): Thickened fluids only
(5 days)
(Prior to allocation, participants in both
groups were restricted to thickened
fluids.)
Prior to allocation, participants indicated moderate
satisfaction in response to the ‘how have you
been feeling’ question and were largely
dissatisfied when asked about drinks, level of
thirst and mouth-cleanliness
After allocation and receiving thin water, Group I
reported statistically significantly higher levels of
satisfaction with their drinks, level of thirst and
mouth-cleanliness compared to Group II. Group
I’s scores indicated higher general satisfaction
than Group II in response to the ‘how have you
been feeling’ question, but the difference was not
statistically significant
B
(Non-randomised
clinical trial)
Carlsson
et al. [49]
N=101
Neurologic disease and head
and neck cancer
MDADI
d
Group I (N =11): Pure
´ed food diet
Group II (N =44): Soft food
Group III (N =46): Regular food
Mean scores across all domains of the MDADI
generally decreased between groups (worsened
HRQoL) with corresponding increases in food
modification (respectively, Groups III, II and I)
Group III compared with Group I showed
statistically significantly higher HRQoL scores
on the MDADI Total score and both Functional
and Physical subscales
Group II compared with Group I showed
statistically significantly higher HRQoL scores
on the Functional subscale
Qual Life Res
123
Table 2 continued
Level of
evidence
Reference Number of participants with
OD (plus aetiology)
a
(HR)QoL assessments Treatment(s)/Groups
b
Authors’ conclusions/key findings
Finizia et al. [50]N=101
Neurologic disease and head
and neck cancer
(Identical subject population
as Carlsson et al. [49])
SWAL-QOL (Swedish
version)
Group I (N =11): Pure
´ed food diet
Group II (N =44): Soft food diet
Group III (N =46): Regular food
Participants with increased texture
modification generally had lower HRQoL
scores than groups with less modified
foods
Group III compared with Group II showed
statistically significantly higher HRQoL
scores on the Food Selection and Symptom
Frequency subscales
Group III compared with Group II showed
statistically significantly higher HRQoL
scores on the subscales Food Selection,
Burden, Mental Health, Social Function,
Eating Desire and the Total score
Group II compared with Group I showed
statistically significantly higher HRQoL
scores on Food Selection and Eating
Duration subscales
McHorney et al. [51]N
Food (Group I, II, II)
=386
N
Liquid (Group IV, V)
=337
Diverse aetiologies
(including cancer, vascular
disease, degenerative
neurologic disease, other
neurologic disease,
obstructive respiratory
disease, trauma, chronic
medical condition,
dementia)
(N
Food
and N
Liquid
selection
from N
Total
=386)
SWAL-QOL Group I (N =214): Regular food
Group II (N =103): Soft food
Group III (N =20): Pure
´ed food
Group IV (N =48): Thickened
liquids
Group V (N =313): Thin liquids
Statistically significant differences in scores
were present on all SWAL-QOL subscales
between Groups I, II and III (food texture
groups). A general trend in reduction in
scores correlating with increasing food
modification was noted, with Group III
showing particularly poor scores
Groups I, II and III differed significantly in
symptom severity. The decrease in
HRQoL scores between Groups I–III
correlated with increased symptom
severity of OD. Dysphagia severity, as
reflected by food texture, was associated
with worse quality of life
Group IV compared to Group V (fluid
modification) showed statistically
significantly lower HRQoL scores on the
Burden and Social Functioning subscales
Thomas et al. [14]N=48–51
Squamous cell carcinoma of
oropharynx
SWAL-QOL, MDADI and
Swallowing domain of the
UW-QOL
e
Groups based on UW-QOL
swallowing scores as reported by
participants;
Group I (N =12–13): ‘Can swallow
liquid food only’
Group II (N =36-38): ‘Cannot
swallow certain solid food’
Group I compared to Group II showed lower
median HRQoL scores on all MDADI
subscales, the SWAL-QOL subscales and
the total score
Qual Life Res
123
Table 2 continued
Level of
evidence
Reference Number of participants with
OD (plus aetiology)
a
(HR)QoL assessments Treatment(s)/Groups
b
Authors’ conclusions/key findings
Vanderwegen et al. [52]N=268
Diverse aetiologies (head and
neck cancer, stroke,
Parkinson’s disease,
Zenker’s diverticulum)
SWAL-QOL (Dutch version) Group I (N =115): Regular food
Group II (N =84): Soft food
Group III (N =38): Pure
´ed food
Group IV (N =38): Thickened
liquid
Group V (N =220): Thin liquids
In all SWAL-QOL subscales, statistically
significant differences were found between
Groups I, II and III. Increasing
modification of food and fluid texture was
associated with worsening HRQoL scores.
Worse QoL was particularly evident for
participants on pure
´ed diet compared with
regular and soft diets
With the exception of sleep, fatigue, and,
demonstrated higher HRQoL among
Group V than Group IV
Increasing dysphagia severity, as reflected
by food texture, was associated with
worsening QoL
Zuydam et al. [53]N=54 Oral and
oropharyngeal squamous
cell cancer
UW-QOL and MDADI Groups based on UW-QOL
swallowing scores as reported by
participants
Group I (N =9): ‘Can swallow
liquid food only’
Group II (N =45): ‘Cannot swallow
certain solid food’
Increased bolus modification was associated
with worse HRQoL; statistically
significant positive correlations were
found between UW-QOL and MDADI
scores, with consistently lower scores in
Group I compared with Group II on the
Emotional, Functional, Physical and Total
scores
a
Adult men and women, unless otherwise stated
b
NPO groups data excluded
c
Swallowing Quality of Life Survey
d
M. D. Anderson Dysphagia Inventory
e
University of Washington Quality of Life Questionnaire
Qual Life Res
123
How do patients perceive this treatment? Is there a time
when the disadvantages will outweigh the benefits?
Although the prevalent theme emerging from the lit-
erature was that modification of food and fluids negatively
impacts HRQoL, this interpretation has several caveats
attached. Firstly, the small number of studies involved
(particularly limited numbers of randomised controlled
trials) limits the power of this finding. Secondly, the dif-
fering terms for bolus modifications that abound in the
literature can make data ambiguous. Further, where par-
ticipants are restricted to more modified textures, this
usually implies greater severity of OD (and likely under-
lying disease), which in turn may imply worse HRQoL.
The included non-randomised trials [14,49–53] all had
subgroups that received a different grade of bolus modifi-
cation. However, the possibility of selection bias cannot be
discounted as these group formations may also be the result
of patient characteristics including disease stage and
severity of OD. Although a pattern of decreased HRQoL
corresponding to increased texture modification was re-
peatedly identified [14,46,47,49–53], this raises the
question of the main contributing cause of the impaired
HRQoL—general disease factors or bolus modification?
Some authors state in their conclusions that groups re-
ceiving increased bolus modification had worse HRQoL
because of increased severity of OD [51,52].
This review includes two level A studies. Both ran-
domised clinical trials by Carlaw et al. [46] and Kara-
giannis et al. [47] identified positive changes in the
HRQoL of the groups permitted thin fluids compared to
participants restricted to thick fluids. However, their re-
sults differed in the scope of HRQoL alterations. Carlaw
et al. [46] found SWAL-QOL subtests measuring swal-
lowing-associated fear and impact of OD symptoms de-
creased in the water protocol phase, but no statistically
significant differences were present between groups on
measures of burden, mental health or fatigue. A statis-
tically significant improvement for participants in the
water protocol phase was present on the composite score.
Conversely, Karagiannis et al. [47] reported improved
well-being to very specific, drinking-related factors only
(thirst, mouth-feel, satisfaction with drinks), not in more
general well-being and attitudes to swallowing. However,
the latter results may have been affected by the use of
an invalidated assessment tool. It should also be noted
that although statistical analysis was completed in both
of these studies, the numbers of participants involved
were very small.
In addition to Carlaw et al. [46] and Karagiannis et al.
[47], who provide valuable information about the impact of
restriction to modified fluids, six level B studies or well-
designed clinical trials were included in this review which
assess both foods and some liquids. Thomas et al. [14]
compared a group restricted to liquid food only to another
group who were ‘unable to swallow’ because ‘it goes down
the wrong way and chokes me’. Scores for these two
groups showed a lack of demarcation, indicating very
similar HRQoL between non-oral patients and those re-
stricted to the most extreme level of bolus modification.
Vanderwegen et al. [52] also noted poorer HRQoL par-
ticularly evident for participants on pure
´ed diet compared
with those on regular and soft diets. The authors concluded
reduced HRQoL scores were associated with increased
swallow dysfunction. They suggested that even for those
patients with severe dysphagia, permanent restriction to
pure
´e should be the last resort.
Carlsson et al. [49], Finizia et al. [50] and Zuydam et al.
[53] also provided evidence for a consistent trend of worse
HRQoL associated with increased bolus modification, de-
spite the use of differing assessment tools. Both Carlsson
et al. [49] and Finizia et al. [50] utilised the same study
population but used different HRQoL assessments
(MDADI and SWAL-QOL, respectively). Regardless of
the differing scopes of the assessments, more modified
textures showed worse HRQoL scores. These results are
comparable with the outcome of a study previously per-
formed by McHorney et al. [51], also using the SWAL-
QOL. A trend was noted that HRQoL worsened when
bolus modification increased. However, there was dis-
agreement between Finizia [50] and McHorney’s et al. [51]
results as to the subscales most affected. These differences
may have been influenced by the more diverse aetiologies
in McHorney et al. [51] study population.
Finally, it is important to note not all QoL tools used by
the before-mentioned studies are oropharyngeal dysphagia-
specific; only the MDADI, SWAL-QOL, Dysphagia Han-
dicap Index and Deglutition Handicap Index are considered
valid measures for HRQoL in OD [54]. In general, the
validity and reliability of an instrument need to be deter-
mined before its use in daily clinic, and research can be
justified.
Conclusion
Increased bolus modification was associated with de-
creased HRQoL among populations with OD. However,
the small number of studies, heterogeneity of the popula-
tions, study designs and tools, and lack of standardisation
of terminology restrict the capacity for strong conclusions
to be drawn. In addition, the severity of OD may have been
related to the applied level of bolus modification. This
creates a causality dilemma regarding the aetiology of
patients’ perception of decreased HRQoL: severity of OD
or impact of bolus modification. As limited information
was able to be found on this specialised topic, an expanded
Qual Life Res
123
search examining the impact of OD on QoL may address
some of these issues.
Clinicians should be aware of the potential negative
impact bolus modification may have on HRQoL and take
this into consideration when choosing to prescribe bolus
modification, particularly in populations (such as chronic
dysphagia) where the balance between swallowing safety
and long-term patients’ well-being may be more indefinite.
Clinicians are encouraged to open a dialogue with their
patients about their HRQoL and where possible make use
of dysphagia-specific QoL tools as part of their assessment
battery for this group to promote holistic assessment and
management of patients with OD.
Recommendations
•More research on HRQoL among participants with
oropharyngeal dysphagia.
•Further exploration of the effects that different bolus
modification management techniques have upon patient
HRQoL outcomes, with particular emphasis on the
impact of modified food textures.
•Future studies examining the impact of bolus modifi-
cation on HRQoL should address the effect disorder
severity may have on QoL results.
•More research is needed addressing patient compliance
with bolus modification as recommended by therapists,
with special emphasis on the patient perceptions of
their self-determination in treatment choices and
patient/caregiver rationale for why individuals do or
do not comply with these recommendations.
•Clinicians should be aware of the benefits and disad-
vantages of bolus modification, including efficacy and
compliance issues as well as its impact on HRQoL.
Acknowledgments The authors declare that they have no conflict of
interest.
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