mannaqure bridging the gap between the dysphagia ...3/29/2018 1 mannaqure dysphagia & dysarthria...

3/29/2018

1

MannaQureDysphagia &

Dysarthria Assessment

Bridging the Gap Between the Monolingual Clinician and the

Spanish-speaking Patient…

Because every event, no matter how large or small is Celebrated

with Food and Fellowshiphttps://youtu.be/HCzfEUz3krY

Carmen Vitton• Carmen completed her Master of Science in Speech-

Language Pathology from Florida State University with an interest in Audiology after beginning her program at the University of Wisconsin-Madison. She completed her Bachelor's in Communication Disorders at the University of Wisconsin-Eau Claire. She was awarded the Accelerated Care Plus (ACP) Innovator of the Year Award in 2013. Rehab Synergies was nominate for Tech Titan’s Technology

Adapter Award in 2015 and 2016.

• Carmen is an American Speech-Language Association ACE Award recipient, has presented at Texas Speech-Language

Hearing Association Conferences and is Resident Assessment Coordinator-Certified (RAC-CT) through the American Association of Nurse Coordinators (AANAC). Carmen is a member of The Dallas Chamber of Commerce Executive Women's Roundtable, along with the following organizations: Dysphagia Research Society, American College of Healthcare Executives and Who's Who Among Top Female Executives.

Jennifer Calvillo Maya• Jennifer earned her Master of Science Degree in

Communication Sciences and Disorders from Texas Christian University in a formal course of study with an emphasis in Culturally and Linguistically Diverse Populations. Jennifer earned her Bachelor's Degree in Communication Sciences and Disorders and a graduate-level minor in Spanish with courses in morphophonology, literary research and bibliography, advanced grammar, composition, and

conversation at Baylor University in Waco, Texas. Jennifer is a member of the Greater Dallas Hispanic Chamber of Commerce. She is RAC-CT through AANAC, a Certified Dementia Practitioner (CDP) through the National Council of Certified Dementia Practitioners and is a member of ASHA's Special Interest Group 14: Communication Disorders and Sciences for Culturally and Linguistically Diverse Populations and Special Interest Group 13: Swallowing and Swallowing Disorders. Jennifer began her career in hospitals and skilled nursing facilities and currently works as a Regional Rehabilitation Director in Texas.

https://youtu.be/HCzfEUz3krY

3/29/2018

2

Lindsey Zamzow Roberts• Lindsey received her Master of Science Degree in Speech-

Language Pathology from the University of North Texas in Denton and her Bachelor's Degree in Speech-Language Pathology with a minor in Psychology from Hardin-Simmons University in Abilene. Lindsey has supervised numerous ASHA Clinical Fellows providing mentorship and guidance to clinicians who are new to the profession. She is currently practicing at a Skilled Nursing Facility providing dysphagia,

cognitive, speech and language treatment to the adult population. She is a member of ASHA's Special Interest Group Division 15: Gerontology. Lindsey is a Certified Alzheimer Educator (CAEd) through National Certification board of Alzheimer Care and a Certified Dementia Practitioner (CDP) through National Council of Certified Dementia Practitioners. Lindsey has received training as a Dementia Care Specialist through the Crisis Prevention Institute and recently provided a continuing education course to Occupational Therapists, Assistants, and SLPs in Texas. She is a member of ASHA's Special Interest Group Division 11: Administration and Supervision.

Purpose of Clinical

Dysphagia/Dysarthria Assessment• To provide an Organized, Goal-Driven evaluation of

interrelated & integrated components of Deglutition

• Aid in Forming part of a Medical Diagnosis;

underlying Pathology

• Abilities/Impairments & Degree

• Identify Motor-Speech Disorders Characterized by

Weakness, Slow Movement, Lack of Coordination as a result of CNS damage

• Establish Medical Necessity for Instrumental Assessment

Introduction to MannaQure

• Comprehensive, norm-referenced

• English and Spanish Dysphagia & Dysarthria Assessment

• Designed to identify, describe and quantify swallowing & oral-function deficits in adults

• Used by monolingual & bilingual SLPs in the

development of POC for Spanish/English speaking patients.

Introduction• SLPs with varying degree of fluency will benefit

• Appropriate variations in regional dialects, cultural differences & accents – which may alter outcomes

– were taken into consideration

• Clinicians require sensitivity to regional and cultural

variations during administration

3/29/2018

3

Rationale• Practice Experience

• Concern – lack of service provision

• Governing Body – resources not available for today’s every-changing health care market

• US Census Bureau 2012:

12-14% of the population in California and Texas alone would be Spanish-speaking only =

Equitable to over 6 Million people, not to mention

the 8 other top-growing states in the US.

Other Fastest Growing States

• Arizona

• Colorado

• Florida

• Illinois

• Nevada

• New Mexico

• New Jersey

• New York

Demand for Bilingual: Increasingly Necessary

Demographic Profile: • 2012 - Of the 150,000 SLPs represented by ASHA, only 7,000 or 5%

indicated that they met the ASHA definition of bilingual service provider

• 2016 - 7%http://www.asha.org/uploadedFiles/Demographic-Profile-Bilingual-Spanish-Service-Members.pdf

ASHA’s Bilingual Service Provider Definition:Requires Native or near-native proficiency in a second language

in lexicon, semantics, phonology, morphology, syntax and pragmatics.

ASHA: No Bilingual Certification See www.ASHA.org/docs/html/RP1989-00205.html

Demand for Bilingual: Increasingly Necessary

Texas Speech-Language-Hearing Association’s Cultural and Linguistic Diversity Committee :

• Trained bilingual SLP must speak a second language fluently

• Has received additional training on the unique development of speech and language skills

• Knows appropriate therapy targets

• Is able to acknowledge how cultural influences affect the therapeutic process

See The Difference Between Spanish-Speaking SLPs and Bilingual SLPs 2014

http://www.asha.org/uploadedFiles/Demographic-Profile-Bilingual-Spanish-Service-Members.pdf

http://www.asha.org/uploadedFiles/Demographic-Profile-Bilingual-Spanish-Service-Members.pdf

3/29/2018

4

ASHA’s 5% (7039) Service Providers:

One-half (50%) were employed in educational

settings:

• 44% Public Schools

• 6% Colleges & Universities

44% Healthcare Settings:

• 25% Non-residential health care facilities

• 12% Hospitals

• 7% Residential healthcare settings

Number of ASHA Bilingual Service Providers

• Texas 1,077

• New York 1,006

• California 857

• Florida 946

It is not certain that these bilingual service providers were familiar with dysphagia/dysarthria assessment &

treatment techniques and/or terminology

Attention Clinicians: Prevalence

ASHA 2008 Special Populations:

• 22% for those fifty years of age and older with an estimated 10 Million Americans evaluated by SLPs each year

ASHA’s Principle of Ethics II, rules B & C:

‘Clinicians should continue life-long learning to develop those skills and knowledge required to provide culturally

and linguistically appropriate services”

• Only13 bilingual programs in the U.S.

Development Process• MannaQure was initially developed in 2013 in order

to identify, describe and quantify swallowing and oral facial functional deficits in the adult Spanish-

speaking population

• MannaQure was published in 2014 with copyright

application submitted secondary to immediate

demand/need in the industry

• Standardized with English-speakers - 2015

3/29/2018

5

Functional Pronunciation Guide

• Created for Clinicians who are not fluent in Spanish

as it pertains to dysphagia and/or dysarthria-related terminology

• Developed to aid SLP in adequate articulation of test items

• Not translated phonetically – direct phonetic

transcription not provided due to lack of consistent vowels & consonants

Functional Pronunciation Guide

• Facilitates confident and comfortable

administration, expression and interpretation of test items.

• SLPs proficient at word, phrase, sentence/bilingual level able to deliver medical terms accurately &

appropriately translated

• Example:

https://youtu.be/yq_mOCRccng

Overview of Product Materials

Patient/Informant Questionnaire

May be administered by:

o Intake Coordinator

o Admissions Personnel

o Social Worker

o Registered Dietitian

o Speech-Language Pathologist

o Occupational Therapist

Overview of Product MaterialsAssessment Subtests:

Communication and Cognitive Evaluation; Receptive & Expressive Language,

Cognitive-Communication Skills

Oral-Mechanism Function Evaluation;

Consisting of 25 response opportunities designed to examine:

✓ Labial (Cranial Nerve VII/Facial Nerve)✓ Lingual (Cranial Nerve XII/Hyoglossal Nerve)✓ Facial Symmetry/Coordination/Function✓ Laryngeal Strength/Elevation/Function

✓ Vocal Quality, Intensity (Cranial Nerve X/Vagus)

✓ Palatial/Respiratory Function (X/Vagus)

https://youtu.be/yq_mOCRccng

3/29/2018

6

Overview of Product MaterialsOral-Facial Stimulability Probe

Intended for patients for whom level of alertness/impairment is

profound – not included in Total Severity Scoring

Examiner’s Manual

Package of Summary ReportsAppendix; provides the examiner with references for additionalpossible responses & medical terminology appropriately and accurately translated for use in your setting

Test Design• Oct 2013 - March 2014 - 145 Total Subjects; 21 years

of age and older, whose country of origin included the U.S., Mexico, Puerto Rico, Costa Rica, Honduras,

Guatemala were examined

• All cohorts primary language was Spanish with

varying dialectical differences

• Of the 145 participants, 95 of them spoke English as a second language

Standardization

Process

Clinical Sample • 85 patients between the ages of 21-99

• Neuro or Respiratory Diagnosis

• Admitted to Acute Care Hospital, Home Health

Agency, or Skilled Nursing Facility

• Onset of signs and symptoms of dysphagia with a Physician’s order for SLP Evaluation with Treatment

as Indicated April 2013-March 2014

3/29/2018

7

Non-Clinical Sample• 5/60 had neuro/respiratory diagnosis

• Each consumed regular texture/thin consistencies without complaint of Signs nor Symptoms of

Dysphagia

• Age range 23-85 years of age

Participating Clinicians: Examiner

Level of Spanish Fluency • 4/12 identified themselves as being fluent with

receptive/expressive language, reading and writing = ASHA’s Bilingual Service Provider definition of

Native or Near-Native Proficiency

• 3 SLPs fluent in receptive /expressive language at

conversational level - not equaling Bilingual Service

Provider

• 5 SLPs non-fluent ; proficient word/phrase level or

sentence levels equal monolingual.

Intra-Rater Reliability• MannaQure was found to have a 95% degree of

intra-rater reliability agreement as evidenced by multiple repetitions of test administration by a single

rater

• Stability observed under same conditions:

manner of presentation scoring, neutral tone,

intensity, sequence of presentation, noise, texture

consistencies presented equal 78.5%, 79, 79/mild

severity

3/29/2018

8

Inter-Rater Reliability• Reliability among examiners effective given common set

of rules for scoring/administration

Three different Clinicians administered battery to three of the same Patients:

Patient 1-Average Total Dysphagia/Dysarthria Severity Level of 81.8 with range of 77.5-85 x 3 SLPs

Patient 2 – Average of 83 with a range of &80-87.5

Patient 3 – Average of 83.6 with a range of 77-91.5

• The three SLPs scoring identified themselves as ranging from mono-lingual to near-native to native proficiency

Internal Consistency Reliability

• Strong with different test items Intended to Measure Disorders characteristic of Dysphagia and Dysarthria as consistently assessing those constructs

• Test deemed suitable for the task of assessment given the reliability producing similar results under consistent conditions

• Soft Palate; .60-.80 - modification of ‘may-pay nay-bay’

• Respiratory; sustain phonation for 15 seconds+

• Oral Mechanics; labial .84, lingual .88, laryngeal .78, respiration .72

• Bedside Evaluation; .95

3/29/2018

9

Test-Retest Reliability• Correlation between 1st set of scores & 2nd set

presented to three patients over time

• Results varied over time due to deficits identified being reduced following 2nd administration

• Increase expected and is Positive Indicator of Effective Treatment

• Relevance to Treatment; Items used to Guide

Interventions & Measure Outcome

• 10th visit Outcome Measure - CMS Claim’s-Based Data

Collection per Middle-Class Tax Relief Act of 2012

Test-Retest Reliability

Battery ValidityPredicted SLPs utilizing the tool during the trial period

would agree:

• Assesses Oral-Mechanism Function, Oral Sensitivity,

Swallow Function

• Effective in Identification of Patient’s Oral & Swallow

Function Deficits necessary to determine Goals for Intervention

• 100% strongly agreed Tool was effective in Identification of Dysphagia & Dysarthria Deficits

Validity

• Obtain Similar Results each time they utilized the tool

• Agreed patients Responded Favorably to their Ability to Present Test Items in Spanish

• Method of Scoring Accurately Depicted Level of Deficits

• Scoring was Intuitive and made sense in a manner they were Able to Measure Over Time

Statements lend support to Content and Construct Validity & Predictive of Performance in Future Therapy

3/29/2018

10

English Clinical Sample• 50 patients ranging in age from 34-101 years

• Neurological or Respiratory Diagnosis

• U.S. country of origin

• Onset Dates of Dysphagia warranting SLP Exam

ranged from May 15, 2015 – July 7, 2015

English Non-Clinical Sample

• 35 Patients ranging in age between 21-93 years

• U.S. country of origin

• Consumed Regular Textures/Thin Liquids

• Self-reported Diagnostic Characteristics of:

Bronchitis, Late-effects CVA

Cerebral Ischemia

Myocardial Infarction

MVA

Lung disease

Dementia

Recommended Screening Guidelines

When to Conduct a Screen:• Pneumonia

• Respiratory Failure

• History of Dysphagia/Dysarthria

• TIA

• CVA

• MS

• Dementia

• ALS

• Myasthenia Gravis

• New Admission

• Enteral Nutrition

• Weight Loss

• Braden Scale Score of 12 or less

• Difficulty Communicating/Slurred Speech

• GERD

• COPD

• CP

3/29/2018

11

Chart Review:• Nursing Notes

• SW Notes

• Hospital Admission/Discharge

records

• Patient/Caregiver

Interview

• RD Notes

• Physician Orders

• H&P

• Minimum Data Set

(MDS)

• Outcome and Assessment Information

Set (OASIS)

• Nursing Assessments;

Fall Risk Score, Pain,

Bladder, Braden

Medication Review• Allergy Relief Tabs

• Cold Medication

• Aspirin

• Amoxicillin

• Baclofen

• Xanax

• Acetaminophen

• Cipro

• Codeine

• Naproxen

Patient Observation:

Signs/Symptoms-Dysphagia• Pocketing of Food

• Poor Head/Neck

Alignment

• Sensation of Food Stuck

in Throat

• Difficulty Managing

Oral Secretions

• Extended Duration of

Intake

• Effortful/Difficulty

Swallowing Meds

• Coughing/Choking

while eating or drinking

• Frequent Throat

Clearing

• Refusal of Meals

• Decreased Appetite

• Impulsivity

• Unexplained/Unintended Weight Loss

• Gurgly Vocal Quality

Observable Signs/Symptoms

• Decreased Respiratory Support

• Facial Grimace

• Facial Asymmetry

• Limited Mandibular Movement

• Decreased Intensity

• Slow Laborious Motor Movements

• Abnormal Pitch/Rhythm

• Poor Dentition

• Decreased O2 Sats

• Malnutrition

• Dehydration

• Watery Eyes

• Runny Nose

• Temp Spikes after

Meals

• Breathy/Nasal/Strained Vocal Quality

3/29/2018

12

Assessment

Assessment Guidelines:

Dysphagia/Dysarthria• Pharyngeal Phase

• Laryngeal

• Respiration

• Bedside Assessment

• Cognitive Status

• Communication

• Oral Phase

• Labial

• Lingual

• Soft Palate

Test Administration/General Instructions

• Spanish/English speaking Patients who demonstrate

mild-profound Oral/Pharyngeal S/S of Dysphagia and/or Dysarthria

• Occupational Therapists specializing in Dysphagia

or SLP treating Dysphagia/Dysarthria may administer

• Clinical competency in Identification/Treatment of

swallowing, respiratory, vocal disorders

• Clinician who speaks little/no Spanish should refer to

the Functional Pronunciation Guide

Test Environment

• Seat Patient upright 90˚ angle with feet on the floor

• Position Patients who must be seen in bed with Head/Neck above Stomach

• Reduce external stimuli & distractions

• Ensure any Dentures or Oral Appliance is in place

• Perform Oral Hygiene as indicated

• Ensure Eyeglasses, Hearing Aids or Auditory Device are available for use

3/29/2018

13

Test TimeVaries depending on:

• Clinician’s Spanish Fluency

• Clinician’s skill level

• Patient’s Level of Alertness, Cooperation

Average of 30 Minutes depending on:

• Familiarity with Tool

• Comfort Level with Functional Pronunciation Guide

• May be delivered in Entirety in One Session

• Attempt to Progress Patient Fairly Rapidly Communication/Cognition portions

• Score item as ‘0’ if No Response in 10-15 Seconds and proceed

Clinical & Universal Precautions

• Handwashing

• Sanitizer containing 60% Alcohol

• Follow Standard and Droplet Precautions Per CDC Guidelines:

Surgical or Procedure Mask, Gown, Gloves should

be worn by Therapists in close contact (less than 3’)

with Patients who have Dx of:

Clostridium Difficile (C diff)

Respiratory Infection

Pneumonia

Test PreparationsPatient/Informant Awareness of Dysphagia/Dysarthria

Questionnaire completed PRIOR to assessment:

• Provide Clinician with Insight & Guidance to Patient

History

• Patient’s Insight to Deficit

• Build Rapport with Patient and/or Caregiver

MannaQure Patient/Staff Interview

1. Do you have difficulty swallowing/communicating?

2. How long have you had difficulty swallowing/communicating?

3. Have you had a recent weight loss?

4. Do you have difficulty managing your saliva?

5. Do you have any difficulty chewing your food?

6. Do you cough when you eat or drink?

7. What do you have difficulty swallowing?

3/29/2018

14

Patient Interview8. What kind of foods are you eating now?

9. What kind of foods did you eat previously?

10. Do you have reflux?

11. Do you have food remaining in your cheek or gums after the swallow?

12. Do you wear dentures during meals?

13. Do you have difficulty with your eyesight?

14. Do you have difficulty speaking?

15. Do people have difficulty understanding you?MannaQure, 2014

Assessment Materials Needed

• Tongue Depressor

• Pen Light

• Stopwatch

• Iced Spoon

• Gloves

• Straw

• Teaspoon

• Cup

MannaQure, 2014

• Trial Textures such as

saltines/graham crackers, diced fruit, pudding

• Trial Consistencies such as thin, nectar, honey, and

pudding thick consistencies

• Standardized Assessment

Test Procedures: Communication and Cognition• Score per item-weighted score; Correct 0.5, or

Incorrect 0

• Cease following 3 Consecutive Incorrect Responses

& Proceed to Next Subtest

• Total Subtest Raw Score/Divide by Total Number of Items, Circle Severity Level

• No Provide Cues or Prompts

• Repetition as necessary due to Clinician’s Spanish-

speaking Level of Fluency

• Refer to Appendix for Spanish Terms for Possible

Responses other than those listed

Oral-Mechanism Function Evaluation

• Visual Demonstration with verbal instruction as

indicated

• Score; Ranging from Able to Perform 0.5-2.5, to

Unable 0

• Items Progress in Degree of Difficulty - scoring weighted accordingly

• Cease following 3 Consecutive Incorrect responses

• Total/Divide by Number of Items, Circle Severity

• Note: Facial Symmetry, Management of Oral

Secretions, Dentition, Vocal Quality, Resonance,

Respiratory Status, Articulatory Imprecision

3/29/2018

15

Bedside Evaluation • Do Not administer to Patients with Profound Deficits

• Least Restrictive Texture/Consistency presentations & proceed to More Restrictive as indicated

• Make determinations regarding Texture/Consistency Modifications and/or Therapeutic Trials considering level of supervision

• Glean information regarding Potential for Improvement

• Discontinue in the Presence of Overt Signs/Symptoms of Aspiration

• Severe S/s; Document & Proceed to Referral Portion; clinical exam alone may differ from instrumental

MannaQure Textures/Consistencies Mirrored National Dysphagia Diet (NDD) American Dietetic Association 2002


Oral PhaseCommunication/SwallowDisturbance

Observable Symptoms

Decreased Labial Control/Seal •Poor Management of Oral Secretions•Leakage of Liquid or Food from the Front or Side of Mouth•Anterior Sulcus Pooling or Residue•Poor Articulatory Precision

Buccal-Facial Paresis/Paralysis •Lateral Sulcus Residue/Pocketing•Biting Cheek Walls

Reduced Oral Sensation •Anterior/Lateral Sulci Residue•Difficulty with Bolus Formation•Suspected Premature Spillage into the Pharynx•Poor Articulatory Precision


Oral PhaseCommunication/Swallow Disturbance

Observable Symptoms

Reduced Lingual Function

•Difficulty with Tongue Tip Elevation•Difficulty with Lateral Movement of the Tongue•Impaired Anterior to Posterior Bolus Movement•Reduced Lingual Coordination and Range of Motion •Oral Apraxia•Residue in Anterior/Lateral Sulci•Residue on the Tongue, Hard or Soft Palate•Piecemeal Deglutition•Suspected Lingual Velar Closure

Dry Mouth/Xerostomia •Reduction in Observable Saliva•Dry, Furrowed or Cracked Tongue•Accumulation of Stringy Mucous•Residue in Anterior/Lateral Sulci •Lingual, Hard or Soft Palate Residue

3/29/2018

16


Oral PhaseCommunication/SwallowDisturbance

Observable Symptoms

Reduced Mandibular Function •Poor/Effortful Mastication•Reduced Lateral Range of Motion•Increased Mastication Time•Poor Articulatory Precision

Reduced Elevation of Soft Palate

•Hyponasality•Hypernasality•Nasal Emissions•Progressively Increased Residue on Palate with

Increased Viscosity or Thicker Foods

Assessment Guidelines: Pharyngeal Phase

Communication/SwallowDisturbance

Observable Symptoms

Delayed or Absent Triggering of the Pharyngeal Swallow

•Vallecular and/or Pyriform Sinus Pooling•Laryngeal Penetration and/or Aspiration BeforeTriggering of the Pharyngeal Swallow

Reduced VelopharyngealFunction

•Leakage of Material through the Nose•Premature Spillage of Material from the OralCavity from the Pharynx

Reduced Tongue Base Retraction

•Unilateral/Bilateral Vallecular Residue

Reduced Pharyngeal Wall Contraction

•Pharyngeal Wall Coating•Residue in the Valleculae and/or PyriformSinuses

Assessment Guidelines: Pharyngeal Phase


Observable Symptoms

Unilateral Pharyngeal Wall Paralysis/Paresis

•Residue in the Left or Right Vallecula and/or Pyriform Sinus•Decreased Pharyngeal Peristalsis

Reduction in Hyoid Movement •Reduced Laryngeal Elevation

Deviant Epiglottic Function •Absence of Epiglottic Function•Incomplete Inversion•Tongue Base Approximation to the Epiglottis•Vallecular Residue•Laryngeal Penetration•Aspiration

Reduced Tongue Base Retraction

•Unilateral/Bilateral Vallecular Residue

Assessment Guidelines:Pharyngeal Phase


Observable Symptoms

Laryngeal Penetration •Coughing/Choking •Wet, Gurgly, Breathy or Harsh Vocal Quality Beforeor After the Triggering of the Pharyngeal Swallow

Aspiration •Coughing/Choking •Wet, Gurgly, Breathy or Harsh Vocal Quality Before/After the Triggering of the Pharyngeal Swallow

Silent Aspiration •No Observable Symptoms•Weight Loss

Reduced Laryngeal Elevation

•Laryngeal Penetration•Aspiration•Residue in the Pyriform Sinuses

Reduced Laryngeal Closure •Laryngeal Penetration•Aspiration

3/29/2018

17

Bedside Subset Scoring

• Circle appropriate Trial Textures/Consistencies

• Ensure all S/s are checked

• Make recommendations as indicated to ENT,

Instrumental Assessment (MBSS, FEES)

• Total Subtest Raw Score/Divide by Total Items, Circle Severity Level

Bedside Evaluation• Assesses Different Phases of Swallow

• Highly Observable Functions weighted more Heavily

• Intra-oral or Intra-pharyngeal performance items are assigned a lesser score

Assessment Guidelines using Stimulability Probe

May be used for Patients with Severe-Profound alertness level

• Assess Level of Sensitivity to determine whether or not the patient is Stimulable for treatment

• Assessment may include:

o Response to cold wet cloth to face (CN V)o Response to iced spoon to lip

o Response to odor using strong scents (CN I)o Observation of swallow elicited with laryngeal massage

o Response to soft touch to face (CN V)o Finger tracking with eye gaze (CN II)

o Response to gag reflex (CN IX) MannaQure, 2014

MannaQure Stimulability Probe

3/29/2018

18

Assessment of Dysarthria

• Imitation of Syllables/Word/Phrases/Sentences

• Sustained Phonation

• Diadochokinetic Rate

• Note During Oral Mechanism-Function Exam:o Facial Symmetry

o Observe Facial Expressions

o Tone

o Strength

o Coordination

o Velopharyngeal Mechanism

o Nasal Airflow

o Laryngeal Function

Assessment of Dysarthria

Recommend Probes of the following Functions:

• Respiration

• Disorders of Phonation: Pitch, Vocal Tremors, Quality

• Articulation

• Prosody

• Resonance

• Speech Intelligibility

• Recording of Conversational Speech Sample and Reading Passage

Hedge, 2006

• Insert Beside scoring example from manual

Total Dysphagia/Dysarthria Degree

of SeverityResults of All Subtests Tallied:

3/29/2018

19

Summary Report

• Includes Recommendations

• NDD Texture/Consistency Level Recommendations

• Concludes with Summary Report for insertion in

Patient’s Medical Record

Summary Report

Interpretation of Results• Report Results

• Relate Results to Cumulative Impact on Diagnostic

and Prognostic Indicators

• Determine Underlying Attributable Cause of

Dysphagia/Dysarthria-related disorders on which to focus treatment

Severity Level Conclusions • Each Subset Percentage of Accuracy may

translate to one of five Severity Levels

• Severity Levels Intentionally Selected to correlate

with Rehab Optima Therapy Documentation Software

• Rehab Optima used by 66% of SNFs in the Nation

(2017); over 40,000 users and over 8,000 sites (2014)

3/29/2018

20

Cultural and Linguistic Diversity

U.S. Census Bureau Statistics

Language Projections to 2020

• In 1980, 23.1 million people (11% of the populations 5 years and older) spoke a Language Other Than English (LOTE) at home

• By 2000, over 70% of the population speaking a LOTE spoke Spanish, Chinese, Japanese, Korean, Vietnamese, or Tagalog (Shin and Bruno, 2003)

• In 2009, 57.1 million people (20% of the population 5 years and older) spoke a (LOTE) at home

• Overall increase of 148%


• The largest numeric increase in the population

speaking a LOTE was for Spanish speakers which

increased by 24.4 million speakers

• The largest percent increase was for Vietnamese

speakers which increased by 533%

• The number of Spanish speakers is projected to

reach between 39 and 42 million in 2020


• Spanish is projected to remain the most commonly spoke language over the next 10 years

• Spanish speakers are projected to represent about 13%

of the total population ages 5 and older to account for over 60% of the population that speaks a LOTE in 2020

• Chinese remains the second most commonly spoken

LOTE, followed by French, Tagalog and Vietnamese

Ortman, J.M., & Shin, H.B., 2011

3/29/2018

21

Additional Statistics

• U.S. is now the second largest Spanish-speaking country second only to Mexico

• U.S. surpasses major Spanish speaking nations including Spain and Columbia

• U.S. is home to 41 million native Spanish speakers

• 11.6 million who are bilingual according to U.S. Census and other government sources

Melendez, 2015

Statistics• By 2050, the U.S. will have the highest Spanish speaking

population in the world at 132.8 million people

• Spanish is the third most used language on the internet

followed by Chinese and English

• Spanish is second to English on social media platforms such as Facebook and Twitter

Melendez, 2015

Bilingual Assessment

Cultural Considerations

• When bilingual assessment is necessary, both the

native and second language should be considered Bedore & Pena, 2008

• Assessment should occur in the native language

“unless it is not feasible to so provide or administer”IDEA, 2006; Prezas & Rojas, 2011

• Sometimes what is considered “best practice” may

not be tangible in a given momentPrezas 2015

3/29/2018

22

Collaboration • Interpreter: a person trained to convey spoken or signed

communications from one language to another.o Via person/phone/videconferencing/electronic device

• Translator: a person trained to translate written text from one language to another.

• Cultural Broker: a person knowledgeable about the patient’s culture and/or speech/language community.

• Linguistic Broker: a person knowledgeable about the patient’s speech community or communication environment. ASHA, Retrieved May 2016

Collaboration• On-Site Colleague: a colleague or other trained on-

site professional who speaks the language that assists with the evaluation.

• Ad Hoc Interpreter: family member, friend or campus volunteer or “chance interpreter” who

speaks the family’s native language. Karlinger, Jacobs, Chen & Mutha, 2007

• Use of assessment materials/sources in patient’s

language

Collaboration Considerations

o When collaborative efforts are necessary, consider:

• Establishing a relationship with the interpreter/translator…etc.

• Spending time with interpreter to discuss

expectations as well as strategize to gain as much information as possible

• Ensure they are fully proficient in both languagesASHA, Retrieved May 2016

Prezas, 2015

Cultural Considerations for

the SLP

3/29/2018

23

Cultural Considerations for the SLP

‘Traditionally the clinician set treatment goals with little or no influence from the client…Today, however,

mutual goal setting is (or should be) the norm”.

Rosenbeck 2017


• …SLPs often face the challenge of providing useful tools to family members of patients with dysphagia.

Riquelme 2004

What do we do?


o Gather information including:

• Patient’s cognitive-communication status

• Patient or family’s view of disability• Impact of their religious group if applicable

• Their view of the role of family members & clinicians

• Gender roles

• Patient’s living situation and family support• Choose culturally relevant materials in their

language

Cultural Considerations: Dysphagia

o Where they shop for food

o Dietary restrictions due to culture or religion

o Dietary preferences dependent upon their culture

o Patient food preferences

o Have family provide home cooked meals if appropriate

3/29/2018

24

Cultural Considerations: Dysphagia Diets

Dietary examples for the Vietnamese culture:

• Common ingredients fish or soy sauce, rice, herbs, fruits and veggies

• Recipes may include lemongrass, mint, ginger, garlic, mint, lime and basil

• Puree suggestion• Chao: Thick porridge of rice; meats, fish, garnish

may be included


Dietary examples for the Vietnamese culture:

• Mechanical Soft suggestions

• Pho: Soup consisting of broth, noodles, herbs and meat

• Ca Kho To: Shallots, fish sauce and spices

• Canh Chua Ca: Sour soup with tamarind flavored broth made with fish, pineapple, tomato and bean sprouts

• Che: Dessert pudding including mung beans, black eyed peas, kidney beans, tapioca, jelly, fruit and coconut cream


Dietary examples for the Indian or Pakistani culture:

• Heavily influenced by region and religion

• Common ingredients include rice, lentils, flat bread,

goat, beef, veggies and tea

• Common spices include red chili powder, turmeric, cardamom, cloves and black pepper



• Puree suggestions

o Daàl: Dried lentils cooked as a thick or thin porridge

o Kheer: Pudding made by boiling rice, broken wheat or vermicelli with milk and sugar

3/29/2018

25




o Nihari: Beef or lamb stew with blend of spices

o Khichdi: Rice and lentils simmered until soft and mushy seasoned with tumeric and salt

o Shami kebab: Small patty of minced meat and

potato or ground chickpea with spicesCarver et al, 2014


Dietary examples for the Mexican culture:

• Common ingredients include tomato, onions,

avocado, cumin, cilantro, garlic and cinnamon

• Puree suggestions

o Arroz con Leche: White rice with milk and cinnamon that can be made into porridge texture

o Camote: Yams with butter and cinnamon that be mashed to puree

98


Dietary examples for the Mexican culture:


o Chorizo con huevo: Ground sausage with scrambled egg

o Arroz con pollo: Minced chicken and fried rice with a

variety of spices

o Capirotada: Bread pudding with brown sugar, cinnamon, almonds, and raisins

99

Cultural Considerations: Dysarthria

o Personal cultural and linguistic background may

influence their assessment and treatment (ex:

dialect)

o Patient/family’s perception of the dysarthria

• Some cultures may view the effects of aging or health conditions to be spiritual in nature rather

than a disorder Harrell, 2014

3/29/2018

26

MannaQure.com

RehabSynergies.com

HomeCEUConnection.com

mannaqure bridging the gap between the dysphagia ...3/29/2018 1 mannaqure dysphagia & dysarthria...

Documents