topic areas and uncertainties - rcslt...3 aspiration aspiration is a consequence of dysphagia and...

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Topic areas and uncertainties

Number Topic area Uncertainty Page number

Identification of dysphagia

1 Identification of swallowing difficulties

There is uncertainty about reliable and valid tools to detect swallowing difficulties including assessments and self-report tools with different patient groups, including those with cognitive difficulties.

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2 Cervical auscultation It is unclear whether listening to the sounds that accompany swallowing using a stethoscope (cervical auscultation) is a reliable and valid tool to diagnose swallowing difficulties in children and adults.

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3 Aspiration Aspiration is a consequence of dysphagia and describes food or liquid going into the lungs rather than the digestive system. There is uncertainty about how common aspiration is and the short and long-term consequences of aspiration in children and adults with dysphagia, including those with head and neck cancer, cerebral palsy, low muscle tone and learning disabilities. For example chest infections can be indicative of aspiration but can also be caused by other factors. It is unclear what increases the risk of aspiration in people with dysphagia. Also, of those people who do have aspiration, we can't predict who will be at a higher risk of pneumonia. There is also uncertainty about the best assessment techniques for identifying aspiration, for example cough reflex testing, videofluroscopy and bedside assessment. There is also uncertainty about what interventions reduce the risk of aspiration.

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Dysphagia interventions/strategies (used across client groups)

4 Use of thickeners to manage dysphagia

Adding a thickener to drinks is a common technique used to help children and adults with dysphagia swallow safely. It is unclear whether drinking thicker fluids helps prevent liquid going into the lungs (aspiration), helps improve the swallow function and/or helps with preventing malnutrition. There is not enough evidence about the risks and potential harms of thickening liquids, for example dehydration. There is uncertainty about when thickeners should be introduced, for example in the acute phase or as a preventative strategy.

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5 Texture modification in the management of dysphagia

Changing the texture of foods is a strategy that is used to manage swallowing problems in adults and children. There is uncertainty about how different textures are described and assessed. It is also unclear how different textures are processed differently by the mouth and swallowing system. More evidence is needed on the effectiveness of changing the texture of foods (for example on nutrition) in different conditions.

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Royal College of Speech and Language Therapists; and

the National Institute for Health Research

Dysphagia Priority Setting Workshop

Wednesday 25th January 2017

RCSLT, 2 White Hart Yard, London, SE1 1NX

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6 Postural changes Speech and language therapists sometimes recommend changes in posture to help people with dysphagia swallow safely. For example a chin tuck posture. More evidence is needed to test the effectiveness of postural changes for different patient groups and the best outcome measures that are used to determine effectiveness.

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7 Non-invasive brain stimulation Non-invasive brain stimulation passes a small current between electrodes on the skull or uses a small current to produce a magnetic field over an area of the brain. There is a lack of evidence to support the safety and effectiveness of non-invasive brain stimulation as a clinical treatment for swallowing difficulties that arise after a stroke.

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8 Neuromuscular Electrical Stimulation

More evidence is needed to determine whether electric stimulation of the muscles (Neuromuscular Electrical Stimulation – NMES) used in swallowing is an effective treatment for children and adults with swallowing difficulties. It is unclear where stimulation should be targeted and what dose of stimulation is safe and most effective.

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9 Dysphagia as a result of intubation or tracheostomy

Patients who have been intubated (with a plastic tube inserted into their windpipe) or had a tracheostomy to maintain an open airway can develop dysphagia. It is unclear what factors increase the risk of dysphagia such as medical conditions and length of intubation.

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10 Tube feeding Treatment for dysphagia often involves tube feeding. This can sometimes be a temporary intervention, followed by a return to oral feeding. More evidence is needed for the most effective interventions to support the transition from tube to oral feeding. For infants and children under three years, there is uncertainty about the long term outcomes of tube feeding. Patients who have degenerative conditions such as motor neuron disease often develop severe dysphagia and are tube fed. The safety and effectiveness (on nutrition, quality of life and survival) of tube feeding is unclear at different stages of the disease.

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Children

11 Children with neurological impairment

Children with neurological impairment such as cerebral palsy and head injury can have difficulties with swallowing safely. Research is needed on the recovery and long-term outcomes of dysphagia in this population. More evidence is needed on what interventions or combinations of interventions (including tube feeding) are effective in supporting eating and drinking, growth and development. It is unclear how much therapy is needed and for how long. Children with cerebral palsy can often have difficulty managing their saliva, resulting in drooling. More research is needed into the effectiveness of therapy for drooling, including botulinum toxin injections and medication.

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12 Cleft lip and palate Cleft life and palate can be associated with difficulties eating and drinking. There is uncertainty about the short and long-term outcomes of feeding aids and intervention. More information is needed on how difficulties with eating and drinking are related to cleft lip, cleft palate and cleft lip and palate.

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13 Behavioural and sensory feeding difficulties

Children can develop difficulties with feeding that are not due to dysphagia for a number of reasons, including early feeding experiences, reflux and autism. These can be behavioural or due to sensory issues. There is uncertainty about effective interventions for behavioural and sensory feeding difficulties.

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14 Feeding difficulties in very early life (neonates)

Some children in very early life can have difficulties feeding. This can be due to being born prematurely or other reasons such as being born with a large tongue (as in Beckwith Wiedemann syndrome). More evidence is needed on the long-term outcomes for children with early feeding problems. There is uncertainty around the most effective interventions for very early feeding difficulties.

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Adults

15 Non-pharmacological swallowing therapy for dysphagia (adults)

It is not clear how effective swallowing therapy is in improving swallow function in different patient groups with dysphagia. For example as a result of a stroke, cancer or as part of a progressive condition such as Parkinson's disease. It is also unclear how different manoeuvres and exercises change swallow function, for example if an effortful swallow is the best approach for patients who have reduced movement of the hyoid bone in the neck when swallowing or the effectiveness of thermal tactile stimulation.

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16 Swallowing therapy in acute and subacute stroke

Dysphagia can occur immediately after a stroke or head injury (in the 'acute' phase) and can recover or can be long-lasting. More evidence is needed on the effectiveness of swallow screening in the acute phase and which interventions are effective at different time points following a stroke or head injury.

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17 Dysphagia management in the elderly

Older people sometimes experience a decline in their ability to swallow. It is not clear what works best to improve safety of swallowing and quality of life, for example postural strategies, exercises, changes to diet and changes to the environment.

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18 Management of dysphagia in head and neck cancer

Patients with head and neck cancer can often experience difficulties swallowing following their treatment. It is not clear whether practicing swallowing exercises before and/or treatment results in better swallowing outcomes after treatment compared with patients who do not carry out exercises. It is also unclear how different surgical techniques for the treatment of head and neck cancer are related to the occurrence of dysphagia following surgery. Dry mouth can occur as a consequence of radiotherapy for head and neck cancer, drug treatments or some medical conditions. The effectiveness of non-drug treatments (such as powered tooth brushing, acupuncture and electrical stimulation) on symptoms and quality of life is unclear.

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19 Parkinson’s disease Parkinson's disease is associated with dysphagia. More research is needed on interventions that don’t involve drug treatments that are used to manage dysphagia with people with Parkinson’s and how effective they are.

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20 Dementia People with dementia can develop difficulties eating and drinking. It is unclear which types or stages of dementia are more likely to be linked with eating and drinking difficulties. More evidence is needed on the most effective ways of assessing and treating dysphagia in this population, for example diagnostic tests such as videofluroscopy. More research is needed into the best treatments such as changes in positioning and diet and tube feeding to help people with dementia carry on eating and drinking, maintain a good quality of life and prevent malnutrition. It is unclear whether interventions are effective in different settings such as homes, acute settings and community care.

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21 Respiratory dysphagia Difficulties with breathing, such as chronic obstructive pulmonary disease (COPD) are linked with dysphagia. It is unclear how many people with conditions such as COPD have dysphagia. It is also unclear how best to prevent aspiration in people with respiratory conditions.

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22 Spinal injuries and surgery Difficulties with swallowing can occur as a result of spinal cord injury and following spine surgery. There is uncertainty about the predictors of recovery of swallow function following surgery and best practice relating the spinal cord injuries.

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23 Dysphagia and adult mental health

Dysphagia is common in adults with mental health difficulties. It is unclear what causes dysphagia and what interventions are effective in treating dysphagia in this population

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24 Effective interventions for dysphagia management in learning disabilities

People with learning disabilities often have dysphagia. It is unclear what the most effective ways are to assess dysphagia in this population. More research is needed into the effectiveness of different interventions such as thickening fluids, oral tasting programmes and risk feeding, including the prevention of admissions to hospital and quality of life.

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1. Identification of swallowing difficulties

Uncertainty There is uncertainty about reliable and valid tools to detect swallowing difficulties including assessments and self-report tools with different patient groups, including those with cognitive difficulties.

Patient group All conditions that are associated with dysphagia

Age range Children and adults

Published research recommendations from systematic reviews

the need for an reliable, standardized, and validated method for detecting oropharyngeal dysphagia (Takizawa et al 2016)

further validation and evaluation of the availability and properties of the self-report dysphagia tools currently available (Keage et al 2015)

further validation and evaluation of appropriate tools to evaluate dysphagia in paediatric populations ( Calvo et al 2016; Heckathorn et al 2016)

practical tools that can be deployed at the bedside and correlate the results with videofluroscopy and flexible endoscopic evaluation of swallowing (FEES) and clinical outcomes such as pneumonia and aspiration events leading to prolonged length of stay (O’Horo et al 2015)

cost-effectiveness of swallowing screening. Potential benefit may be seen not only in terms of pneumonia but also in terms of length of hospital stay, morbidity, and mortality (Geeganage et al 2012)

reliability, validity, and feasibility of swallowing screens and formal swallowing evaluations (Geeganage et al 2012)

assessment tools with the same methodological rigor for all patient groups with dysphagia, and beyond just screening (Geeganage et al 2012)

tools for detecting swallowing in nursing homes (Antunes & Lunet 2012)

how screening features associated with aspiration translates to accuracy in identification of dysphagia (Daniels et al 2012)

continued research is required to determine which water swallow protocol is valid and if the consideration of non-swallowing features improves sensitivity and specificity in the identification of dysphagia not just aspiration (Daniels et al 2012)

further research on screening accuracy of bedside Water Screen Tests (Brodsky et al 2016)

validity and clinical usefulness of bedside clinical examinations. Further research is required (Teasell et al 2013)

further research is required to determine conclusively when a Videofluoroscopic Modified Barium Swallow study should be administered (Teasell et al 2013)

it is unclear whether pulse oximetry is a clinically viable tool for the detection of dysphagia and aspiration following stroke (Teasell et al 2013)

Clinical guidelines RCP Stroke Guidelines (2016): There is good evidence that a multi-item dysphagia screening protocol that includes at least a water intake test of 10 teaspoons and a lingual motor test is more accurate than screening protocols with only a single item (Martino et al, 2014). Additionally a systematic review (Kertscher et al, 2014) and cost

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effectiveness analysis (Wilson and Howe, 2012) suggest that the investigation of dysphagia with instrumental assessments (providing direct imaging for evaluation of swallowing physiology) helps to predict outcomes and improve treatment planning (Bax et al, 2014).

RCSLT Member Survey (2015) and expert review

Speech and Language Therapists submitted uncertainties on this topic that included:

dysphagia assessment techniques

tools that are sensitive to poor transmission of food through the pharynx as well as aspiration

instrumental techniques such as FEES

visual aides to support people with learning difficulties tolerate dysphagia assessment (self-report measures are unreliable)

References Antunes & Lunet (2012) Effects of the Head Lift Exercise on the Swallow Function: A Systematic Review Gerodontology, 29: 247–257

Brodsky et al (2016) Screening Accuracy for Aspiration Using Bedside Water Swallow Tests: A Systematic Review and Meta-Analysis. Chest 150 (1), pp 148– 163.

Calvo I, Conway A, Henriques F, & Walshe M (2016). Diagnostic accuracy of the clinical feeding evaluation in detecting aspiration in children: a systematic review. Developmental Medicine & Child Neurology, 58(6), 541-553

Daniels et al (2012) Valid Items for Screening Dysphagia Risk in Patients with Stroke: A Systematic Review. Stroke. 2012;43:892-897

Geeganage et al (2012). Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD000323. DOI: 10.1002/14651858.CD000323.pub2.

Heckathorn D E, Speyer R, Taylor J, & Cordier R (2016). Systematic Review: Non-Instrumental Swallowing and Feeding Assessments in Pediatrics. Dysphagia, 31(1), 1-23

Keage et al (2015) A Systematic Review of Self-reported Swallowing Assessments in Progressive Neurological Disorders Dysphagia February 2015, Volume 30, Issue 1, pp 27–46

O’Horo et al (2015) Bedside Diagnosis of Dysphagia: A Systematic Review http://onlinelibrary.wiley.com/doi/10.1002/jhm.2313/abstract

Takizawa et al (2016) A Systematic Review of the Prevalence of Oropharyngeal Dysphagia in Stroke, Parkinson’s Disease, Alzheimer’s Disease, Head Injury, and Pneumonia. Dysphagia:31(3):434-41

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2. Cervical auscultation

Uncertainty It is unclear whether listening to the sounds that accompany swallowing using a stethoscope (cervical auscultation) is a reliable and valid tool to diagnose swallowing difficulties in children and adults.




A review by Largarde et al (2016) recommended that more research was needed to find out:

validity of cervical auscultation should in larger patient samples

which outcomes should be measured to find out the validity of this tool

causes of the variance in intra-rater reliability among speech language therapists

validity and reliability of cervical auscultation in infants and children Work by Leslie et al has suggested that clinicians cannot identify the difference between sounds that are related to dysphagia and ‘non–dysphagic’ sounds (e.g. Leslie et al 2007)



reliability of cervical auscultation

value of cervical auscultation in dysphagia assessments

effectiveness of listening to the swallow on the back of the neck vs the front

competency framework for cervical auscultation

References Lagarde, Marloes L (2016). The reliability and validity of cervical auscultation in the diagnosis of dysphagia: a systematic review. Clinical rehabilitation, 30 (2), 199.

Leslie P, Drinnan MJ, Coyle JL, Zammit-Maempel I, Ford GA, Wilson JA (2007). Cervical auscultation synchronized with images from laryngoscopy swallow evaluations. Dysphagia: 22(4):290-8.

Teasell at al (2013) Evidence-Based Review of Stroke Rehabilitation. Dysphagia and Aspiration Following Stroke www.ebrsr.com

http://www.ebrsr.com/

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3. Aspiration

Uncertainty Aspiration is a consequence of dysphagia and describes food or liquid going into the lungs rather than the digestive system. There is uncertainty about how common aspiration is and the short and long-term consequences of aspiration in children and adults with dysphagia, including those with head and neck cancer, cerebral palsy, low muscle tone and learning disabilities. For example chest infections can be indicative of aspiration but can also be caused by other factors. It is unclear what increases the risk of aspiration in people with dysphagia. Also, of those people who do have aspiration, we can't predict who will be at a higher risk of pneumonia. There is also uncertainty about the best assessment techniques for identifying aspiration, for example cough reflex testing, videofluroscopy and bedside assessment. There is also uncertainty about what interventions reduce the risk of aspiration.





prevalence and long-term respiratory effects of aspiration in larger cohorts of children with traumatic brain injury (Morgan 2010)

the best tools for the prediction, identification and treatment of pneumonia (Teasell et al 2013)

validity and clinical usefulness of the water swallowing test and the swallowing provocation test. Further research is required to determine the usefulness of the Gugging Swallowing Screen test at predicting aspiration risk (Teasell et al 2013)

the impact of flexible endoscopic evaluation of swallowing (FEES) on the incidence of pneumonia and factors associated with dysphagia recovery (Teasell et al 2013)

Reporting of proportions of patients who develop pneumonia or have signs of aspiration should be an important outcome measure in all dysphagia and feeding-related trials (Geeganage et al 2012)

RCSLT Member Survey (2015) an expert review


identifying risk of silent aspiration

effectiveness of cough reflex testing in reducing aspiration and aspiration pneumonia rates

impact of cough reflex testing (or equivalent method of screening for risk of silent aspiration) after stroke and after extubation on pneumonia rates and what financial impact this would have in a typical NHS hospital

use of FEES and swallow screening to identify risk

risk factors/predictors for aspiration and aspiration pneumonia

link between aspiration and the development of pneumonia

factors contributing to severity of consequences of aspiration for those people where degree of aspiration cannot be reduced

impact of aspiration on developing lungs and other aspects of childhood development, including relationship with eating and drinking

evidence around aspiration pneumonia /chest infections for people with cerebral palsy and learning disabilities

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is some aspiration safe and under what circumstances?

the impact of aspiration in head and neck patients

link between low muscle tone and aspiration

what difference high-quality dysphagia management makes to aspiration pneumonia post-stroke

informed choice for patients, families and staff following assessment of risk of aspiration

effective support in managing feeding at risk of aspiration

which dysphagia interventions reduce aspiration risk

impact of prophylactic antibiotics in children at risk of aspiration

References Geeganage et al (2012). Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD000323. DOI: 10.1002/14651858.CD000323.pub2.

Morgan (2010). Dysphagia in childhood traumatic brain injury: a reflection on the evidence and its implications for practice. Developmental neurorehabilitation:, 13 (3), 192.

Teasell at al (2013) Evidence-Based Review of Stroke Rehabilitation. Dysphagia and Aspiration Following Stroke. www.ebrsr.com


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4. Use of thickeners to manage dysphagia

Uncertainty Adding a thickener to drinks is a common technique used to help children and adults with dysphagia swallow safely. It is unclear whether drinking thicker fluids helps prevent liquid going into the lungs (aspiration), helps improve the swallow function and/or helps with preventing malnutrition. There is not enough evidence about the risks and potential harms of thickening liquids, for example dehydration. There is uncertainty about when thickeners should be introduced, for example in the acute phase or as a preventative strategy.




effectiveness of using thickeners in patients with head and neck cancer (Barbon & Steele 2015)

whether thickened fluid and texture modified foods in the right patients can provide sufficient energy and protein (Anderson et al 2013)

risk of dehydration when using thickened fluids and how to prevent it (Anderson et al 2013)

possible harms associated with thickened liquids in medically fragile infants, premature infants and children with multiple complex medical diagnoses (Gosa 2011, Clarke & Robinson, 2004)

effects of thickeners on the developing gut as well as the impact of physiological maturation on dysphagia-related aspiration (Gosa 2011)

functional, temporal and physiological effects of different viscosities of thickened liquids on swallowing (Gosa 2011, Steele et al 2015)

matching assessment stimuli to the properties of breast milk or infant formula (Gosa 2011)

specific thickness levels that provide therapeutic benefit by reducing risk for penetration/aspiration and/or improving swallowing function (Cichero et al 2016)

optimal viscosity level for each phenotype of dysphagic patients and descriptors, terminology and viscosity measurements must be standardised (Newman et al 2016)

impact of thickening liquids and texture modification on health-related quality of life (Swan et al 2015)



evidence for thickening fluids in reducing aspiration and pneumonia

effects of thickener on the lungs and gastrointestinal tract

use of thickeners in paediatric dysphagia and the potential impacts on constipation, absorption, hydration and appetite

the safety of thickener use with babies – when and what is safe in terms of gut absorption and reducing the risk of necrotising enterocolitis

links between different types of thickener, fluid intake and risk of dehydration

using thickeners across the lifespan/long-term use

comparing thickener versus no thickener with specific compensatory strategies in food/drinks

use of thickener with people with learning disabilities and dysphagia, including a comparison with oral healthcare and postural strategies

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reasons for using thickener at bedside in the NHS

increasing knowledge of natural thickeners

use of thickened fluids and airway protection strategies in preventing aspiration in respiratory dysphagia

impact of caregiver non-compliance with recommendations for thickened fluids in care homes and nursing homes (e.g. on hydration levels, prevention of chest infections)

determining ‘least risky’ consistencies in risk feeding scenarios (e.g. is greater aspiration of thin fluids less risky than less aspiration of thicker fluids?)

health impact of thickened fluids (cost saving/preventing hospital admissions)

timing of the introduction of thickeners (acute or preventative)

Guidelines The International Dysphagia Diet Standardisation Initiative (IDDSI) has developed globally standardized terminology and definitions for texture-modified foods and liquids applicable to all individuals with dysphagia (Cichero et al 2016).

References Anderson et al (2013) Systematic Review and Evidence Based Recommendations on Texture Modified Foods and Thickened Fluids for Adults (≥18 years) with Oropharyngeal Dysphagia. e-SPEN Journal , Volume 8 , Issue 4 , e127 - e134

Barbon CEA, Steele, CM (2015) Efficacy of Thickened Liquids for Eliminating Aspiration in Head and Neck Cancer: A Systematic Review Otolaryngol Head Neck Surg: 152(2): 211–218.

Cichero et al (2016) Development of International Terminology and Definitions for Texture-Modified Foods and Thickened Fluids Used in Dysphagia Management: The IDDSI Framework. Dysphagia: doi:10.1007/s00455-016-9758-y

Clarke P & Robinson MJ (2004).Thickening milk feeds may cause necrotizing enterocolitis. Archives of Disease in Childhood Fetal and Neonatal Edition, 89(3); pp F280

Gosa, M (2011) Thickened liquids as a treatment for children with dysphagia and associated adverse effects: A systematic review. Infant, child & adolescent nutrition (1941-4064), 3 (6), p. 344.

Kaneoka et al (2016). A systematic review and meta-analysis of pneumonia associated with thin liquid vs. thickened liquid intake in patients who aspirate. Clinical Rehabilitation, 10.1177/0269215516677739

Newman et al (2016). Effect of Bolus Viscosity on the Safety and Efficacy of Swallowing and the Kinematics of the Swallow Response in Patients with Oropharyngeal Dysphagia: White Paper by the European Society for Swallowing Disorders (ESSD). Dysphagia, 31:232-249. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4929168/

Steele et al (2015) The Influence of Food Texture and Liquid Consistency Modification on Swallowing Physiology and Function: A Systematic Review. Dysphagia 30 (1), pp 2–26

Swan et al (2015) Living with oropharyngeal dysphagia: effects of bolus modification on health-related quality of life—a systematic review. Qual Life Res 24:2447–2456

http://dx.doi.org/10.1177%2F0269215516677739

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5. Texture modification in the management of dysphagia

Uncertainty Changing the texture of foods is a strategy that is used to manage swallowing problems in adults and children. There is uncertainty about how different textures are described and assessed. It is also unclear how different textures are processed differently by the mouth and swallowing system. More evidence is needed on the effectiveness of changing the texture of foods (for example on nutrition) in different conditions.




It is still unclear whether texture modified food and thickened fluid in the right patients can provide sufficient energy and protein and thereby prevent malnutrition (Andersen et al 2013)

evidence is needed regarding differences in oral processing behaviours for foods with different textural characteristics (Steele et al 2015).

urgent need to generate empirical evidence to describe different classes of chewable food, so that the corresponding expected differences in oral processing and swallowing behaviour can be defined (Steele et al 2015).

development of valid methods for observing, describing, and measuring oral stage behaviours during assessment tasks that probe a variety of different solid foods (Steele et al 2015).

Impact of thickening liquids and texture modification on health-related quality of life (Swan et al 2015)

evidence on the benefits and risks of modifying the consistency of food and fluids is mandatory to improve the care of people with dementia and dysphagia (Flynn et al 2014)

RCSLT Member Survey (2015)


effective use of texture modification to manage dysphagia

dysphagia management - alternatives to thickeners and texture modification

evidence for recommending two textures at the same time

use of texture modification in deteriorating conditions

capacity in texture modification with people with learning disabilities

benefits of speech and language therapy beyond diet modification/safer eating strategies in late radiotherapy toxicity

determining 'least risk' consistencies in risk feeding scenarios

long-term use of texture modification

patient/carer/parent preferences for texture/fluid modification guidelines e.g. list of specific foods vs. descriptive (such as fork-mashable

Current work and guidelines

The International Dysphagia Diet Standardisation Initiative (IDDSI) has developed globally standardized terminology and definitions for texture-modified foods and liquids applicable to all individuals with dysphagia (Cichero et al 2016).

References Andersen et al (2013) Systematic Review and Evidence Based Recommendations on Texture Modified Foods and Thickened Fluids for Adults (≥18 years) with Oropharyngeal Dysphagia. e-SPEN Journal , Volume 8 , Issue 4 , e127 - e134

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Cichero et al (2016) Development of International Terminology and Definitions for Texture-Modified Foods and Thickened Fluids Used in Dysphagia Management: The IDDSI Framework. Dysphagia: doi:10.1007/s00455-016-9758-y

Flynn et al (2014) Modifying the consistency of food and fluids for swallowing difficulties in dementia. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD011077. DOI: 10.1002/14651858.CD011077.

Steele et al (2015) The Influence of Food Texture and Liquid Consistency Modification on Swallowing Physiology and Function: A Systematic Review. Dysphagia: 30, pp 2–26

Swan et al (2015) Living with oropharyngeal dysphagia: effects of bolus modification on health-related quality of life—a systematic review. Qual Life Res 24:2447–2456

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6. Postural changes

Uncertainty Speech and language therapists sometimes recommend changes in posture to help people with dysphagia swallow safely. For example a chin tuck posture. More evidence is needed to test the effectiveness of postural changes for different patient groups and the best outcome measures that are used to determine effectiveness.




postural alterations and manoeuvres in well-designed and -controlled studies using quantifiable, relevant outcome measures in specific populations (Ashford 2009)

the use of the chin-tuck posture in preventing pneumonia with the population with stroke or other subpopulations of persons with neurologically induced dysphagia (Ashford 2009)

variations of head positioning for improving swallowing function (Teasell et al 2013)



whether oral healthcare and postural changes can be as effective for people with learning disabilities as modified diets/thickened drinks in prevention of aspiration.

importance of ‘upright status’ and whether supine/semi-supine increases risk of aspiration

effectiveness of 45⁰ reclining position and when this should be used

optimal feeding position for neonates

References Ashford J J (2009). Evidence-based systematic review: Oropharyngeal dysphagia behavioral treatments. Part III-impact of dysphagia treatments on populations with neurological disorders. Journal of rehabilitation research and development: 46 (2): 195.

Barkmeier et al (2002). Laryngeal activity during upright vs. supine swallowing. Journal of applied physiology, 93(2), 740-745.

Inagaki et al (2009). Influence of food properties and body position on swallowing-related muscle activity amplitude. J Oral Rehabil, 36(3), 176-183.

Sakuma et al (2010). Relationship between ease of swallowing and deglutition-related muscle activity in various postures. J Oral Rehabil, 37(8), 583-589.

Su et al (2015). Temporal and Physiologic Measurements of Deglutition in the Upright and Supine Position with Videofluoroscopy in Healthy Subjects. Dysphagia. 30(4):438-44



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7. Non-invasive brain stimulation

Uncertainty Non-invasive brain stimulation passes a small current between electrodes on the skull or uses a small current to produce a magnetic field over an area of the brain. There is a lack of evidence to support the safety and effectiveness of non-invasive brain stimulation as a clinical treatment for swallowing difficulties that arise after a stroke. Nb. There are two main types of non-invasive brain stimulation: TDCS (transcranial direct current stimulation) and rTMS (repetitive Transcranial Magnetic Stimulation).

Patient group Stroke

Age range Adults


larger randomized-controlled trials are needed to better understand the effect of non-invasive brain stimulation on post-stroke dysphagia. Future studies should enrol a large, homogeneous population and be well controlled (Pisegna et al 2016)

if non-invasive brain stimulation is best for the patient and why (Pisegna et al 2016)

even though no studies demonstrated statistically significant negative effect sizes or adverse outcomes, safety measures need to be more fully developed and put in place to protect patients before non-invasive brain stimulation can be considered for clinical use (Pisegna et al 2016)

transcranial direct current stimulation may improve dysphagia outcomes, however additional research trials with larger sample sizes are necessary to conclude a beneficial effect (Teasell et al 2013)

future studies would benefit from the standardization of outcomes and stimulation parameters to decrease the variability and heterogeneity of the results and the long-term outcomes (Yang 2015)


None

References Pisegna et al (2016) Effects of non-invasive brain stimulation on post-stroke dysphagia: a systematic review and meta analysis of randomised controlled trials. Clinical neurophysiology: 127, Issue 1

Liao et al (2016). Repetitive transcranial magnetic stimulation as an alternative therapy for dysphagia after stroke: A systematic review and meta-analysis. Clinical Rehabilitation, Apr 25. Pii


Yang (2015) Effectiveness of Non-invasive Brain Stimulation in Dysphagia Subsequent to Stroke: A Systemic Review and Meta-analysis, Dysphagia, 30 (4), pp 383-391.


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8. Neuromuscular Electrical Stimulation

Uncertainty More evidence is needed to determine whether electric stimulation of the muscles (Neuromuscular Electrical Stimulation – NMES) used in swallowing is an effective treatment for children and adults with swallowing difficulties. It is unclear where stimulation should be targeted and what dose of stimulation is safe and most effective.




mixed findings reported across studies suggest that some forms of sensory NMES have the potential to benefit individuals with dysphagia, but that much more research is needed to elucidate the stimulation parameters best suited to the various outcomes of interest (Clark et al 2009).

treatment dosage and how optimal dosage may vary across stimulation parameters and populations (Clark et al 2009).

whether the advantage of localized stimulation provided by intramuscular NMES outweighs the convenience afforded by surface NMES (Clark et al 2009).

when in the disease process or recovery NMES is most beneficial and whether optimal timing varies across populations (Clark et al 2009).

benefits of NMES in children (Clark et al 2009).

some of the participants in the studies published are mixed acquired and progressive disorders which impacts on the usefulness of interpreting the results (Ludlow et al 2007)

it is unclear whether transcutaneous electrical stimulation improves swallowing function, or reduces the incidence of aspiration pneumonia (Teasell et al 2013)

evidence is insufficient to indicate that neuromuscular electrical stimulation alone is superior to swallow therapy (Chen et al 2016)

high-quality studies of neuromuscular electrical stimulation with larger sample sizes (Tan et al 2013).

the effects of Pharyngeal Electrical Stimulation (PES) on longer-term aspiration and dysphagia are not clear and need to be studied in future trials (Scutt et al 2015)

A RCT has found no effect of PES on aspiration or clinical dysphagia and futher studies are planned in stroke patients with severe dysphagia or those requiring intensive care including ventilation (Bath et al 2016)



use and efficacy of NMES

NMES for specific aetiologies

the impact of stimulating muscles in a different order to typical neurological activation on efficacy and long-term effects

effectiveness of Pharyngeal Electrical Stimulation (PES)

Clinical guidelines NICE - Transcutaneous Neuromuscular Electrical Stimulation (NMES) for oropharyngeal dysphagia Interventional procedures guidance [IPG490] 1.1 Current evidence on the efficacy of transcutaneous neuromuscular electrical stimulation (NMES) for oropharyngeal dysphagia is limited in quality. The evidence on safety is limited in both quality and quantity but there were

17

no major safety concerns. Therefore, this procedure should only be used with special arrangements for clinical governance, consent and audit or research. 1.2 Clinicians wishing to undertake transcutaneous NMES for oropharyngeal dysphagia should take the following actions.

Inform the clinical governance leads in their NHS trusts.

Ensure that patients understand the uncertainty about the procedure's safety and efficacy and provide them with clear written information. In addition, the use of NICE's information for the public is recommended.

Audit and review clinical outcomes of all patients having transcutaneous NMES for oropharyngeal dysphagia

1.3 NICE encourages further research into transcutaneous NMES for oropharyngeal dysphagia, which should clearly document the indications for treatment and the details of patient selection. Research should document the timing of initiation of treatment after onset of symptoms, as well as precise information about the procedure technique. Outcome measures should include freedom from tube feeding, quality of life and duration of treatment effect.

References Bath et al (2016). Pharyngeal Electrical Stimulation for Treatment of Dysphagia in Subacute Stroke. Stroke: 47:1562-1570.

Chen Y, et al (2016). The effects of surface neuromuscular electrical stimulation on post-stroke dysphagia: systematic review and meta-analysis. Clinical Rehabilitation. 30(1): p. 24-35.

Clark et al (2009) Evidence-Based Systematic Review: Effects of Neuromuscular Electrical Stimulation on Swallowing and Neural Activation American Journal of Speech-Language Pathology: Vol. 18, 361-375.

Ludlow et al (2007). Effects of surface electrical stimulation both at rest and during swallowing in chronic pharyngeal dysphagia. Dysphagia, 22(1); pp 1 – 10

Scutt et al (2015) Pharyngeal Electrical Stimulation for Treatment of Poststroke Dysphagia: Individual Patient Data Meta-Analysis of Randomised Controlled Trials. Stroke Research and Treatment http://dx.doi.org/10.1155/2015/429053

Tan et al (2016) Transcutaneous neuromuscular electrical stimulation can improve swallowing function in patients with dysphagia caused by non-stroke diseases. A meta-analysis. J Oral Rehabil. 40 (6), 472-80.


Yi-Wen et al (2016). The effects of surface neuromuscular electrical stimulation on post-stroke dysphagia: a systemic review and meta-analysis, Clinical Rehabilitation, 2016, Vol. 30(1) 24–35

http://dx.doi.org/10.1155/2015/429053


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9. Dysphagia as a result of intubation or tracheostomy

Uncertainty Patients who have been intubated (with a plastic tube inserted into their windpipe) or had a tracheostomy to maintain an open airway can develop dysphagia. It is unclear what factors increase the risk of dysphagia such as medical conditions and length of intubation.

Patient group Patients who have been intubated or have had a tracheostomy



high-quality studies using homogeneous patient populations to assess the influence of prolonged intubation on dysphagia and to determine whether select medical comorbidities put patients at greater risk are needed (Skoretz 2010).

empirical evidence for or against the use of the Modified Evans Blue Dye Test is not strong enough to direct clinical practice. There is a strong necessity for further well-designed diagnostic accuracy studies using a standardised protocol to bridge the gap between clinical practice and documented evidence (Bechet et al 2016)



effects of tracheostomy on swallowing and management

when to deflate a tracheostomy cuff to advance weaning even when poor secretion management is suspected

tracheostomy care and related practice

use of tracheostomy speaking valves for supporting improved upper airway function/strength

role of the speech and language therapist in tracheostomy management and rehabilitation

how to up-skill community paediatric speech and language therapists in tracheostomy competence

incident and presentation of post-extubation dysphagia in neonates

use of blue dye test in assessment

References Bechet et al (2016). Diagnostic Accuracy of the Modified Evan’s Blue Dye Test in Detecting Aspiration in Patients with Tracheostomy: A Systematic Review of the Evidence. Dysphagia (2016) 31: 721.

Bordon et al (2011). Swallowing dysfunction after prolonged intubation: analysis of risk factors in trauma patients. Am J Surg, 202. doi:10.1016/j.amjsurg.2011.06.030

Brodsky et al (2014). Factors associated with swallowing assessment after oral endotracheal intubation and mechanical ventilation for acute lung injury. Ann Am Thorac Soc, 11. doi:10.1513/AnnalsATS.201406-274OC

Daly et al (2016). Finding the red flags: swallowing difficulties after cardiac surgery in patients with prolonged intubation. J Crit Care, 31. doi:10.1016/j.jcrc.2015.10.008

Ding & Logemann (2005). Swallow physiology in patients with trach cuff inflated or deflated: a retrospective study. Head Neck, 27(9), 809-813.

Moraes et al (2013). Clinical prognostic indicators of dysphagia following prolonged orotracheal intubation in ICU patients. Critical Care, 17(R243).

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Scheel et al (2015). Endoscopic Assessment of Swallowing After Prolonged Intubation in the ICU Setting. Ann Otol Rhinol Laryngol. doi:10.1177/0003489415596755

Skoretz, SA (2010). The incidence of dysphagia following endotracheal intubation: a systematic review. Chest (0012-3692), 137 (3), p. 665.

Solh et al (2003). Swallowing disorders post orotracheal intubation in the elderly. Intensive Care Med, 29. doi:10.1007/s00134-003-1870-4

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10. Tube feeding

Uncertainty Treatment for dysphagia often involves tube feeding. This can sometimes be a temporary intervention, followed by a return to oral feeding. More evidence is needed for the most effective interventions to support the transition from tube to oral feeding. For infants and children under three years, there is uncertainty about the long term outcomes of tube feeding. Patients who have degenerative conditions such as motor neuron disease often develop severe dysphagia and are tube fed. The safety and effectiveness (on nutrition, quality of life and survival) of tube feeding is unclear at different stages of the disease.

Patient group Patients with dysphagia and are tube fed



further randomised clinical trials of PEG versus nasogastric tube feeding for adults with swallowing disturbances should be conducted with rigorous observation of internal validity. They should include previously planned and executed follow-up periods (Gomes Jr et al 2015)

further RCTs on specific groups such as children who have cerebral palsy need to be undertaken to evaluate fully the impact of both nutritional and health benefits ( Gantasala et al, 2013).

factors other than PEG that affect survival and the possible survival advantage of Radiologically Inserted Gastrostomy (RIG) (Katzberg & Benatar 2011)

safety and effectiveness of PEG insertion in those with Amyotrophic Lateral Sclerosis (ALS), within the context of a prospective clinical trial is required, with proper adjustment for possible confounders, most importantly severity of disease (Katzberg & Benatar 2011)

prospective cohort studies to compare outcomes in patients who have a PEG placed at different levels of nutrition or malnutrition (Katzberg & Benatar 2011)

effects of PEG placement on patients and their caretakers as well as on quality of life need to be evaluated in a controlled fashion (Katzberg & Benatar 2011)



dysphagia interventions moving from tube feeding to oral feeding

impact of early interventions on reducing need for tube feeding and nutritional intake

long term outcomes for infants and children under the age of three years who have tube feeding on sensory processing in relation to oral feeding, oral aversions

longitudinal studies on managing tube weaning e.g. promotion of a good, oral sensory programme to reduce oral aversions

swallow management in nursing home at end of life care

impact of PEG on quality of life in all progressive neurological conditions

timing of starting of non-oral feeding nasogastric/PEG and outcomes.

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aspiration risk and taster amounts for people who are tube fed via a PEG

decision making when considering PEG feeding for dysphagia

grief counselling for the loss of oral feeding

risks and benefits of homemade tube feeding

Guidelines National Clinical Guideline for Stroke, 5th edition (RCP 2016): Cochrane reviews have compared routes of enteral tube feeding. One reviewed 11 RCTs comparing gastrostomy versus nasogastric tubes in adults with swallowing difficulties (Gomes Jr et al, 2015), including four trials in people after stroke (Norton et al, 1996, Bath et al, 2000,Dennis et al, 2005, Hamidon et al, 2006). Although gastrostomy reduced intervention failure, there was no difference between the interventions in weight change, pneumonia or mortality. Most studies were small with considerable heterogeneity and methodological limitations. Geeganage et al (2012) reviewed five RCTs comparing gastrostomy with nasogastric tube feeding in acute and sub-acute stroke. Although gastrostomy feeding was associated with fewer feeding failures, less gastrointestinal bleeding and fewer pressure sores, there was no significant difference in length of hospital stay, dependency or mortality. Beavan et al (2010) conducted a multicentre RCT with people with stroke who required nasogastric tube feeding due to dysphagia. In a sample of 104 people, those who had a nasogastric tube secured using a nasal bridle received a higher proportion of prescribed feed and fluid compared to the control group who had tubes secured using standard practice. Mahoney et al (2015) identified the need for training and protocols in confirming the placement and securing of nasogastric tubes. A Cochrane review by Good et al (2014) reviewed medically assisted hydration in adults receiving palliative care, and concluded there was no clear evidence of benefit with assisted hydration as problems from side effects can be as distressing as symptoms associated with withholding fluids. Guidance for critical care:

Miller, K. R., Kiraly, L. N., Lowen, C. C., Martindale, R. G., & McClave, S. A. (2011). “CAN WE FEED?” A Mnemonic to Merge Nutrition and Intensive Care Assessment of the Critically Ill Patient. Journal of Parenteral & Enteral Nutrition, 35(5), 643-659. doi:10.1177/0148607111414136

References Ezekiel Wong Toh Yoon et al (2016). Outcome of Rehabilitation and Swallowing Therapy after Percutaneous Endoscopic Gastrostomy in Dysphagia Patients Dysphagia 31:730–736

Gantasala et al (2013). Gastrostomy feeding versus oral feeding alone for children with cerebral palsy. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD003943.

Gomes Jr et al (2015). Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances Cochrane Database of Systematic Reviews 2015, Issue 5. Art. No.: CD008096.

Good et al (2014). Medically assisted hydration for adult palliative care

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patients. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD006273

Katzberg & Benatar (2011). Enteral tube feeding for amyotrophic lateral sclerosis/motor neuron disease Cochrane Database of Systematic Reviews 2011, Issue 1. Art. No.: CD004030

Mahant, S., Jovcevska, V., & Cohen, E. (2011). Decision-making around gastrostomy-feeding in children with neurologic disabilities. Pediatrics, 127(6), e1471-1481. doi:10.1542/peds.2010-3007

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11. Children with neurological impairment

Uncertainty Children with neurological impairment such as cerebral palsy and head injury can have difficulties with swallowing safely. Research is needed on the recovery and long-term outcomes of dysphagia in this population. More evidence is needed on what interventions or combinations of interventions (including tube feeding) are effective in supporting eating and drinking, growth and development. It is unclear how much therapy is needed and for how long. Children with cerebral palsy can often have difficulty managing their saliva, resulting in drooling. More research is needed into the effectiveness of therapy for drooling, including botulinum toxin injections and medication.

Patient group Children and young people with neurological impairment and dysphagia

Age range Children and young people


large participant samples to robustly define recovery and prognosis for paediatric dysphagia post-TBI (Morgan et al 2010)

higher-quality, appropriately statistically powered RCTs to evaluate the efficacy of interventions for oropharyngeal dysphagia (Morgan et al 2010)

effectiveness of multimodal (medical, oral-motor, behavioural, environmental interventions and adaptations) approaches to improve feeding performance, growth, and development. Well-designed RCTs with long-term outcomes should be undertaken as well in order to evaluate the effectiveness of these multimodal approaches (Snider et al 2011)

trial of gastrostomy feeding versus oral feeding for children with cerebral palsy to resolve the current uncertainties about medical management for children with cerebral palsy who have physical difficulties with eating (Gantasala et al 2013)

optimal treatment intensity and duration of therapy. There is also a need for further debate and discussion regarding the current clinical context for service delivery, given that the majority of interventions are still offered on a weekly or two-weekly basis (Morgan et al 2010)

the number of botulinum toxin injections, and the number of repeated doses of medication needed to manage drooling effectively and the adverse effects of repeated botulinum toxin injections and repeated doses of medications. Measurement of the client/carer satisfaction with these interventions (Walshe et al 2012)

new service delivery models (for example, group versus individual treatment) that may enhance access to therapy services for patients and their families. Telehealth is one such option that has not yet been explored in this group, which may help to increase choice and enhance access to therapy services and facilitate a range of socioeconomic benefits (Morgan et al 2010)

interventions based in real-world settings such as the school and home environment that are most salient to the participant (Morgan et al 2010)

More research is needed particularly in the area of child / carer satisfaction and impact of interventions on quality of life (Walshe et al 2012)

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Identified research priorities

The Childhood Disability (James Lind Alliance (JLA), 2014) identified the following as their 20th priority:

Are oro-motor treatment strategies (e.g. oral motor exercises, sensory stimulation, sensorimotor activities etc.) effective to improve eating and drinking or speech for children and young people with neurodisability? Are there identifiable subgroups that benefit more from the strategies?



effect new drugs have on swallowing in the population with physical disability e.g. Sinemet in children with cerebral palsy

paediatric dysphagia interventions

effective impairment based therapies for children with acquired brain injury

dysphagia assessment and intervention for adults with cerebral palsy

paediatric dysphagia particularly acute

dysphagia treatments shown to influence neuroplasticity

effectiveness of therapy in improving swallow safety in infants/children

use of oral motor exercises in children with hypotonia and saliva difficulties

parental confidence with supporting children with eating, drinking and feeding difficulties

early interventions for children at risk of dysphagia

management of feeding and swallowing difficulties in medically complex children/multiple co-morbidities (e.g. cleft + trisomy 21)

syringe feeding evidence and guidelines

parent delivered feeding and swallowing interventions

Ongoing research NIHR NETSCC Topic 16004718: Interventions to improve eating ability in children with neurodisability. Receiving applications

References Gantasala et al (2013). Gastrostomy feeding versus oral feeding alone for children with cerebral palsy. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD003943.

Morgan, AT (2010). Dysphagia in childhood traumatic brain injury: a reflection on the evidence and its implications for practice. Developmental neurorehabilitation:, 13 (3), 192.

Snider et al (2010). Feeding Interventions for Children with Cerebral Palsy: A Review of the Evidence. Physical & Occupational Therapy In Pediatrics Vol. 31 , Iss. 1,2011

Walshe et al (2012) Interventions for drooling in children with cerebral palsy. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD008624

http://www.jla.nihr.ac.uk/priority-setting-partnerships/childhood-disability

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12. Cleft lip and palate

Uncertainty Cleft life and palate can be associated with difficulties eating and drinking. There is uncertainty about the short and long-term outcomes of feeding aids and intervention. More information is needed on how difficulties with eating and drinking are related to cleft lip, cleft palate and cleft lip and palate.

Patient group Cleft lip and palate

Age range Children


Further large, high quality randomised controlled trials, with developmental and behavioural outcomes measured well into childhood, are needed to assess the effectiveness of feeding aids and support for babies with clefts of the lip, palate or lip and palate (Bessell et al 2011)

Intervention studies which provide adequate data for subgroup analysis, comparing outcomes for cleft lip, cleft palate and cleft lip and palate (Bessell et al 2011)


The Cleft Lip & Palate (JLA, 2012) identified the following as their 9th priority:

What is the best way to manage infants with a cleft of the lip and/or palate undergoing primary surgery before, during and after hospital e.g. fluids, pain control, antibiotics, probiotics, arm splints, feeding practices?



impact of early/infant intervention for children born with cleft palate

management of clefts presenting with co-morbidities/additional dysphagia risks


References Bessell et al (2011). Feeding interventions for growth and development in infants with cleft lip, cleft palate or cleft lip and palate. Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD003315

http://www.jla.nihr.ac.uk/priority-setting-partnerships/cleft-lip-and-palate

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13. Behavioural and sensory feeding difficulties

Uncertainty Children can develop difficulties with feeding that are not due to dysphagia for a number of reasons, including early feeding experiences, reflux and autism. These can be behavioural or due to sensory issues. There is uncertainty about effective interventions for behavioural and sensory feeding difficulties.

Patient group Children and young people with feeding difficulties

Age range Children


prospective RCTs on psychological approaches to manage behavioural/sensory feeding problems with specific intervention protocols and some longitudinal data would be beneficial (Lukens & Silverman, 2014).

before and after measures , especially when nutritional manipulation is involved would be beneficial ( Lukens & Silverman, 2014)

studies to date have small populations of participants, or focus on very specific populations, e.g. children who have autism and sensory feeding problems an early history of chronic reflux, or have great variation in the sample. Further research in this area is crucial, particularly in relation to premature infants who present with persistent feeding problems (Lukens & Silverman, 2014).



- children with aversive feeding behaviours from early feeding experiences

- prevention of behavioural feeding issues - traditional weaning versus baby led weaning in babies with reflux - VERVE child interaction in feeding - intervention approaches for sensory based feeding disorders - sensory feeding difficulties/autism - therapy for behavioural feeding difficulties in autism - solution-focussed brief therapy for feeding difficulties - parental confidence with supporting children with eating, drinking and

feeding difficulties - improved identification of children at risk of behavioural and sensory

feeding difficulties - prevention of behavioural and sensory feeding difficulties

References Lukens, C. T., & Silverman, A. H. (2014). Systematic review of psychological interventions for pediatric feeding problems. Journal of Pediatric Psychology, jsu040.

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14. Feeding difficulties in very early life (neonates)

Uncertainty Some children in very early life can have difficulties feeding. This can be due to being born prematurely or other reasons such as being born with a large tongue (as in Beckwith Wiedemann syndrome). More evidence is needed on the long-term outcomes for children with early feeding problems. There is uncertainty around the most effective interventions for very early feeding difficulties.

Patient group Neonates

Age range Infants born < 37weeks GA to 1 month corrected age


oral motor interventions such as non-nutritive sucking have some benefits with reduction in the need for tube feeds and quicker transition to full oral feeding and therefore warrant further research (Arvedson et al 2010; Greene et al 2016; Pinelli & Symington 2005).

longitudinal studies should be undertaken to identify when problems persist and/or resolve (Greene et al 2016).

specific strategies in relation to weight gain and type of feeding, i.e. breast vs. bottle (Greene et al 2016).

benefits of non-nutritive sucking in relation to physiological stability and nutritional benefits such as weight gain (Foster et al 2016; Pinelli & Symington, 2005).

Impact of an oral readiness protocol on the introduction of oral feeding for infants born preterm (Crowe et al 2012).

benefits and risks of sending infants home early with enteral feeding, and gradual oral weaning ( Collins et al 2015).

Use of cup feeding to establish breast feeding compared with gavage feeding (Collins et al 2016).


The Preterm Birth (JLA, 2014) identified the following as priorities:

What is the optimum milk feeding strategy and guidance (including quantity and speed of feeding and use of donor and formula milk) for the best long-term outcomes of premature babies?

What type of support is most effective at improving breast feeding for premature babies?



long-term oral feeding outcomes for children born very prematurely

evidence of impact of high flow therapy on feeding in infants and children

feeding patterns in infants who are known to neonatal abstinence services

feeding intervention in infants with macroglossia (due to Beckwith Wiedemann syndrome) after birth and why they don't they succeed with breastfeeding



breathing and feeding

http://www.jla.nihr.ac.uk/priority-setting-partnerships/preterm-birth

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studies which focus on non-nutritive sucking with infant participants who have typical types of feeding disorders that SLTs would assess and manage

important factors necessary for the introduction of oral feeding, i.e. physiological stability, development of infant states; weight and nutrition factors; normal developmental pathway that infants follow (ie. swallowing developing before sucking)

nutritive and non-nutritive skills in infants

minimally invasive instrumental swallowing assessments appropriate for the neonatal setting

identification of neonates most likely to benefit from feeding and swallowing interventions

identification of aspiration in neonates

signs of aspiration on neonatal chest x-ray

early intensive therapies for infants at risk of feeding and swallowing difficulties

management of feeding and swallowing problems in medically complex infants with multiple co-morbidities

optimal feeding position for neonates (e.g. elevated sidelying)

optimal feeding duration for neonates developing oral feeding (e.g. maximum duration of oral feeding sessions)

differential diagnosis of dysphagia vs reflux vs 'colic' in infants

impact of parental involvement in neonatal therapies

References Arvedson et al (2010). Evidence-based systematic review: effects of oral motor interventions on feeding and swallowing in preterm infants. American Journal of speech-language pathology, 19(4), 321-340.

Collins et al (2016). Avoidance of bottles during the establishment of breast feeds in preterm infants. Cochrane Database of Systematic Reviews 2016, Issue 10. Art. No.: CD005252

Collins et al (2015). Early discharge with home support of gavage feeding for stable preterm infants who have not established full oral feeds. Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD003743

Crowe et al (2012). Instruments for assessing readiness to commence suck feeds in preterm infants: effects on time to establish full oral feeding and duration of hospitalisation. Cochrane Database of Systematic Reviews 2012, Issue 4. Art: CD005586.

Foster et al (2016). Non‐nutritive sucking for increasing physiologic stability and nutrition in preterm infants. Cochrane Database of Systematic Reviews 2016, Issue 10. Art. No.: CD001071.

Greene et al (2016). Oral stimulation for promoting oral feeding in preterm infants. Cochrane Database of Systematic Reviews 2016, Issue 9. Art. No.: CD009720.

Pinelli & Symington (2005). Non-nutritive Sucking for promoting physiologic stability and nutrition in preterm infants. The Cochrane Database of Systematic Reviews, Issue 4, Art. No. CD001071, Pub 2, DOI: 10.1002/14651858. CD001071.Pub

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15. Non-pharmacological swallowing therapy for dysphagia (adults)

Uncertainty It is not clear how effective swallowing therapy is in improving swallow function in different patient groups with dysphagia. For example as a result of a stroke, cancer or as part of a progressive condition such as Parkinson's disease. It is also unclear how different manoeuvres and exercises change swallow function, for example if an effortful swallow is the best approach for patients who have reduced movement of the hyoid bone in the neck when swallowing or the effectiveness of thermal tactile stimulation.


Age range Adults


proof of the efficacy of non-pharmacological swallowing therapy for swallowing disorders in Parkinson's patients in large randomised placebo-controlled trials are required (Deane et al 2001)

the precise effects of the head lift exercise both on cancer and stroke patients (Antunes & Lunet 2012)

studies need to be replicated considering more carefully the variables that may influence and confound the outcomes of the head lift exercise, such as age, gender, duration of dysphagia, aetiology of dysphagia, initial severity of dysphagia, mental status, physical status, respiratory status and patient compliance with the home protocol. (Antunes & Lunet 2012)

future research on behavioural dysphagia treatments should focus on clinical trials that target specific cohorts of subjects i.e. head and neck cancer (McCabe 2009)

the hypothesis that patients with dysphagia with decreased hyoid movement may benefit from the effortful swallow manoeuvre because of the increased submental activation is based on physiological outcomes and requires appropriate testing (Wheeler-Hegland 2009)

future research should include interrater reliability measures; good design principles; and quantifiable, relevant outcome measures in the study of postural alterations and manoeuvres for the treatment of oropharyngeal dysphagia (Wheeler-Hegland 2009)

many questions about the effects of therapy in oropharyngeal dysphagia as applied by speech and language therapists remain unanswered. Although some positive significant outcome studies have been published, there is a need for further research using randomized controlled trials (Speyer et al 2010)

the benefit of high intensity swallowing therapy with dietary prescription at improving swallowing ability and return to a normal diet in patients with dysphagia post stroke (Teasell et al 2013)

Quality-of-life measures provide useful information about patient important outcomes and may help explain differences in adherence to treatment (Gomes Jr et al 2015)



effectiveness of swallowing exercises/therapy for dysphagia for different aetiologies

bedside dysphagia input

evidence for thermal tactile stimulation

oro-motor exercises for dysphagia therapy

30


management of risk feeding in community settings

Facial Oral Tract Therapy (FOTT)

further research on expiratory muscle training (recent positive results in patient groups previously not included in intervention programmes)

intensity of therapy required to make change

economic evaluation of swallowing therapy (e.g. impact on bed days, reduction in tube feeding)

how families embrace dysphagia management particularly in ethnic minorities

improving compliance in dysphagia management by caregivers

carer compliance and safeguarding and whether safeguarding alerts improve compliance with dysphagia recommendations

Implementation of swallow recommendations by nursing/care home staff following discharge from speech and language therapy

dysphagia therapy that can be carried out without high-cost equipment and tests

timing and intensity needed in various therapies for dysphagia in order to have a functional impact

impact of staff training in dysphagia in management of dysphagia in acute and community settings by multi-disciplinary teams

clinical outcomes for dysphagia interventions

long term benefits on participation/activity outcomes

longitudinal outcomes

how to measure outcomes effectively

how practitioners use talk to achieve clinical outcomes

functional outcomes

agreed outcome measures that are used across patient groups

use of Therapy Outcome Measures with dysphagia

References Adam et al (2013) A Systematic Review and Meta-analysis of Measurements of tongue and hand strength and endurance using the Iowa Oral Performance Instrument (IOPI). Dysphagia. 2013 Sep;28(3):350-69

Antunes & Lunet (2012) Effects of the Head Lift Exercise on the Swallow Function: A Systematic Review Gerodontology, 29: 247–257

Carnaby and Madhaven (2013). A Systematic Review of RCTS in the Field of Dysphagia Rehabilitation. Current Physical Medicine and Rehabilitation Reports, Volume 1 (4), pp 197–215.

Deane et al (2001). Non-pharmacological therapies for dysphagia in Parkinson's disease. Cochrane Database of Systematic Reviews 2001, Issue 1. Art. No.: CD002816. DOI: 10.1002/14651858.CD002816.

Drulia & Ludlow (2013). Relative Efficacy of Swallowing Versus Non-swallowing Tasks in Dysphagia Rehabilitation: Current Evidence and Future Directions. Curr Phys Med Rehabil Rep. Dec;1(4):242-256

Frymark (2009) Systematic Review EBSR on Oropharyngeal dysphagia behavioural intervention. J Rehabil Res Dev. 2009;46(2):195-204

Geeganage et al (2012). Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD000323. DOI: 10.1002/14651858.CD000323.pub2.

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Gomes Jr et al (2015). Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances Cochrane Database of Systematic Reviews 2015, Issue 5. Art. No.: CD008096.

Hansen & Jakobsen (2010). A decision-algorithm defining the rehabilitation approach: 'Facial oral tract therapy'. Disabil Rehabil, 32(17), 1447-1460.

Hegland et al (2016). Rehabilitation of Swallowing and Cough Functions Following Stroke: An Expiratory Muscle Strength Training Trial. Arch Phys Med Rehabil, 97(8), 1345-1351.

McCabe (2009). Evidence-based systematic review: Oropharyngeal dysphagia behavioral treatments. Part IV--impact of dysphagia treatment on individuals' postcancer treatments. Journal of rehabilitation research and development,, 46 (2), p. 205.

Pitts et al (2009). Impact of expiratory muscle strength training on voluntary cough and swallow function in Parkinson disease. Chest, 135(5), 1301-1308.

Plowman et al (2016). Impact of Expiratory Strength Training in Amyotrophic Lateral Sclerosis. Muscle and Nerve, 54(1), 48-53.

Speyer et al (2010) Effects of Therapy in Oropharyngeal Dysphagia by Speech and Language Therapists: A Systematic Review. Dysphagia, 25 (1), pp 40–65


Wheeler-Hegland (2009). Evidence-based systematic review: Oropharyngeal dysphagia behavioral treatments. Part V--applications for clinicians and researchers. Journal of rehabilitation research and development, 46 (2), p. 215.


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16. Swallowing therapy in acute and subacute stroke/head injury

Uncertainty Dysphagia can occur immediately after a stroke or head injury (in the 'acute' phase) and can recover or can be long-lasting. More evidence is needed on the effectiveness of swallow screening in the acute phase and which interventions are effective at different time points following a stroke or head injury.

Patient group Stroke and head injury



which components of swallowing therapy are beneficial in acute and subacute stroke (Geeganage et al 2012)

cost-effectiveness of swallowing screening. Potential benefit may be seen not only in terms of pneumonia but also in terms of length of hospital stay, morbidity, and mortality (Geeganage et al 2012)

Research studies into dysphagia and under-nutrition need to ensure that standardised outcome measures are used to allow comparison of trials. However, measuring nutritional status is difficult and there are no indicators validated in the stroke population. Reporting of proportions of patients who develop pneumonia or have signs of aspiration should be an important outcome measure in all dysphagia and feeding-related trials. Few studies assessed quality of life, which has relevance when balancing the risks and benefits of interventions in severely disabled stroke survivors (Geeganage et al 2012)



intervention for acute dysphagia

timing of dysphagia rehabilitation

paediatric dysphagia particularly acute paediatric problems

dysphagia in acute conditions

management of dysphagia in a generalist acute setting

use of cough reflex testing in reducing aspiration in acute stroke





dysphagia therapy that can be carried out without high-cost equipment and tests

timing and intensity needed in various therapies for dysphagia in order to have a functional impact

impact of staff training in dysphagia in management of dysphagia in acute and community settings by multi-disciplinary teams

Ongoing research NIHR HS&DR Stroke Sentinel Audit Programme: Investigating and Evaluating Stroke Therapy (SSNAPIEST)

NIHR Research for Patient Benefit grant for a project to improve oral self-care practices for stroke patients after discharge from hospital stroke services. The project will work with patients and professionals to co-design an oral healthcare “STOP” toolkit to improve the tooth and gum healthcare needs of stroke survivors ( Prof Craig Smith)

33

References Geeganage et al (2012). Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD000323. DOI: 10.1002/14651858.CD000323.pub2.

Rey-Matias (2016). Rehabilitation Techniques in Dysphagia Management among Stroke Patients: A Systematic Review. International Journal of Physical Medicine & Rehabilitation. 4: 340.

Schepp et al (2012) Swallowing Screens after Acute Stroke: A Systematic Review. Stroke: 43(3): 869–871.

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17. Dysphagia management in the elderly

Uncertainty Older people sometimes experience a decline in their ability to swallow. It is not clear what works best to improve safety of swallowing and quality of life, for example postural strategies, exercises, changes to diet and changes to the environment.

Patient group Older people at risk of dysphagia, all conditions associated with dysphagia

Age range Elderly


more research conducted with other study designs and investigators are necessary, especially for comparison with other feasible options, such as multiple swallowing, which has been shown to contribute to the amount of pharyngeal residue (a higher risk for aspiration) in the elderly with declining oropharyngeal ability (Antunes & Lunet 2012)

the behavioural, dietary and environmental modifications for elders with dysphagia emerging in this past decade are promising, nonetheless, the state of the evidence calls for more research (Antunes & Lunet 2012)

A European Union Geriatric Medicine Society white paper (Beijens et al (2016) made the following research recommendations:

the best viscosities for fluids and consistencies for solids

optimum time to commence enteral feeding and how early should a percutaneous tube be placed

where water intake is a problem, should other ways of administration be used e.g subcutaneous fluid intake (hypodermoclysis) or rectal feeding

larger randomized clinical trials on the integration of interventions and strategies for oropharyngeal dysphagia in the elderly

the ethical and legal issues related to end of life care and oropharyngeal dysphagia



cognitive stimulation groups or lunch groups in care of the elderly settings

managing dysphagia in the elderly population

the usefulness of cough reflex testing on an elderly rehabilitation ward

delirium and its effect on swallowing /language in the older adult

effectiveness of compulsory annual swallowing training completed by nursing/care home staff

the impact of regular, intensive swallowing training for nursing home staff on cultural change within homes to benefit clients with swallowing difficulties


oral care/teeth in elderly and impact on the risk of dysphagia

the most effective way to manage dysphagia in nursing homes




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outcomes of intensive training to staff in nursing homes (kitchen and care staff) on patient experience swallowing support and improvements in meal/snack time experience

clinical impact of carers support group for dysphagia, including support of chefs

effectiveness of compulsory annual swallowing training completed by nursing/care home staff

References Antunes & Lunet (2012) Effects of the Head Lift Exercise on the Swallow Function: A Systematic Review Gerodontology, 29: 247–257

Baijens et al (2016). European Society for Swallowing Disorders – European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome . Clinical Interventions in Aging: 11 Pages 1403—1428

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18. Management of dysphagia in head and neck cancer

Uncertainty Patients with head and neck cancer can often experience difficulties swallowing following their treatment. It is not clear whether practicing swallowing exercises before and/or treatment results in better swallowing outcomes after treatment compared with patients who do not carry out exercises. It is also unclear how different surgical techniques for the treatment of head and neck cancer are related to the occurrence of dysphagia following surgery. Dry mouth can occur as a consequence of radiotherapy for head and neck cancer, drug treatments or some medical conditions. The effectiveness of non-drug treatments (such as powered tooth brushing, acupuncture and electrical stimulation) on symptoms and quality of life is unclear.

Patient group Head and neck cancer

Age range Adults


randomised controlled trials of post-treatment therapeutic exercises need to be better planned and preceded by good vanguard studies. The dropout rate in all published trials has been unacceptably high, each study has had an overly onerous exercise burden for patients (Perry et al 2016)

good qualitative research studies to better understand patients' tolerance for undertaking swallowing exercises during treatment would likely improve the design of such exercise interventions and thereby enhance fidelity to treatment (Perry et al 2016)

Interventions need to be better designed as simple to follow, easy to undertake exercises, and the 'dosage' (duration, timing) of exercises needs to be feasible and based on evidence of effect (Perry et al 2016)

Realistic time points for assessment need to be agreed as standard across studies for comparison and/or aggregation of data to occur (Perry et al 2016)

future research on behavioural dysphagia treatments should focus on clinical trials that target specific cohorts of subjects i.e., head and neck cancer (McCabe 2009)

additional studies need to be undertaken to evaluate the precise effects of the head lift exercise both on cancer and stroke patients (Antunes & Lunet 2012)

future research should test postural alterations and manoeuvres in well-designed and controlled studies using quantifiable, relevant outcome measures, including pulmonary health outcomes (McCabe 2009)

studies should examine their effects on populations with dysphagia with similar aetiologies - location of deficit, type of treatment etc. (McCabe 2009)

more prospective studies with homogeneous subgroups for tumour stage and location using high-quality physiologic assessments with FEES or VFS to compare the correlation between dysphagia and the various surgical techniques (Lips 2015)

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Further well-designed and conducted double-blind trials with sufficient numbers of participants are required to determine the benefits of interventions for dry mouth. Trials should include outcomes which are important to people such as dry mouth symptoms, quality of life, together with duration of effectiveness and satisfaction with the intervention (Furness et al 2013)



effectiveness of prophylactic swallowing exercises in head and neck cancer, including in the prevention of fibrosis during radiotherapy treatment

which swallow exercises to give, how often and for how long

whether patients doing swallowing exercises within the first year following treatment have better swallowing outcomes

the efficacy of swallow exercises in late-onset dysphagia post radiotherapy

dysphagia, oromotor and speech outcomes in head and neck cancer patients

short, medium and long term outcomes of direct oromotor therapy

long term implications on swallow and speech in surgical head and neck cancer patients

long term swallowing outcomes in head and neck cancer

the efficacy of swallow exercises in late-onset dysphagia post radiotherapy

evidence base for pre-oncology dysphagia pre-habilitation

is the impact of different treatments for larynx cancer (laryngectomy, chemoradiotherapy, laryngeal conservation surgery vs chemoradiotherapy in multi-centre studies

national database for total glossectomy with agreed outcomes and set time points.

The relationship between dry mouth and dysphagia is unclear

Long-term swallowing outcomes in head and neck cancer. Recent evidence suggests that post-radiotherapy, swallowing function may decline over time, with an increase in chronic aspiration rates. There is limited data on UK patients and uncertainty on how best to manage these patients

Impact of prophylactic gastrostomy on swallowing outcomes

palliative care for head and neck cancer eg. Decision-making around feeding, comfort feeding, carers’ perspectives and how best to support them, SLT role in palliation.

assessment technologies e.g. cough reflex testing, high resolution manometry, FEES measurements/scales, self assessment of swallowing

Tongue strength training

Expiratory muscle strength training

McNeil swallowing intervention

impact of lymphoedema massage on internal oedema

free water protocols

early feeding in post-surgical patients

long term swallowing outcomes in head and neck cancer

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Research ongoing NIHR HTA: Palliative radiotherapy in addition to self-expanding metal stent for improving outcomes of DYSPHAGIA and survival in advanced oesophageal cancer: ROCS (Radiotherapy after Oesophageal Cancer Stenting) Study (due to complete 2019)

Cancer Research UK: Dysphagia/Aspiration at risk structures (DARS) trial is to determine whether reducing the dose to the pharyngeal constrictors with dysphagia-optimised intensity- modulated radiotherapy (Do-IMRT) will lead to an improvement in long- term swallowing function without having any detrimental impact on disease-specific survival outcomes.

Cancer Research UK: Post-operative Adjuvant Treatment for HPV-positive Tumours (PATHOS) aims to investigate whether swallowing function can be improved following transoral resection of HPV-positive oropharyngeal cancers reducing the intensity of adjuvant treatment protocols (radiotherapy an chemotherapy) – multicentre trial

Cancer Research UK: A trial looking at different treatments for people with oropharyngeal cancer (CompARE) – swallowing function is an outcome measure

Cancer Research UK has recently funded a UK arm of ‘Best of’ where patients will be randomised to surgery or radiotherapy for oropharyngeal cancer.

Guidelines NICE guideline NG36 (2016) Cancer of the upper aerodigestive tract: assessment and management in people aged 16 and over recommends:

Consider swallowing‑ exercise programmes for people having radiotherapy.

Consider mouth‑opening exercises for people having radiotherapy who are at risk of reduced mouth opening

Consider voice therapy for people whose voice has changed because of their treatment.

Moderate quality evidence from a single randomised trial (Carnaby-Mann 2012, 28 patients) suggests uncertainty over whether high-intensity swallowing therapy during cancer treatment improves swallowing and nutrition outcomes in patients undergoing treatment for oropharyngeal cancer. High-intensity swallowing therapy was beneficial compared to either usual care or sham therapy in terms of rates of return to normal diet (risk ratio (RR) 2.5, 95% confidence interval (CI) 0.58 to 10.8, and RR 2.32, 95% CI 0.54 to 9.95, respectively), functional swallowing (RR 3, 95% CI 0.73 to 12.39 and RR 2.79, 95% CI 0.68 to 11.42, respectively), rates of non-oral feeding (RR 0.5, 95% CI 0.15 to 1.61 and RR 0.93, 95% CI 0.23 to 3.81, respectively) and the proportion of patients with greater than 10% weight loss (RR 0.67, 95% CI 0.24 to 1.86 and RR 0.62, 95% CI 0.22 to 1.71), but the differences between groups did not reach statistical significance. Low quality evidence from a single randomised trial (Tang 2010, 69 patients) suggests that in patients who have had radiotherapy for nasopharyngeal cancer, swallow function is improved by rehabilitation exercises (RR 2.06, 95% CI 1.07 to 3.97, compared with no rehabilitation), but the period over which swallow function was measured in this study is not clear.

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The effects of preventative speech and language therapy in patients being treated for cancer of the upper aerodigestive tract was investigated in a single randomised trial (Kotz 2012, 26 patients) and two observational studies (Ahlberg 2011, 205 patients, and Carroll 2008, 18 patients). Low quality evidence suggests that over 12 months of follow-up, diet and functional oral intake scale both returned to normal more quickly in patients who received preventative therapy compared to those who received usual care (Kotz 2012), but the differences between groups at each time point were very small. Very low quality evidence suggests uncertainty over the benefit of preventative therapy. One trial (Carroll 2008, 18 patients) found no statistically significant benefit in terms of aspiration, posterior tongue base movement, or vertical hyoid movement. Very low quality evidence from a second observational study (Ahlberg 2011) found no difference in rates of PEG tube use after six months between patients receiving preventative therapy and those who did not (RR 1.15, 95% CI 0.57 to 2.34), whilst patients who had received preventative swallowing therapy were less likely to be free of swallowing difficulties after six months (RR 0.79, 95% CI 0.63 to 0.98). A third trial (Virani 2015, 50 patients) found that fewer patients who performed preventative exercises required a PEG tube 3 months after finishing their cancer treatment (RR 0.31, 95% CI 0.11 to 0.82), but there was no significant difference between groups in terms of PEG tube use at completion of treatment, or in terms of change in functional intake scale (FOIS) scores. Two observational studies provided very low quality evidence on the effect of timing/amount of therapy on swallow outcomes. One study (Kulbersh 2006, 37 patients) suggests that in patients with cancer of the upper aerodigestive tract treated with chemotherapy or radiotherapy and concomitant chemotherapy, those who receive swallowing therapy before their cancer treatment suffer from less long-term dysphagia symptoms than those who receive post-treatment swallowing therapy (follow up 6–20 months). A second study (Cavalot 2009, 43 patients) suggests that in patients undergoing partial laryngectomy for larynx carcinoma, the use of both pre- and post-surgery swallowing therapy reduces the time to resumption of swallowing when compared to patients receiving only post-surgery swallowing therapy (mean difference 11.38 days shorter, 95% CI 8.72 to 14.04 shorter). Two observational studies (Duarte 2013 and Hutcheson 2013, 85 and 497 patients, respectively) provided very low quality evidence about the effect of patients’ adherence to their swallowing therapy on outcomes. The results suggest that patients who comply with their prescribed swallowing therapy are more likely to return to a normal diet (Hutcheson 2013, follow-up median 22 months, RR 1.12, 95% CI 1.02 to 1.22), and require a gastrostomy tube for a shorter time after their treatment (median duration of gastrostomy tube dependence 68 days and 113 days for adherent and non adherent patients, respectively, p = 0.007). However, results of the second trial suggest uncertainty over whether adherence to treatment reduced weight loss or swallowing pain 1 month after treatment (Duarte 2013, 85 patients).

References Antunes & Lunet (2012) Effects of the Head Lift Exercise on the Swallow Function: A Systematic Review Gerontology, 29: 247–257

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Furness et al (2013) Interventions for the management of dry mouth: non-pharmacological interventions. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD009603.

Lips (2015) Supracricoid laryngectomy and dysphagia: A systematic literature review. The Laryngoscope, 125 (9), p. 2143.

McCabe (2009). Evidence-based systematic review: Oropharyngeal dysphagia behavioral treatments. Part IV--impact of dysphagia treatment on individuals' postcancer treatments. Journal of rehabilitation research and development: 46 (2), p. 205.

Perry et al (2016). Therapeutic exercises for affecting post-treatment swallowing in people treated for advanced-stage head and neck cancers. Cochrane Database of Systematic Reviews 2016, Issue 8. Art. No.: CD011112.

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19. Parkinson’s disease

Uncertainty Parkinson's disease is associated with dysphagia. More research is needed on interventions that don’t involve drug treatments that are used to manage dysphagia with people with Parkinson’s and how effective they are.

Patient group Parkinson's disease

Age range Adults


consensus is needed on what 'standard' non-pharmacological swallowing therapy for dysphagia is in Parkinson's disease (Deane et al 2001)

proof of the efficacy of non-pharmacological swallowing therapy for swallowing disorders in Parkinson's patients in large randomised placebo-controlled trials (Deane et al 2001)

well-designed randomized controlled studies using larger patient populations are necessary to evaluate clinical applicability and the potential therapeutic effects of new treatment techniques (Van Hooren et al 2014)

more studies are needed that use the SWAL-QOL questionnaire (an outcome tool that measures quality of life) when assessing individuals with Parkinson’s Disease for a quality of life diagnosis in swallowing and its variables, considered by instrument domains (Carneiro et al 2013)



effectiveness of dysphagia rehabilitation in progressive conditions

References Carneiro et al (2013) Quality of life in dysphagia in Parkinson’s Disease: A systematic review. Quality of life in dysphagia in Parkinson's disease: a systematic review. Revista CEFAC, 15(5), 1347-1356

Deane et al (2001) Non-pharmacological therapies for dysphagia in Parkinson's disease. Cochrane Database of Systematic Reviews 2001, Issue 1. Art. No.: CD002816.

Van Hooren et al (2014) Treatment Effects for Dysphagia in Parkinson's Disease: A Systematic Review. Parkinsonism Relat Disord:20(8):800-7.

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20. Dementia

Uncertainty People with dementia can develop difficulties eating and drinking. It is unclear which types or stages of dementia are more likely to be linked with eating and drinking difficulties. More evidence is needed on the most effective ways of assessing and treating dysphagia in this population, for example diagnostic tests such as videofluroscopy. More research is needed into the best treatments such as changes in positioning and diet and tube feeding to help people with dementia carry on eating and drinking, maintain a good quality of life and prevent malnutrition. It is unclear whether interventions are effective in different settings such as homes, acute settings and community care.

Patient group Dementia

Age range Adults


limited evidence is available for clinical diagnostic assessment as well as for diagnostic tests like VFSS and FEES, interventions like dietary and postural modifications and for the medical management of dysphagia in dementia (Alagiakrishnan et al 2015)

Future studies should include larger sample sizes with better matching of control and intervention groups, more data on potential confounders and more precise diagnosis of the type and severity of dementia (Sampson et al 2015)

future interventions, and combinations of promising interventions in comprehensive nutritional programs, could be tested in multisite randomized trials. Investigators should be encouraged to design trials that view intake and weight gain as intermediate outcomes so as to provide stronger evidence of the effects on function, behaviour, infection risk, and wound healing. Ethical concerns about withholding feeding treatments may limit the range of possible control conditions, including a randomized comparison of oral assisted feeding and tube feeding (Hanson et al 2011)

future intervention studies need to be more targeted to population with specific stages of dementia or levels of feeding difficulty (Liu et al 2014)

Clinically important outcomes such as quality of life should be considered as well as nutritional status and survival (Sampson et al 2009)

current evidence of a variety of individual interventions on different outcomes also indicates possibilities for mixed interventions, where future research could focus to explore the potential effects on certain mealtime outcomes (Liu et al 2014)

future work might be worthwhile to examine the effects of those interventions with moderate evidence in various settings to expand the benefits to larger population with dementia (Liu et al 2014)


The Dementia (JLA, 2013) identified the following as their 6th priority:

What are the most effective ways to encourage people with dementia to eat, drink and maintain nutritional intake?

http://www.jla.nihr.ac.uk/priority-setting-partnerships/dementia

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longitudinal study of dementia, looking at factors affecting quality of life, e.g. dysphagia management, sensory strategies, oral care, aspects of care within nursing homes

how do we design and deliver training to meet care staff needs (communication and dysphagia)?

dementia dysphagia management

the role of the SLT in working with adults with learning disabilities and dementia

why some people with learning disabilities/dementia begin to refuse fluid intake at stage 3 when they eat texture C food

effectiveness and timing of dementia reviews

mental capacity and ethics in dysphagia management

References Abdelhamid et al (2016) Effectiveness of interventions to directly support food and drink intake in people with dementia: systematic review and meta-analysis. BMC Geriatrics (2016) 16:26.

Alagiakrishnan et al (2013) Evaluation and management of oropharyngeal dysphagia in different types of dementia: A systematic review. Archives of Gerontology and Geriatrics Volume 56 (1), Pages 1–9

Hanson et al (2011) Oral Feeding Options for People with Dementia: A Systematic Review J Am Geriatr Soc;59(3):463-72.

Liu et al (2014) Interventions on Mealtime Difficulties in Older Adults with Dementia: A Systematic Review. Int J Nurs Stud: 51(1):14-27

Paranji et al (2016) A Nationwide Study of the Impact of Dysphagia on Hospital Outcomes Among Patients With Dementia. American Journal

of Alzheimer’s Disease & Other Dementias: 1-7

Sampson et al (2009) Enteral tube feeding for older people with advanced dementia. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD007209.

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21. Respiratory dysphagia

Uncertainty Difficulties with breathing, such as chronic obstructive pulmonary disease (COPD) are linked with dysphagia. It is unclear how many people with conditions such as COPD have dysphagia. It is also unclear how best to prevent aspiration in people with respiratory conditions.

Patient group Chronic obstructive pulmonary disease and respiratory conditions

Age range Adults


Future studies are needed to document the prevalence of oropharyngeal dysphagia in homogeneous groups of patients with COPD, and to assess the relationship between respiration and swallowing using simultaneous measures of swallowing biomechanics and respiratory function (O’Kane 2009)



links between COPD and dysphagia

use of thickened fluids and airway protection strategies in preventing aspiration in respiratory dysphagia

dysphagia in Respiratory Conditions

References O'Kane (2009). Oropharyngeal dysphagia in patients with chronic obstructive pulmonary disease: a systematic review. Revista CEFAC (1516-1846), 11 (3), p. 449.

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22. Spinal injuries and surgery

Uncertainty Difficulties with swallowing can occur as a result of spinal cord injury and following spine surgery. There is uncertainty about the predictors of recovery of swallow function following surgery and best practice relating the spinal cord injuries.

Patient group Patients with traumatic and non-traumatic spinal cord injuries Patients requiring cervical spine surgery (for non-cord injuries)



Recent systematic review on interventions following spinal cord injuries remains inconclusive due to poor quality studies (Valenzano et al 2016)

Clinical guidance on spinal cord injury management available from USA acknowledges SLT involvement (Consortium for Spinal Cord Medicine. 2008)


Members submitted uncertainties on this topic that included:

Predicting recovery of swallow function following anterior cervical spine surgery for single and multi-level fractures

Practice relating to spinal cord injuries

Swallowing outcomes following anterior cervical spine surgery

positioning - studies in normal to suggest that upright is not always the safest position to prevent aspiration, which may help to manage those with pharyngeal dysfunction, such as in spinal cord injury

Guidelines NICE guideline NG41 (2016). Spinal injury: assessment and initial management. https://www.nice.org.uk/guidance/ng41 Clinial Reference Group for Spinal Cord Injury (2016). Early Acute Management in Adults with Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. (Consortium for Spinal Cord Medicine 2008) includes: Recommendation 72. Develop protocols that allow rehabilitation specialists to become involved early in the management of persons with SCI, immediately following injury during the acute hospitalization phase. Although the initial phase of treatment of newly injured patients centres on medical interventions to resuscitate and stabilize, this phase can last several days. During this time, the patient is often moved from the emergency room to the operating room to the ICU or appropriate unit. Many clinicians are involved with the care of the patient and are developing plans for the rest of the hospitalization, if not longer. Evaluations by various members of the multidisciplinary team using standardized guidelines should assess the type, level, and severity of the injury to aid in the development of a comprehensive plan of care. Pathways, standing orders, and protocols for patients with SCI that allow for the early evaluation, assessment, and treatment by physical therapists, occupational therapists, rehabilitation nurses, and speech and language

https://www.nice.org.uk/guidance/ng41

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pathologists immediately trigger the involvement of these and other rehabilitation team members. Early intervention by rehabilitation specialists may shorten length of stay during the acute hospitalization phase by preventing secondary complications and moving the patient more quickly toward discharge to the next level of care.

References Cameron et al (2009). Outcomes of patients with spinal cord injury before and after introduction of an interdisciplinary tracheostomy team. Critical Care and Resuscitation, 11(1), 14-19.

Chen et al. (2013). Dysphagia following combined anterior-posterior cervical spine surgeries. J Neurosurg Spine, 19(3), 279-287.

Consortium for Spinal Cord Medicine (2008). Early acute management in adults with spinal cord injury: A clinical practice guideline for health-care professionals. Journal of Spinal Cord Medicine, 31(4), 403-479.

Leonard et al (2011). Dysphagia Following Cervical Spine Surgery With Anterior Instrumentation: Evidence From Fluoroscopic Swallow Studies. Spine: 36(25), 2217-2223.

Smith-Hammond et al (2004). Prospective analysis of incidence and risk factors of dysphagia in spine surgery patients - Comparison of anterior cervical, posterior cervical, and lumbar procedures. Spine (Phila Pa 1976), 29(13), 1441-1446.

Winslow et al (2001). Dysphonia and dysphagia following the anterior approach to the cervical spine. Archives of Otolaryngology - Head & Neck Surgery, 127(1), 51.

Zeng et al (2013). Early dysphagia complicating anterior cervical spine surgery: incidence and risk factors. Arch Orthop Trauma Surg, 133(8), 1067-1071.

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23. Dysphagia and adult mental health

Uncertainty Dysphagia is common in adults with mental health difficulties. It is unclear what causes dysphagia and what interventions are effective in treating dysphagia in this population.

Patient group Mental health difficulties

Age range Adults


Further research on the causative factors for dysphagia in adults with mental health difficulties should help to inform targeted interventions (Aldridge & Taylor 2012)

Clinicians managing dysphagia in individuals within this population would benefit from knowledge of interventions of proven effectiveness in this group, of which there are currently none. There is a clear need for studies evaluating the effectiveness of dysphagia interventions in this group using randomized controlled trials (Aldridge and Taylor 2012).



role of the speech and language therapist in functional mental health and dysphagia

dysphagia in mental health and learning disabilities

effectiveness of treatments with adults with mental health diagnoses

impact of medication on dysphagia in learning disabilities and mental health

impact of medication on dysphagia, for example antipsychotics with side effect of increased saliva production

References Aldridge & Taylor (2012) Dysphagia is a Common and Serious Problem for Adults with Mental Illness: A Systematic Review Dysphagia March 2012, Volume 27, Issue 1, pp 124–137

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24. Effective interventions for dysphagia management in learning disabilities

Uncertainty People with learning disabilities often have dysphagia. It is unclear what the most effective ways are to assess dysphagia in this population. More research is needed into the effectiveness of different interventions such as thickening fluids, oral tasting programmes and risk feeding, including the prevention of admissions to hospital and quality of life.

Patient group Learning disabilities

Age range Adults


See information on Topics 1, 3, 4, 5 and 6 Nb. This topic has been included due to the large number of uncertainties on learning disabilities and dysphagia submitted by speech and language therapists. It overlaps with a number of other topics, including 1, 3, 4, 5 and 6.


Speech and Language Therapists submitted uncertainties on learning disabilities that included:

risk feeding and learning disabilities

oral tasters and learning disabilities

Intervention for dysphagia and prevention of hospital admissions/aspiration pneumonia/chest infections in learning disabilities

selective eating support

dysphagia assessment tools for dysphagia

safety of thickener use

facilitating and assessing capacity in learning disabilities and dysphagia, including texture modification and non-oral feeding

psycho-social impact of dysphagia

effectiveness of dysphagia interventions, oral healthcare and postural changes versus modified diets/thickened drinks in prevention of aspiration

why some people with learning disabilities begin to refuse fluid intake



how to ensure adequate fluid intake

syringe feeding and safe administration of medicines in liquids

clinical outcomes in adults with learning disabilities dysphagia

References See information on Topics 1, 3, 4, 5 and 6

topic areas and uncertainties - rcslt...3 aspiration aspiration is a consequence of dysphagia and...

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