dysphagia general

7/23/2019 Dysphagia General

http://slidepdf.com/reader/full/dysphagia-general 1/36

Level 2 / 11-19 Bank Place T 61 3 9642 4899 [email protected] Victoria 3000 F 61 3 9642 4922 www.speechpathologyaustralia.org.au

The Speech Pathology Association of Australia Limited ABN 17 008 393 440

PositionPaper

Dysphagia: General

Copyright ©The Speech Pathology Association of Australia Limited 2004

Disclaimer: To the best of the Speech Pathology Association of Australia Limited’s (“the Association”) knowledge, this information is valid at the time of publication. The Association

makes no warranty or representation in relation to the content or accuracy of the material in thispublication. The Association expressly disclaims any and all liability (including liability for

negligence) in respect of the use of the information provided. The Association recommends youseek independent professional advice prior to making any decision involving matters outlined inthis publication.



Speech Pathology Australia

iDysphagia: General Position PaperCopyright © The Speech Pathology Association of Australia Ltd 2004

Contents

Speech Pathology Australia Position Statement ..................................................................... 11. History of the Dysphagia Position Paper..........................................................................22. Definitions .........................................................................................................................2

2.1 Dysphagia .................................................................................................................22.2 Service/Service Providers......................................................................................... 2

3. Client Groups and Disorders ............................................................................................24. Changes and Trends.........................................................................................................45. Client Services ..................................................................................................................4

5.1 Service Delivery.........................................................................................................45.2 Models of care ..........................................................................................................4

6. Referral..............................................................................................................................56.1 Sources of Referral ...................................................................................................56.2 Methods of Referral ..................................................................................................56.3 Reasons for Referral .................................................................................................56.4 Information Required at Time of Referral..................................................................56.5 Prioritisation ..............................................................................................................6

6.6 Urgent Referrals ........................................................................................................67. Team Work........................................................................................................................78. Assessment, Diagnosis and Management ....................................................................... 8

8.1 Background History ..................................................................................................88.2 General Observation .................................................................................................98.3 Communication Status............................................................................................108.4 Clinical Oropharyngeal Assessment .......................................................................108.5 Suitability for Oral Trial ............................................................................................108.6 Oral Trial/Bedside Examination/Mealtime Observation..........................................118.7 Referral for Instrumental assessment (as appropriate)........................................... 118.8 Overall Impression ..................................................................................................128.9 Diagnosis.................................................................................................................128.10 Management Plan ...................................................................................................12

9. Treatment........................................................................................................................139.1 Oral phase disorders...............................................................................................159.2 Velopharyngeal disorders ....................................................................................... 159.3 Oropharyngeal transit disorders ............................................................................. 169.4 Pharyngeal disorders ..............................................................................................169.5 Cricopharyngeal disorders......................................................................................179.6 Penetration + Aspiration .........................................................................................17

10. Documentation ...............................................................................................................1710.1 Timelines .................................................................................................................1810.2 Standards................................................................................................................1810.3 Reporting requirements ..........................................................................................1810.4 Discharge and Resolution Planning........................................................................1910.5 Confidentiality .........................................................................................................19

11. Education and Counselling.............................................................................................1911.1 At Referral ...............................................................................................................1911.2 After Clinical Assessment .......................................................................................1911.3 Prior to Discharge ...................................................................................................2011.4 Client/Carer Education............................................................................................20




ii Dysphagia: General Position PaperCopyright © The Speech Pathology Association of Australia Ltd 2004

12. Services Management ....................................................................................................2012.1 Qualifications...........................................................................................................20

12.1.1 Skills and Minimum Standards..........................................................2012.2 Professional Development ...................................................................................... 2012.3 Information Technology ..........................................................................................21

12.4 Budgets...................................................................................................................2112.5 Workplace Health and Safety Issues ...................................................................... 2112.6 Physical Resources.................................................................................................2112.7 Continuous Quality Improvement ...........................................................................21

12.7.1 Measuring Methods...........................................................................2112.8 Marketing and Public Relations .............................................................................. 22

13. Education........................................................................................................................2213.1 Clinical Education....................................................................................................2213.2 Staff Training...........................................................................................................2213.3 Research .................................................................................................................22

13.3.1 Funding..............................................................................................2314. Legal Issues ....................................................................................................................23

14.1 Code of Ethics.........................................................................................................23

14.2 Knowledge and Skills..............................................................................................2314.3 Speech Pathologists’ Responsibilities....................................................................2314.4 Duty of Care ............................................................................................................23

14.5 Standard of Care.....................................................................................................2414.6 ‘Proxy’ Intervention .................................................................................................2414.7 Consent for Speech Pathologist Involvement ........................................................2414.8 Indemnity Cover and Insurance .............................................................................. 2414.9 Service Guidelines...................................................................................................2514.10 Summary...............................................................................................................25

Appendices.............................................................................................................................26 Appendix A: Glossary of Assessments of Dysphagia ....................................................26 Appendix B: Acknowledgements ................................................................................... 29

References..............................................................................................................................30




Page 1 Dysphagia: General Position PaperCopyright © The Speech Pathology Association of Australia Ltd 2004

Speech Pathology Australia Position Statement

• Speech pathologists have a pivotal role to play in the assessment and management of

dysphagia (swallowing disorders). The speech pathologist may act as clinician,consultant, team manager, educator, and/or researcher. The extent of involvementdepends on the nature of the clinical setting and population.

• Safety guidelines should be followed where they exist. For this reason clinicians should

be familiar with workplace occupational health and safety policies, relevant PositionPapers from Speech Pathology Australia and other relevant legislation and guidelines.

• Speech pathologists should be aware of the medico-legal implications and the

responsibilities of working with clients who have dysphagia.

• Speech pathologists should be familiar with and follow local workplace and governmentpolicies and procedures where available.

• Speech pathologists should have knowledge of the current Speech Pathology Australia

Code of Ethics (2000) and the Principles of Practice (2001) that states that decision-making in dysphagia should incorporate awareness of the ethical principles ofautonomy, non-maleficence, beneficence and justice.

• Speech pathologists should work within their scope of practice. Where experience orskills are limited appropriate advice, mentoring and peer support should be sought.

• Consistent, full and accurate recording and documentation of all areas of client

assessment and management should occur.

•

Projects on feeding / swallowing / dysphagia should be incorporated into generaldepartmental Quality Assurance or Total Quality Management Procedures asappropriate.

• Speech pathologists should manage clients with dysphagia as part of a team where

possible to achieve the best possible outcomes.

• This paper reflects available evidence, issues and current clinical practice as it presents

at this point in time.

• This paper contains minimum standards of practice. It is a guideline for speechpathologists assessing, treating and managing clients with dysphagia, not an exhaustive

examination of the topic.

• This Position Paper should be reviewed every three years.





1. History of the Dysphagia Position Paper

Work on the first Dysphagia Position Paper was commenced in 1991, as a result of an increasinginvolvement in the field of dysphagia by Australian speech pathologists. The paper was releasedin 1994, the same year the first Competency Based Occupational Standards (CBOS) for Speech

Pathologists were released. Both these papers established baseline competency skills for newly

graduated and experienced speech pathologists. Australian university speech pathologyprograms undergo regular accreditation to demonstrate that graduates meet the basiccompetencies established by Speech Pathology Australia.

2. Definitions

2.1 Dysphagia

Etymologically the term dysphagia is compounded from the Greek words dys = disorderedand phagein = to eat ( Winstein, 1983), meaning a swallowing disorder.

Dysphagia is not a disease in itself but is a term that refers to a condition, a disorder or asymptom that may be genetic, developmental, acquired, functional or iatrogenic in origin. It canbe caused by structural, physiological and /or neurological impairments affecting one or more

stages of swallowing, namely the preparatory, oral, pharyngeal, and/or oesophageal stages. Thismay present as a difficulty with sucking, drinking, eating, controlling saliva, protecting the airwayor swallowing. As a consequence dysphagia may lead to asphyxiation or pneumonia (Langmore,Terpenning, Schork, Chen, Murray, Lopatin and Loesche 1998; Martin, 1994), or failure to meetan individual’s nutrition, hydration (Davalos, Ricart, Gonzalez-Huix, Soler, Marrugat, Molins, Sunerand Genis (1996); Langmore et al 1998; Martin, 1994) and social needs (Ekberg, Hamdy, Woisard,Wuttge-Hannig & Ortega, 2002) as well as impacting on development of oral and communicationskills (Morris, 1985).

2. 2 Service/Service Providers

The term service or service provider refers to the person or organisation that is providing aservice to an individual. It incorporates all speech pathologists, including those who are

employed by organisations such as state departments of health, community service, andeducation and training, non-government agencies, universities and speech pathologists in privatepractice.

3. Client Groups and Disorders

Reports of dysphagia are common, especially among people with a disability and those ofincreasing age. The incidence of dysphagia in adults older than 50 years vary between 7 to 44%although this number may be artificially low as clients with this problem do not always seekmedical advice (Wilkinson & de Picciotto, 1999; Bloem, Lagaay, van BeeK, Haan, Roos and

Wintzen, 1990; Tibbling & Gustafsson, 1988).

Up to 25% of hospitalised clients and 30 to 60% of clients in nursing homes experienceswallowing problems (Lin, Wu, Chen , Wang and Chen, 2002); Lee, Sitoh, Lieu, Phua andChin,1999; Layne, Losinski, Zenner and Ament, 1989; Brin & Younger, 1988; Groher &

Bukatman, 1986; Siebens, Trupe, Siebens, Cook, Anshen Shanauer and Oster, 1986).

Precise prevalence figures are not available for childhood dysphagia due to a lack of consistent

diagnostic criteria and an absence of large-scale studies using standard classification schemes. A review of studies conducted in the late 1980s and 1990s cites rates between 2 and 29% inchildren without other developmental or health problems (Kedesdy & Budd, 2001) whereasapproximately 50% of individuals with cerebral palsy have dysphagia (Groher, 1991; Groher &

Bukatman, 1986).





The disorders listed below illustrate the diversity of clients who may experiencedysphagia but are by no means exhaustive.

Neurological

• Cerebrovascular disease

• Traumatic brain injury

•

Brain tumour• Hypoxic brain injury

• Cranial nerve abnormalities

• Meningitis

• Dementia

• Parkinson’s Disease

• Motor Neurone Disease

• Myasthenia Gravis

• Huntington’s Disease

• Multiple Sclerosis

• Cerebral Palsy

•

Developmental disability including chromosomal and congenital syndromes• Post Polio Syndrome

Mechanical

• Cancer

• Tracheostomy

• Cervical spine disease

• Pharyngeal pouch, Zenker's diverticulum

• Cricopharyngeal dysfunction

• Pharyngeal and oesophageal webs

• Oropharyngeal malformations; for example, cleft lip and palate

• Craniofacial anomalies

•

Oesophageal disorders including gastro oesophageal reflux

Surgical

• Head and neck surgery – including oral surgery, partial and total laryngectomy,

thyroidectomy, neck dissections

• Oesophagectomy

• Vascular surgery; for example, carotid endarterectomy

• Cervical spine surgery

• Other surgery involving or gaining access through the head or neck

Trauma

• Intubation injury

•

Trauma to the head and neck; for example, blow to the neck, object penetration• Inhalation burns

Metabolic

• Diabetes

• Thyroid dysfunction

Other

• Radiation to the head and neck

• Age related changes

• Respiratory difficulty; for example, shortness of breath, Chronic Obstructive Airway

Disease (COAD)

•

Scleroderma• Decreased or fluctuating level of consciousness





• Medication; for example, sedatives, antipsychotics, chemotherapy

• Psychiatric conditions

• HIV/AIDS

4. Changes and TrendsThe proportion of speech pathologists' time devoted to the assessment andmanagement of dysphagia has increased markedly over recent years. This has come

about through a number of factors:

• Increased research on the incidence and diversity of client groups shown to be affected

by dysphagia;

• Political factors, such as pressure to reduce length of hospital stay where interventionby speech pathologists for dysphagia is perceived as reducing the incidence ofaspiration pneumonia and the time needed for alternative nutrition;

• Philosophical shift, recognising the value of intervention in improving nutrition, health

and well-being;

• Medical advances which have resulted in speech pathologists treating more medically

complicated patients who are often more acutely ill and therefore more likely to bedysphagic;

• Recognition by health professionals of the role of the speech pathologist in the

management of dysphagia in neonates;

• Improvement of and access to technology available for assessment and treatment;

• The move to evidence based practice underpinning work practice;

• The recognition that teams which include speech pathologists have better outcomes for

clients with dysphagia (Logemann, 1988).

5. Client Services

5. 1 Service Delivery

Speech pathologists assess and manage dysphagia in metropolitan, regional, rural and remotesettings.

They work with individuals across the lifespan and may be employed in hospitals or other healthservices, disability services, community services, non-government agencies, educationauthorities ( Speech Pathology Services in Schools, 2002), residential facilities or private practice.

The speech pathology service provided will depend on the needs of the client, the location, thepolicies of prioritisation and available resources.

5.2 Models of Care

Speech pathologists working with dysphagic clients may utilise a range of service delivery modelsincluding:

• Assessment, diagnosis, and management of dysphagia in both general and specialist

swallowing clinics

• Consultation

• Education of client, carer, health professional

• Resource development and provision

A speech pathologist’s role need not be restricted to a single area. They may work concurrentlyin:

• Different service delivery models

• Provision of services in a variety of facilities

• Provision of student supervision





Provision of service delivery may at times need to be re-evaluated in line with changing needs.These may be influenced by changes in:

• Policy at a Local, State/Territory or Federal government level

• Philosophy of the service provider

• Availability of human and financial resources

6. Referral

6.1 Sources of Referral

Each facility should have a policy documenting from whom referrals can be accepted. Referralsources may include, but are not restricted to:

• Hospital medical staff

• General practitioners

• Nursing staff

• Allied health professionals

• Client/family/carers

•

Teachers

• Blanket referral ie neurology ward

6.2 Methods of Referral

Referrals for dysphagia services may be received verbally (via pager/phone/in person), or inwriting. Each facility should determine the preferred method of referral and ensure all referringagents are aware of how to refer to the speech pathology service.

6.3 Reasons for Referral

A client may be referred for an evaluation of swallowing function based on the presence ofsymptoms of dysphagia or known risk factors. These include, but are not limited to, the following:

•

Oral-pharyngeal disturbances including reduced movement or sensation of oralstructures, weak or incoordinated suck, delayed swallow, weak cough or alterations inrespiratory status during oral intake

• Neurological impairment: birth trauma, stroke, head injury, cervical spine injury, brain

injury, and progressive neurological disease

• Respiratory conditions; for example, excessive oxygen desaturation during feeding,

COAD, chest infection, aspiration pneumonia

• Diminished level of alertness

• Poor oral condition; for example, gum disease

• Presence of tracheostomy

• Dysphonia post extubation

•

Oral-pharyngeal surgery• Presence of feeding tubes

• Feeding dependency

• Premature birth

• Advanced age

• Self report of difficulty swallowing

• Anxiety/fear of swallowing

6.4 Information Required at Time of Referral

• Name and role of the person making the referral

• Consulting physician or general practitioner

•

Client identifying information (e.g. name, date of birth)• Gestational age (where applicable)





• Location of client (e.g. address, ward, contact details)

• Reason for referral (see above)

• Degree of urgency (to assist in prioritisation)

• Medical diagnosis

• Type of nutrition; for example, Nil By Mouth (NBM), Naso Gastric Tube (NGT)

•

Medication and method of administration

6.5 Prioritisation

Dysphagia has been implicated in the development of dehydration and malnutrition (Davalos et al1996), chest infection and pneumonia (Langmore et al 1998; Martin, 1994). Early identification andmanagement is therefore critical in order to prevent or minimise such complications.

Services to clients with dysphagia should be provided in an effective, safe and timely manner.The nature of dysphagia and its potentially serious consequences need to be reflected in

prioritisation of dysphagia services.

Prioritisation systems will vary depending upon the individual service and evidence regarding

‘best practice’ for that setting, the available resources and geographical location. Each serviceshould document its prioritisation process using clearly defined parameters. Prioritisation of newreferrals against the current caseload needs to be considered. Prioritisation policies should be in

accordance with the Code of Ethics (2000).

It is common practice for a benchmark to be set for response time to dysphagia referrals.Reference to local policy and procedures and relevant national, state/territory guidelines shouldbe made.

6.6 Urgent Referrals

The definition of an urgent referral is multifactorial, and will depend on local policies andprocedures. Below are some of the client and clinical factors that should be considered whendetermining urgency:

• Acute versus chronic presentation (e.g. neonates, recent inability to tolerate oralintake,critical care);

• Medical condition (e.g. diagnosed/suspected aspiration pneumonia, documented

coughing, choking or gagging on oral intake or saliva);

• Medical prognosis (e.g. palliative care) (N.B. In some cases it may be too early,

inappropriate or insufficient information may be available to provide a prognosis.);

• Nutritional status (e.g. NBM, with no enteral nutrition, suspected dysphagia withconsequent malnutrition/significant weight loss/failure to thrive);

• Mitigating medical factors (e.g. inability to swallow medication).

In settings where client intake/admission occurs out of regular working hours, consideration

should be given to after-hours management of dysphagia, such as in the evenings, on weekends,or on public holidays. Services should have resources or contingency plans to meet urgent after-

hours needs. This may include having in place procedures that determine the management of aclient who is admitted after hours with dysphagia. For example, clients at potential risk ofdysphagia may be kept Nil By Mouth overnight with hydration until seen by a speech pathologist,

or provision of an on-call speech pathologist on weekends or public holidays. Other teammembers such as medical, nursing, and dietetics staff involved in the care of the client withdysphagia need to be consulted in planning these procedures.

In a community/out-patient setting consideration should also be given to the availability of urgentappointment slots.

Documentation of the prioritisation process as part of a policies and procedures manual enablesthe speech pathology service to provide clients and referring agencies with a rationale forcaseload management decisions.





7. Team Work

Clients should have access to a multidisciplinary team to ensure the provision of a holisticservice. This pertains not only to the evaluation of the swallowing problem and determination ofits aetiology, but also to its treatment and management (Logemann, 1994; Miller & Languor,

1994). The multidisciplinary team works in close cooperation with the client, their family and/or

significant others.

Multidisciplinary teams are cost-effective, and have been shown to improve clients’ weight andcaloric intake, reduce the risk of aspiration, have better outcomes and provide a source ofsupport for clients, and carers (Jones & Altschuler, 1987; Lucas & Rodgers 1998; Martens,Cameron & Simonsen, 1990). In addition the team approach can increase staff awareness ofswallowing problems and their symptoms (Logemann, 1998).

Key team members on the dysphagia management team include:

• Speech pathologists

• Medical personnel - the medical team may include specialists from disciplines such as

otorhinolaryngology, gastroenterology, neurology, paediatrics, radiology, rehabilitationmedicine, respiratory medicine, general practice

•

Dentistry, orthodontics, dental hygienists• Nursing

• Direct support workers/carers

• Client/patient

• Family members

• Physiotherapists

• Occupational therapists

• Social workers

• Dietitians

• Pharmacist

• Other team members may include, but are not limited to, radiographers, teachers,

psychologists and social workers.





8. Assessment, diagnosis and management

Assessment, Diagnosis and Management Flow Chart(The headings and their application in this flow chart are expanded over the page)

Background history

↓ Immediate observations

↓

Communication status

↓ Clinical oropharyngeal assessment

Suitable for oral trials Unsuitable for oral trials

↓

Referral for instrumental assessment (as appropriate)

↓ Overall impression / Diagnosis

↓

Management plan

The speech pathologist is essential to the assessment and management of the client, includingscreening, clinical or bedside assessment, instrumental assessment and swallowing treatment.Dysphagia management is a seamless process that may begin in the acute phase of medical

intervention and proceeds as the client advances through the continuum of care. Services can beintroduced at any stage of the continuum and“… will terminate when the client is either nutritionally stable or able to eat at his or her highest

functional level with or without swallowing compensations” (Sonies, 2000, p.101).

Information in all sections below should be applied as pertaining to the workplace. That is,prenatal history will be relevant for those assessing paediatric clients but not for those in aged

care; similarly jaw function will be evaluated using different parameters depending on whether theclinician is assessing chewing of solids or sucking from a bottle.

When assessing the client, ensure that any aids for communication, vision and hearing areavailable for the examination. Clinicians must comply with occupational health and safety

requirements; for example, gloves, eye protection, nose mask, hand washing, currentimmunisation (e.g. Hepatitis B).

Even when a client is non-compliant with the assessment, or aspects thereof, it should bedocumented that assessment of these areas was attempted.

See the glossary for further information and references for the following techniques.

8. 1 Background History

Basic Competence implies the basic knowledge that would be expected from a grade one/new

graduate speech pathologist. Advanced Competence implies a greater knowledge andunderstanding of how additional physical, mental and physiological factors can impact on

swallowing. These skills are expected of clinicians who operate specialist clinics, have greaterexperience and or are at higher grades. These competencies should be supported by evidence-based practise and supporting research where available.





Basic Competence Advanced Competence

• Relevant background history

(prenatal/birth history, developmentalhistory including feeding, biographical,cultural, religious, behavioural, surgical)

•

Knowledge of previous speech pathologyinvolvement including the relevant reportswhere available

• Previous swallowing or related difficulties

• Medical history/diagnosis

• Nutritional, respiratory and cognitivefunction)

• Premorbid nutritional status, includingmethod of intake

• Current form and method of nutrition

(including breast, bottle, tube feeding forinfants, texture, technique and

precautions)• Vision and hearing

• Education/vocation

• Prognosis

• Client’s/carer’s goals

• Communicable diseases

• Relevant medications and their method of

administration (e.g. liquid/tablets etc.)

• Related issues such as gastro-

oesophageal disorders

• History of current swallowing difficulties

• Potential side effects of medications on

swallowing, appetite, salivary function,alertness and nutrient absorption

• Review relevant x-rays/x-ray reports

when applicable

8. 2 General Observation


• Level of alertness/responsiveness

• Posture/position

• Level of activity/mobility

• Presence of nasogastric tube,

tracheostomy tube (size, type),gastrostomy tube, intravenous line,central line

• Implications of the presence of a

nasogastric tube or tracheostomy tube onswallowing function

• Ability to be positioned in optimal feedingposition and number of staff required toobtain same

• Presence of primitive and/or abnormal

reflex patterns

• Respiratory function at rest and during

speech where applicable

• Spontaneous swallow frequency

• Presence of oral dyspraxia

• Oxygen requirements/oxygen saturation

levels if available

• Knowledge of causes and implications of

variations in body temperature regulation

• Hand to mouth coordination

• Mouthing behaviours

• Shortness of breath (SOB)/respiratoryrate for all clients with a respiratory

diagnosis





8.3 Communication Status(Assessment of communication status may not be applicable in infants or in some adults.)


• Orientation

• Comprehension

•

Hearing

• Speech/vocalisation/intelligibility

• Language

• Voice quality

• Obtain interpreter if required (refer toworkplace policy and procedures)

• Assessment of need for augmentative

and alternative communication strategies

in the event of complex communicationneeds

8.4 Clinical Oropharyngeal Assessment


• Inspection of face, oral cavity and

oropharynx

• Comment on structure, symmetry,sensation

• Ensure oral cavity is cleared prior toassessment

• Oral tissue (colour/moisture/integrity)

• Speech production and oral motor (praxis)

tasks

• Cranial nerve assessment

• Saliva management

• Airway protection

• Oral hygiene• Presence and condition of teeth

• Visuoperceptual ability

•

Knowledge of the maturation of theswallow

8.5 Suitability for Oral Trial


Evaluate and comment on

• Level of alertness

• Airway protection

• Positioning

• Fatigue

•

Voice quality• Impact of the environmental setting

In addition

• Familiarity with emergency procedures for

aspiration/choking

• Ensure physiotherapist/nursing staff

available if required (e.g. tracheostomyassessment)

• Knowledge of the importance ofstrategies for optimal positioning

• Knowledge of the impact of spinal

deformity on lung and gastric function

• Competency in the assessment andmanagement of tracheostomy.





8.6 Oral Trial / Bedside Examination / Mealtime Observation


Comment on

• Mouth opening

•

Lip seal/spillage• Lip closure on spoon

• Sucking ability

• Jaw function

• Tongue function/movement

• Chewing efficiency

• Oral control of bolus

• Efficiency of oral transfer

• Oral residue post swallow

• Initiation of swallow

• Laryngeal elevation/hyoid movement

•

Cough• Swallow-respiratory coordination

• Voice change

• Rate/quantity of bolus given

• Trial appropriate management strategies

(e.g. swallowing manoeuvres – seetreatment section)

• Impact/use of mealtime equipment

• Impact of taste, temperature, size of boluson swallowing

• Carer participation/skill and knowledge

• Knowledge of how feeding dependence

vs independence can affect swallowing

•

Associated mealtime behaviours; forexample, PICA of foreign objects,regurgitation, distractibility

• Impact of nasal congestion/upper

respiratory tract infection on taste andswallowing

• Impact of cranio-facial abnormalities onswallowing

8.7 Referral for Instrumental Assessment (as appropriate)


Knowledge of the application andlimitations of, and suitability for,videofluoroscopic evaluation

Knowledge of the application, limitations andsuitability of the following assessments:

• Fiberoptic endoscopic evaluation ofswallowing (FEES)

• Cervical auscultation (CA)

• Pharyngeal manometry

• Pulse oximetry

•

Ultrasound• Nuclear scintigraphy

• Blue dye test (Trache clients only)

• Electromyography





8.8 Overall Impression


• Integration of significant features gained

from background, observations,

communication status, clinicalassessment, suitability for oral trials,instrumental assessment and swallowingtrials

• Comment on possibility of gastro

oesophageal dysfunction and its effect

on oropharyngeal swallowing disorders• Relate communication/feeding/

swallowing to other areas of physicaland cognitive function

8.9 Diagnosis


• Document type of dysphagia: preparatory;

oral; pharyngeal; oesophageal

•

Describe the underlying causes• Determine and document severity: mild/

moderate/severe/profound. Relate toexpectations of normal developmentwhere applicable

• Evaluate risk of aspiration and airway

obstruction

• Describe contributing factors such as

medication regime

8.10 Management Plan


• Recommendation of oral or non-oral

status

• Awareness of implications of non-oral

intake

• If oral intake recommended, indicate foodtexture and fluid consistency

• Recommended method and equipment

for feeding (e.g. breast/bottle, spoon)

• Advise on optimal positioning for feeding/

swallowing

• Recommended bolus size and rate of

intake• Advise re client’s ability to takemedication or the need to modify this

• Reiterate the need for a formal oral care

plan for all clients

• Education of client, carer or medical team

to reduce risk of aspiration and/orimprove swallow function

• Use of appropriate AAC strategies as

indicated

• Identify and teach strategies/techniques

to optimise oral intake

Identify and teach strategies/techniques to assistprogression to oral intake

• Advise client/family/carers of treatment

• Where available apply appropriate

outcomes tool to measure changes






options, their risks, benefits, efficacy andevidence base

• Document proposed frequency and form

of intervention; for example, ongoingassessment, treatment, monitoring,

intermittent reviews• Institute a mealtime management plan for

staff/carers detailing all the aboveincluding: when not to feed, under whatcircumstances oral intake should beceased, and when to initiate a speechpathology review

• Involve the client in the management plan

• Recommend/document the need for

further medical/allied health assessment ifindicated

• Collaboration with multidisciplinary team

in provision of recommendations toaddress nutritional needs, seating andpositioning, equipment for meals/feeding,and respiratory health

• Consideration of legal and ethicalimplications in design of managementplan

9. Treatment

Treatment plans should only be formulated following the assessment of the client’s swallowing

abilities. The treating speech pathologist must be able to determine and describe the presentingsymptoms, which aspect(s) of swallowing function is impaired (e.g. poor airway protection), andthe cause of dysfunction (e.g. vocal fold paresis caused by recurrent laryngeal nerve damage) to

enable the introduction of appropriate treatment.

The goals of effective dysphagia management/treatment include:

1. Increasing swallowing efficiency (through intervention)2. Increasing swallowing safety, to minimise aspiration risk. (Whilst all care should be taken

to reduce risk it cannot be fully eliminated. Thus considered evaluation of risks andbenefits are critical in determining management.)

3. To recommend the most appropriate diet/fluid consistency and to determine whentransition from one form of nutrition to another is appropriate, such as from enteral tooral, or puree to a soft-chopped diet

4. To determine, in conjunction with a dietitian and/or medical officer, the most appropriatemethod to maintain or increase nutrition and hydration; this may include oral, or non-oralmeans, or a combination of these

5. Maximising the social aspect of eating/drinking where possible

Effective management includes the ability to recognise:

1. Factors which are impeding progress and the ability to modify goals and treatmentprograms accordingly

2. The need for involvement of other service providers

3. The need for involvement and support of family/carers4. When goals have been achieved and services should cease





Logemann (1998) reports that the key to effective dysphagia management is understanding aclient’s anatomy and swallow physiology, medical diagnosis, and prognosis. Client managementwill also differ according to individual client needs.

Logemann (1998) divides treatment into two general categories of management, these beingcompensatory management and therapeutic strategies. Compensatory management includes the

use of techniques to compensate for loss of function. Compensatory strategies are utilised toassist in altering the flow of the bolus in a way that compensates for compromised oropharyngealfunction, without changing the underlying physiology (e.g. head turn, chin tuck). In contrast,

therapeutic strategies are designed to improve swallow function by changing the underlyingswallow physiology and facilitating optimal functioning of available oropharyngeal structures (e.g.improving the strength and range of movement of muscles used in swallowing). Swigert (2000)

identifies that some treatment techniques can be both compensatory and therapeutic (facilitative).Swigert (2000) uses the example of the super-supraglottic swallow being used as a therapeuticstrategy to close the airway entrance before and during the swallow. In doing so the risk of

misdirection of food into the airway is reduced allowing oral intake. The swallow is still impaired;however the technique allows the person to compensate sufficiently to eat.

The application of therapeutic strategies depends on several factors, including client ability,clinical competence and the resources available at the speech pathology clinic. In some

instances other team members (e.g. nursing staff), the client and / or the client’s next of kin maybe trained by the speech pathologist in compensatory or therapeutic strategies.

An outline of recognised compensatory and therapeutic strategies is listed below. The list is notexhaustive and should be used as a guide only. For more detail on specific treatment techniques,their use and application, clinicians should seek appropriate texts and journal publications. Inselecting suitable strategies clinicians must evaluate the suitability of the treatment based on theclient’s needs, and the perceived outcome. Clinicians should also ensure that where possible thetechniques selected are underpinned by evidence and that the basis of this evidence be regularlyevaluated.

For convenience, the techniques are presented according to recognised stages of swallowing;however, these can in no way be considered discrete as the success or failure of each stage will

have flow-on effects to other aspects of the swallow. In the management of adult clients,strategies are defined as compensatory and rehabilitative (therapy); however, it should be noted

that any compensatory strategy that results in swallowing (either of bolus or saliva) is alsorehabilitative. In paediatric management the intervention seeks to facilitate normal developmentalstages and the refinement of oral feeding skills. In effect, both seek to establish successful oral

nutrition whilst minimising risk.

Finally:

• Strategies associated with swallowing disorders with clients with tracheostomies are

not dealt with in this paper.

• Techniques annotated with an * may be new and require further research and/or mayrequire the clinician to avail themselves of further training.

• Surgical and medical procedures such as cricopharyngeal myotomy, laryngeal

diversion, botulinum toxin injection, vocal fold injection to improve airway closure ormedication designed to affect saliva are not addressed as these practices are beyondthe scope of the speech pathologist. The speech pathologist, however, should be awareof these options and when and to whom to refer.

• Biofeedback may include a number of instrumental techniques including manometry,

videofluoroscopy, cervical auscultation, respitrace and glottography.

• Training in the use of Cervical Auscultation and SEMG is highly recommended before

use.





9.1 Oral phase disorders

Possible indicators Possible strategies

Clinical:

• Spillage from the lips

•

Oral pooling or residue post swallow• Prolonged oral phase

• Reduced tongue movement (may include

weak suck)

• Multiple swallows

• Biting of soft tissues

• Loss/change of taste, temperatureperception

Instrumental:

• Poor bolus preparation

•

Poor bolus propulsion• Prolonged oral phase

• Premature loss of bolus

Compensatory:

• Postural (chin up/down)

•

Positioning (e.g. seating)• Labial/chin support

• External pressure to cheek

• Dump & swallow

• Modified texture diet

• Lip and tongue exercises

• Changing sensory input (taste,

temperature)

• Changing feeding process - considerrate, presentation of food, assistivedevices, placement of equipment intomouth

•

Dentures in situ

• Oral hygiene

• Teach client to clear mouth (finger,

cheek muscle recruitment, rinse / spit)

Contd. Over…


Rehabilitation:

•

Targeted oro-motor exercises (lips,tongue tip/blade/base, buccal, jaw)

• Mouthing toys to increase strength anddecrease hyper-sensitivity

• Targeted instrumental techniques which

are used as a biofeedback measure inmuscle strengthening (SEMG, Electricalstimulation)*

9.2 Velopharyngeal disorders


Clinical:

• Misdirection of food or fluid to naso-pharynx

• Slow/prolonged breast/bottle feeding

• Hypernasal speech/vocalisation

Instrumental:

• Loss of food fluid to naso-pharynx

• Inappropriate tongue humping

• Poor velopharyngeal closure for

swallow

Compensatory:

• Palatal prosthesis

• Selection of specialised equipment such asteats or straws

• Texture modification of food/fluids

Rehabilitation:

• Velopharyngeal exercises





9.3 Oropharyngeal transit disorders

Possible indicators Strategies

Clinical:

•

Delayed onset of swallow• Uncoordinated suck-swallow


• Coughing/gagging on swallowing

Instrumental:

• Sounds of food/fluids in pharynx priorto initiation of swallow on cervicalauscultation

• Sounds of swallow-respiratory

incoordination on cervical auscultation

• Bolus to valleculae/pyriform prior to

initiation of swallow.

Compensatory:

•

Chin tuck• Enhancing sensory input


• Changing bolus size

• Selection of specialised equipment such as

teats or straws

• Modifying texture of food/fluids (thicker)

• Modified rate of intake

• Supra-glottic swallow

Rehabilitation:

• Brushing & icing/thermal tactile stimulation

•

SEMG/Biofeedback *• Electrical stimulation *

9.4 Pharyngeal disorders


Clinical:

• Reduced laryngeal excursion


• Altered voice quality (wet voice)

•

Coughing/gagging on swallowing

Instrumental:

• Increased sounds post swallow oncervical auscultation (e.g. gurgling,wet respirations or increasedrespiratory rate)

• Reduced base of tongue to

pharyngeal wall

• Inadequate or untimely epiglotticdeflection

• Uncoordinated swallow

•

Asymmetry• Pharyngeal residue

Compensatory:

• Head rotation/tilt

• Super-supraglottic swallow

• Effortful swallow

Rehabilitation:

• Pharyngeal range of movement exercises

(vocal fold/tongue base & pharyngeal wall,laryngeal elevation

• Masako (tongue hold) manoeuvre

• Shaker (head lift) exercises

• SEMG/biofeedback *

• Electrical stimulation to improve muscle

strength*





9.5 Cricopharyngeal disorders


Clinical:• Client complains of food sticking in

throat


• “Hoicking”/throat clearing

Instrumental:

• Reduced upper oesophagealsphincter opening (duration or degree)

• Residue in pyriform sinus

• Uncoordinated swallow

• Reduced laryngeal elevation

Compensatory:• Mendelsohn (laryngeal elevation) manoeuvre

• Modification of food/fluids (thinner)

Rehabilitation:

• Effortful swallow (co-ordination)

• Shaker manoeuvre (laryngeal excursion)

• SEMG to train Mendelsohn and Effortfulswallows

9.6 Penetration + aspiration


Clinical:

• Wet voice

• Throat clearing

• Cough

• Change in breathing pattern

• Fever

•

Change in lung status

Instrumental:

• Sounds of food/fluid entering larynx

prior to swallow initiation (CA)

• Wet respiration post swallow onauscultation

• Penetration to laryngeal vestibule/

through vocal folds

Compensatory:

• Optimal positioning during feeding/swallowing

• Supraglottic swallow

• Rate/pacing of intake

• Modification of feeding equipment

• Super supraglottic swallow

• Effortful swallow

• Texture modification of food and fluids

(thicker/smoother) *

• Free water protocol *

• Alternative feeding (NG, PEG)

Rehabilitation:

• Biofeedback (Respiritrace, Glottograph) *

• SEMG to support effortful swallow *

• Shaker manoeuvre (hyo-laryngeal elevation)

* may be new and require further research and or may require the clinician to avail themselves offurther training

10. Documentation

Documentation should ensure all medico-legal and accreditation requirements are met. Thorough

documentation is important and should include but not be limited to:

• A baseline of the client’s condition

• Assessment results and management plan

• Progress or decline

• Changes in the client’s condition which may impact on progress

•

Advice to staff and/or carers• Precautions





• Recommendations for further investigation

• Reasons for ceasing treatment/intervention

Speech pathologists need to ensure that advice is recorded in writing. Verbal information, adviceor management changes should be followed up by written confirmation. The speech pathologistshould also refer to their employer’s departmental policy, relevant legislation and guidelines

10.1 Timelines

Documentation following client contact should occur in a timely manner as appropriate to therequirements of the service. This should be clearly defined in each service’s Policy and Procedure

manual.

10.2 Standards

Standards of documentation should be specified in local organisational Policy and Procedure

manuals. The following is recommended as a minimum standard:

• Brief summary of background information – relevant medical history, medications,

current medical diagnosis and reason for referral.

•

General observations; for example, posture/positioning, presence of feedingtubes/oxygen, cognitive status and alertness; current feeding status.

• Communication: brief summary of speech and language and functional communication.

• Clinical oromuscular assessment: all structures and their function to be commented on,even when no abnormalities are detected (lips, tongue, palate, voice, cough, laryngealand hyoid movement).

• Decision related to advisability of conducting an oral food trial.

• Swallow function based on the oral trial or mealtime observation. In some cases more

than one assessment may be indicated and the rationale for delaying judgement shouldtherefore be documented. The outcome of the food/fluid trial, including the amounttaken, and level of assistance required.

• Manoeuvres/strategies trialled and their effectiveness.

•

Overall impression and diagnosis: integrate assessment results, including severity,significant features of the swallowing function, provide a dysphagia diagnosis byexpounding the underlying causes, presence or absence of signs of laryngealpenetration, perceived aspiration risk from oral intake or saliva.

• Plan/Goals - Determine and provide therapy plans including: diet/fluid modifications;Strategies for swallowing (including medications); Referral to other agencies; Referral forinstrumental assessment if clinically indicated; Timeline for review; Signs which indicatethat the client should cease oral intake and be reviewed by speech pathology as amatter of priority. Document whether this plan has been communicated to other teammembers and/or relevant others.

• As in other areas of practice, all documentation must be signed, dated and when part ofnursing or progress notes, the time should also be included.

10.3 Reporting requirements

• It is important that speech pathologists report on findings of assessment and progress

or outcomes of intervention according to Speech Pathology Australia guidelines ondocumentation and maintenance of individual records.

• It is recommended that speech pathologists report back to the referral agency regarding

assessment findings in language that can be understood by the referring agent, whetherthis be a relative/family member /carer, a medical practitioner, teacher, or other alliedhealth professional.

• Reports should provide case specific recommendations for management of anindividual’s dysphagia.

Care must be taken to ensure that all reports remain confidential and reports conform to theprovisions of the relevant privacy legislation.





The service is expected to establish an appropriate system for the preparation and storage ofwritten documentation including assessment results, reports, client management plans,interventional goals, progress notes and outcomes. Reference should be made to local policy.

10.4 Discharge and Resolution Planning

Once a client is discharged from Speech Pathology care, documentation regarding the rationale

for discharge and need for an ongoing treatment program should be specified in the client’smedical file or speech pathology file, whichever is applicable.

Reasons for discharge may include the following:

• Goals achieved

• Client reached optimal pre-morbid level of functioning

• Intervention inappropriate (due to medical deterioration, lack of client/carer cooperation,

as determined by medical team)

• Client discharged from hospital

• Client/carer fails to attend

• Client transferred to another facility/speech pathology service

•

Client’s level of function plateaued

• Client deceased

People to be informed of client’s discharge status:

• Medical team and/or caring practitioner

• Client/family/carer

• Relevant health professionals involved in client’s care

Should the client require ongoing care, with the client’s permission a written care plan including

the following information should be forwarded to the client /carer and all health professionalsinvolved:

• Background information of client

•

Speech pathology intervention and progress to date (including currentrecommendations, outcomes of instrumental assessment and management plan)

• Recommendations for follow up by health professionals as indicated (e.g. private

speech pathologist, dietitian)

10.5 Confidentiality

Client documentation is to remain confidential at all times in accordance with the Code of Ethics (Speech Pathology Australia, 2000), CBOS (Speech Pathology Australia, 2001) and relevant

privacy legislation.

The storage, duration and appropriate means of disposal of client information should be asspecified by organisational and state/territory requirements.

11. Education and Counselling

11.1 At Referral

• Provision of information that answers, “What is dysphagia?”

• Explanation of the risks associated with dysphagia

• Explanation of symptoms/signs for the client, which might be consistent with dysphagia

• Explanation of the assessment process

11.2 After Clinical Assessment

• Explanation of the results of the assessment, including prognosis





• Explanation of further assessment that may be warranted

• Presentation of the proposed management plan, including rationale and discussion ofany risks associated with that plan (e.g. risk of dehydration that may be associated withpoor intake of thickened fluids). This may also include provision of information regarding

methods and outcomes of alternative/supplementary feeding.

• All information must be balanced, evidenced based where possible and presented in lay

terms. Visual presentation to support verbal information (diagrams text, video andcomputer images and anatomical models) may assist and should be used asappropriate.

11.3 Prior to Discharge

• Ensure that the management plan is understood by all parties involved.

• Ensure that strategies are in place to support that plan.

• Ensure that client/carer is aware of signs / symptoms associated with a deterioration inswallowing function and aspiration-related complications. Provide information on whatto do and who to contact in this event

• Negotiate appropriate follow-up with the client/significant others.

11.4 Client/Carer Education

The managing speech pathologist should ensure that where training is required for the client or

carer to implement a management plan that they are provided with an optimal method tomaximise understanding of what is required. This may include use of interpreters, visual andwritten aids.

12. Services Management

12.1 Qualifications

Speech pathologists should be eligible for Practising membership of Speech Pathology Australia.Further information is available from the Speech Pathology Australia website athttp://www.speechpathologyaustralia.org.au

12.1.1 Skills and Minimum Standards

It is recommended that the speech pathologist dealing with a person with dysphagia hasknowledge of and skills to fulfil minimum standards for management of dysphagic clients

as documented in this paper. The level of skill may need to be identified for bothemployer and employee prior to appointment. A speech pathologist should recogniseand acknowledge their limitations and not work beyond the scope of their competence(Speech Pathology Australia, 2000, Code of Ethics, Section 5.3; Speech Pathology Australia, 2001, CBOS ). Where skill is lacking appropriate training, supervision and

mentoring should be sought.

12.2 Professional Development

All practising speech pathologists are:

• Encouraged to maintain, update and extend their knowledge through participation inongoing professional development activities (Speech Pathology Australia, 2000, Codeof Ethics );

• Jointly obligated with the service employer to identify individual training needs and

negotiate as to the most appropriate method to achieve this (Speech Pathology Australia, 2001, Principles of Practice );

• Expected to undertake self–education activities as part of this commitment to

professional development such as participation in the Professional Self Regulationprogram conducted by Speech Pathology Australia;

•

Encouraged to share their knowledge and expertise with their colleagues (SpeechPathology Australia, 2001, Principles of Practice );





• Support others who are expanding the knowledge base of the profession (SpeechPathology Australia, 2001, Principles of Practice ).

12.3 Information Technology

Access to information technology has become an integral component of service delivery and

professional development. Organisations should aim to provide access to information technologyfor staff.

12.4 Budgets

Budgetary considerations may limit the extent of resources available. For this reason documentedprioritisation will assist with service provision.

12.5 Workplace Health and Safety Issues

Employers are legally obligated to provide a suitable work environment. This should comply withCommonwealth, State and local regulations for building, fire and safety. Individual requirementswill vary according to the method of service provision. General standards are outlined in the

Principles of Practice (Speech Pathology Australia, 2001), and specific information pertaining toschools can be found documented in the Speech Pathology Services in Schools Position Paper

(Speech Pathology Australia, 2003). Policies should exist for:

• Infection control

• Occupational Health & Safety requirements for conducting instrumental swallowing

assessments

• Manual handling

• Emergency evacuation

• Staff requirements in Cardio-Pulmonary Resuscitation (CPR), fire training

• Management of Coughing and Choking policy

• Mealtime assessments in external facilities (i.e. schools)

• Duty of care

12.6 Physical Resources

Equipment of a sufficient standard should be supplied to allow the speech pathologist to fulfil theminimum requirements for assessment, and treatment of dysphagia.

12.7 Continuous Quality Improvement

• The practising speech pathologist should be aware of and performing continuous

quality improvement activities in relation to dysphagia management.

• Quality procedures are an integral part of continuous quality improvement.

Development of quality procedures should be related to evidence based best practice and any

guidelines or standards outlined by Speech Pathology Australia.

12.7.1 Measuring methods

• Measurement tools are wide and varied, and range from clinical observationalmeasures and reports of significant others, to checklists, screening tests, andassessments designed to measure presence of symptoms of dysphagia andseverity of dysphagia. The most frequently used outcomes tools in Australia arethe Therapy Outcome Measures Dysphagia Scale for a) Disability (TOMDD) and b) Impairment (TOMDI) and the Royal Brisbane Hospital Outcome Measure forSwallowing (RBHOMS) (Gupta, 1998)

• Such measures may be utilised before, during and after intervention

• It is important that the speech pathologist is aware of available tools and is

competent, in recognising when to use them and how to interpret them

•

Speech pathologists should be aware of the World Health Organizationdefinitions for health, disease, body structure and function, and need.





12.8 Marketing and Public Relations

Speech pathologists should liaise with their supervisor regarding policies on media contact.Caution should be exercised in any public statements and when talking to the media individualsshould clearly state whom they are representing. Further information may be found in the

Principles of Practice (Speech Pathology Australia, 2001). It is expected that speech pathologists

will act in accordance with the Code of Ethics (Speech Pathology Australia, 2000).

13. Education

13.1 Clinical Education

• All Australian university speech pathology courses equip students with basic skills indysphagia (Speech Pathology Australia, 2001, CBOS ). Practical skills in the area ofdysphagia are, however, dependent upon the individual student’s clinical placement.Whilst every effort is made to ensure students receive sound practical skills, individualstudent’s experiences will vary from setting to setting.

• Speech pathology students should be provided with the opportunity to observe anexperienced speech pathologist conducting a dysphagia assessment and interventionwhere possible.

• Speech pathology students should be provided with the opportunity to participate as

much as their skill allows in the assessment, interpretation and management of clientswith dysphagia during their clinical training where possible.

• The supervising speech pathologist may provide the opportunity for students to

become clinically competent in the assessment and treatment of dysphagia howeverthey ultimately maintain clinical responsibility for the clients’ care.

13.2 Staff Training

• Speech pathologists have an important role in contributing to the training of other health

professionals in identifying symptoms of dysphagia.• Speech pathologists may train, monitor and supervise other health professionals

involved in supporting a client with dysphagia.

• Training may include provision of information, demonstration, supervision or monitoring

of practice of other staff about an individual or a group of people with dysphagia. Thistraining may enable other staff to carry out therapeutic manoeuvres as recommendedby the speech pathologist with an individual on a regular basis, in order to effect agreater response to that intervention. The speech pathologist has a responsibility totailor the level of information to the needs and abilities of the person receiving thetraining. Documentation detailing the information provided in such training sessions isrequired. Any variations to these instructions must be given in writing. The speechpathologist must document at what point they are transferring duty of care. Speech

pathologists maintain the responsibility for monitoring, supervising and altering thetreatment program.

13.3 Research

• A large proportion of dysphagia research is mediated by teaching staff at AustralianUniversities.

• There are a growing number of post-graduate courses at Masters and Doctoral level

(PhD and Professional Doctorate) that provide opportunities for research intodysphagia.

• Speech pathologists in clinical practice should be encouraged to apply the rigors of

research to their quality improvement projects and to share their results with speechpathology colleagues in clinical and research communities.





13.3.1 Funding

• Postgraduate positions and research grants may be available through philanthropictrusts, universities, Speech Pathology Australia or in conjunction with the speechpathologist’s place of employment.

• Some tertiary institutions have initiated conjoint research positions that span the

university, health or educational setting.• From time-to-time State and Federal government bodies may offer health-related

grants. Although often very competitive, these grants should be investigated as asource of research funding.

14. Legal Issues

The following matters should be considered by speech pathologists working with clients withdysphagia.

14.1 Code of Ethics

Speech pathologists should adhere to the Speech Pathology Australia Code of Ethics (2000) and

to any codes, directions or principles applicable to the body employing the speech pathologist,(e.g. Code of Conduct for the Victorian Public Sector).

14.2 Knowledge and Skills

Speech pathologists working with clients with dysphagia should understand and possess theskills to meet standards for speech pathology services documented in this position paper. Theemploying body or service purchaser may determine the level of skill which it requires prior to

appointment of the speech pathologist. All speech pathologists should understand theCompetency Based Occupational Standards (CBOS) for Speech Pathologists (Speech Pathology

Australia, 2001).

Speech pathologists should undertake any mandatory training required of employees of theemploying body or service purchaser; that is, workplace, health and safety training, childprotection training.

14.3 Speech Pathologists’ Responsibilities

Individual speech pathologists’ responsibilities will usually be identified in their positiondescription, employment contract, contract for services, or policies and procedures of the school,the employing body, or service purchaser.

However, regardless of the specified responsibilities, the law imposes a duty on all speechpathologists to exercise reasonable care and skill in the provision of advice and treatment (i.e. anobligation to exercise the ‘standard of care’) where the speech pathologist owes a duty of care

(see section 14.4 below).

14.4 Duty of Care

A speech pathologist owes a duty of care to another person where the speech pathologist oughtreasonably to foresee that their conduct may be likely to cause loss or damage to a class ofpersons to which the other person belongs. On this basis, it is clear that speech pathologists

owe a duty of care to their students. Speech pathologists may also owe a duty of care to theiremploying body or service purchaser.

Where a speech pathologist owes another person a duty of care and the speech pathologistbreaches the standard of care required, (either by a specified act, a failure to act, or providingmisleading information or advice), the speech pathologist may be liable for damages in a civil

action brought by or on behalf of the person to whom the speech pathologist owed the duty of

care.





14.5 Standard of Care

The standard of care which must be exercised by a speech pathologist is the reasonable careand skill of the ordinary skilled speech pathologist exercising or professing to have this specialskill. It is important to note that an inexperienced speech pathologist must meet the standard of a

reasonably competent and experienced practitioner providing speech pathology services.

Accordingly, a speech pathologist who is aware that they lack the required level of skill in aparticular area must seek further advice and guidance immediately. Such further advice and

guidance may involve requesting support from a more experienced speech pathologist, theemploying body or the service purchaser.

The courts will determine the standard of care required of a speech pathologist in each particularcase. In the past courts have found medical practitioners to be negligent; that is, to havebreached the standard of care required, notwithstanding that the medical practitioner’s treatmentwas in accordance with a practice accepted as proper by a reasonable body of medical opinion

skilled in the relevant field. However, a court must have strong reasons for substituting its judgement for the clinical opinion of the medical practitioner where it has been properly arrived atand is supported by a responsible body of medical opinion. Accordingly, speech pathologists’advice and treatment should always be in accordance with practices accepted as proper by areasonable body of opinion skilled in speech pathology, but speech pathologists should be aware

that acting in such a manner will not automatically preclude a court from finding them negligent.Further, it is important that speech pathologists are aware of recent literature in their field, currentbest practices carried out by others in their field, and Speech Pathology Australia’s Code of

Ethics (2000).

14.6 ‘Proxy’ Intervention

Where a speech pathologist does not carry out an intervention personally, and instead instructs

and/or supervises another person carrying out the intervention, the speech pathologist may beliable for any negligence resulting from the intervention, irrespective of the fact that the speechpathologist was not carrying out the intervention personally. The law refers to this as ‘vicarious

liability’ and it may render the speech pathologist liable where their agent or ‘proxy’ breaches theduty of care owed by the speech pathologist while the ‘proxy’ acts as a representative of the

speech pathologist. Therefore, it is necessary for ‘proxies’ to exercise the same standard of careas that required of the speech pathologist instructing or supervising them, and for alldocumentation (i.e. Individual Education Plans, progress notes, negotiated contracts) regarding‘proxy’ interventions to be maintained. In addition, the service plans must include adequate timeand resources to train ‘proxies’ and monitor programs.

14.7 Consent for Speech Pathologist Involvement

The speech pathologist must obtain the client’s consent prior to providing speech pathologyservices, including assessment, to the client. The client must be informed in broad terms of thenature of the treatment to be provided prior to giving consent. Consent should be in writing and is

invalid unless it is voluntary. A client under the age of 18 years can consent to the provision ofspeech pathology services, provided the client has sufficient intelligence and maturity tounderstand the nature and consequences of the particular treatment. Where the client lacks the

capacity to consent, or their capacity to consent is in doubt, the consent of the client’s parent orguardian must be obtained.

All processes employed by speech pathologists should adhere to privacy legislation and freedomof information legislation.

14.8 Indemnity Cover and Insurance

It is the responsibility of speech pathologists to ensure they have appropriate professional

indemnity insurance cover. Professionals should be aware that there may be instances where theemploying body will not necessarily indemnify them for their actions. It is recommended that allpractising Speech Pathology Australia members have professional indemnity insurance.





Speech pathologists should clarify the insurance situation for accidental loss, theft or damage toresources during transport with their insurer.

14.9 Service Guidelines

It is recommended that the speech pathologist adhere to all approved guidelines of the

employing body in terms of clinical and service management.

14.10 Summary

In summary, a speech pathologist managing clients with dysphagia should:

• Adhere to the Speech Pathology Australia Code of Ethics (2001) and any employing

body’s code of conduct.

• Adhere to the code of conduct and all relevant policies/service guidelines of the

employing body.

• Not undertake intervention that is outside their experience or expertise as aprofessional.

• Not overstate their expertise.

•

Seek advice from senior speech pathologists and/or fellow professionals asappropriate.

• Prior to treatment, obtain the client and/or parent/guardian’s consent to treatment.

Admission to hospital may imply global consent in some instances or a generic consentmay be obtained on admission

• Keep the client and parent/guardian well informed of the intervention program.

• Keep up-to-date with professional developments.

• Ensure that proxies receive suitable training.

• Undertake all mandatory training.

• Keep accurate records.

• Ensure that all advice given to the client, parent/guardian, professionals or staff is

documented.

•

Keep copies of all reports.

• Keep up-to-date with report writing.

• Ensure that the client environment is safe.

• Ensure that there is adequate professional indemnity insurance cover.





Appendix A: Glossary of Assessments of Dysphagia

A.1 Bedside or clinical dysphagia assessment

The bedside assessment, unlike the cranial nerve assessment examines the dynamic integration

of oral pharyngeal function during swallowing. Miller (1992) documented that the aims of anydysphagia examination are to: (a) establish the possible cause of dysphagia (b) assess theperson’s ability to protect their airway (c) determine the likelihood of safe oral intake (d)recommend alternative nutritional management (e) determine the need for further diagnosticstudies and (f) establish a baseline of clinical data. It is true that at its most basic level it indicatesa client’s ability to eat and drink. However it can tell a clinician much more than this. Observationsof alertness, independence, decision making, and visuoperceptual skills can be made. Thebedside, or clinical dysphagia assessment, is one of the most controversial, yet widely usedassessments of dysphagia. This clinical assessment is unreliable in detecting aspiration andidentification of aspiration should not be the purpose of the swallowing assessment (DePippo etal., 1992; Groher, 1994; Linden et al., 1993; Ruf & Stevens, 1995; Splaingard, Hutchins, Sulton &Chaudhuri, 1988). Rather it is an evaluation of the entire mealtime event. This is especiallyimportant for those clients for whom more invasive investigation would be difficult or in whom itmay be contra-indicated. In these situations, efforts should be made to use additional non-

invasive assessments such as pulse oximetry or cervical auscultation.

A.2 Blue dye test

The blue dye test has been previously used with clients with a tracheostomy tube in situ. Theclient is given fluid or food impregnated with an inert blue dye, obtainable upon prescription.

Saliva may also be impregnated with blue dye. Following administration of the bolus, thepresence of blue dye in or around the tracheostomy tube is noted upon suctioning (a) during theswallow, (b) immediately after the swallow, and/ or (c) after a set observation period. A blue dye is

chosen as it provides a non-organic colour immediately distinguishable from blood, sputum ormucous. There have been conflicting reports of the validity of the technique (Wilson, 1992;Logemann, 1994; Thompson-Henry & Braddock, 1995). There is also some evidence that clients

may experience gastric irritation from food dyes. At present there is no standardised protocol for

this procedure. Speech pathologists who are not experienced in tracheostomy tube managementare not advised to use this test unless there is adequate qualified supervision.

A.3 Cervical auscultation

Cervical auscultation is an assessment of the sounds of swallowing and swallow-relatedrespirations. It is intended to complement the clinical or bed-side assessment of swallowing asdescribed above. Cervical auscultation is a non-invasive, non-imaging tool. Using a stethoscopeclinicians can monitor the quality of swallowing sounds and respiratory sounds post swallow. Thenumber of swallows required to clear a bolus and the delay in swallow reflex initiation can also bescrutinised. Healthy swallowing sounds and post swallow sounds are different to the swallow andpost swallow sounds of dysphagic individuals. The clinician skilled in cervical auscultation can

also determine whether compensatory strategies are assisting the dysphagic client. For example,the clinician can determine whether the client is actually “holding their breath” during the

supraglottic swallow manoeuvre, and how effective the manoeuvre is for that individual.

Swallowing sounds can also be recorded, and digitised so that that they can be evaluated usingcomputer software. A contact microphone or accelerometer is placed on the skin surface of a

specified point on the cervical region with the signal recorded onto audiotape or videotape (as insimultaneous videofluoroscopy), or directly onto the computer. The recorded sounds are digitisedand can then be analysed using acoustic software programs such as the Computer Speech

laboratory (CSL by Kay Elemetrics). The duration of swallowing sounds, their intensity and theirfrequency characteristics can then be analysed to objectively show differences between healthyswallows and dysphagic swallows (Cichero & Mudoch, 1998; Cichero & Murdoch, 2002a, Cichero& Murdoch 2002b). Additional training will be required to use this method correctly.





A.4 Electroglottography

The electroglottograph (EGG), also known as the Laryngograph, was initially developed as a non-invasive electrical impedence device for observing vocal fold contact during phonation

(Logemann, 1994; Perlman & Liang, 1991). It is hypothesised that the EGG could capture the

activity of the larynx as the airway closes during swallowing (Sonies, 1991). Duringelectroglottography an electrode is placed on either side of the neck over the thyroid cartilage.One electrode transmits a signal, while the other receives the signal after it has been modified bythe impedance of the neck. The deflections can be used as an indicator of laryngeal elevation. Itis however subject to interference of artefact by movements of the head and tongue (Kaatzke etal, 1996). It is not a routinely used assessment and requires additional training.

A.5 Electromyography

Electromyography describes the recording and study of the intrinsic electrical properties ofskeletal muscle (Dorland, 1982). Electromyography as it relates to swallowing assessmentdescribes the technique of assessing the function of the muscles involved in swallowing

(Logemann, 1994; Sonies & Baum, 1998). It provides information about the timing and relativeamplitude of muscle contraction during swallowing and the frequency of motor neurone firing.

EMG can be invasive or non-invasive. Muscles typically under investigation include the floor ofthe mouth, or submental muscles, and those associated with laryngeal elevation. Additionaltraining will be required to use this method correctly.

A.6 Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

FEES is able to demonstrate via imaging the presence of dysphagia including laryngeal

penetration, tracheal aspiration, pharyngeal residue and bolus spillage into the pharynx prior tothe initiation of the swallow. FEES is considered to be a specialist skill requiring the speechpathologist to undertake further training in its application.

The procedure, reported by Kidder, Langmore and Martin (1994) is an extended version of flexiblefiberoptic laryngoscopy (Langmore, Schatz & Olsen, 1988; Sonies 1991). Kidder, reported that the

technique is versatile, portable, provides immediate information and can be recorded ontovideotape for later analysis. He suggested that it complements, rather than replacesvideofluoroscopy swallowing studies and that the equipment and necessary expertise is availablein most hospitals. An advantage of the FEES is that the anatomy can be viewed directly.

It is not possible to view the total dynamics of the swallow during a FEES assessment, as themovement of the epiglottis temporarily obscures the view during swallowing. It is possible to

detect aspiration occurring prior to a swallow, or from residue remaining in the pharynx after aswallow. It is reported that if aspiration occurs during the swallow, residue would be visible in thelarynx and trachea once those regions return to view after the epiglottis has returned to an uprightposition (Langmore et al., 1988; Sonies, 1991). FEES is able to show the direction of bolus flow

and reportedly, the appropriateness of certain treatment techniques. The technique can also beused for review assessment to gauge improvement or decline in status.

A.7 Nuclear scintigraphy

Nuclear scintigraphy uses radionuclide scanning during the ingestion of a radioactive bolus(usually technetium-99m) (Sonies & Baum, 1988; Sonies, 1991; Silver et al., 1991; Silver & VanNostrand, 1994) to track the bolus as it passes from the oropharynx to the oesophagus. Theradiopharmaceutical is not absorbed after ingestion, nor does it become attached to thegastrointestinal mucosa (Benson & Tuchman, 1994).

Scintigraphy is an expensive, dynamic assessment of swallowing, requiring a gamma scintillationcamera, a low-energy collimator and a dedicated computer (Sonies & Baum, 1988). Measuressuch as pharyngeal transit time, number of swallows required to clear pharyngeal residue andregurgitation can be obtained. Although scintigraphy is said to offer precise quantification ofbolus volume in any area at a particular time or over time, (Fleming et al, 1990; Hamlet et al, 1989;

Humphries et al, 1987) there is much debate in the literature as to the tool's ability to detect andquantify aspiration (Benson & Tuchman, 1994; Sonies & Baum, 1988). In the field of dysphagia,





scintigraphy has been used primarily for the assessment of gastrointestinal reflux (Silver et al,1991). Nuclear scintigraphy is conducted by a medical officer trained in nuclear medicineimaging techniques.

A.8 Pharyngeal manometry

Pharyngeal manometry assesses the pressure dynamics of the pharynx and upper oesophagealsphincter during swallowing. Pharyngeal manometry provides a means of measuring motor

activity of the pharyngeal muscles, by measuring pressure changes caused by musclecontraction in the pharynx. It is predominantly used to investigate (a) pressure response of theupper oesophageal sphincter (UES) to swallowing, (b) timing of pharyngeal contraction, (c) UES

relaxation and (d) the relationship between these events (Sonies, 1991). Pharyngeal manometryrequires the use of solid state pressure sensors that have a sufficiently fast response frequency toreact to rapid pressure changes that occur during the pharyngeal stage of the swallow. Thesensors are encased in a fine diameter tubing, typically 3 mm, and are passed transnasally so

that sensors are located at (a) the base of the tongue, (b) UES, and (c) cervical oesophagus(Logemann, 1994). Other investigators, such as McConnel (1988), have an additional sensorplaced at the laryngeal inlet. Pharyngeal manometry is a procedure performed by agastroenterologist. Manofluorography (simultaneous manometry and fluoroscopy) is usedpredominantly for research purposes. Pharyngeal manometry is frequently used where

gastroesophageal reflux is suspected.

A.9 Ultrasound

Ultrasound of swallowing is a technique that visualises the soft tissue of the oral cavity andhypopharynx during swallowing, using a transducer placed submentally below the chin to obtainan image. It does this by "the imaging of deep structures of the body by recording the echoes ofpulses of 1-10 megahertz ultrasound reflected by tissue planes where there is a change indensity" (Dorland, 1982, p.703). Any commercial ultrasound real-time sector or phased-arraysystem can be used, and the equipment and necessary expertise is available in most hospitalsand radiology services. The information is transmitted to a monitor where the image is updatedmany times per second. The image represents a single 2D plane at any one time.

The physics of sound travel proves a limitation to the ultrasound technique. While sounds travelsthrough fluids and soft tissues, it does not travel well through fat, due to its complex tissuestructure. This limits the type of client with whom ultrasound swallowing assessment can beused. Another limitation of the technique is that sound will not pass through bone or air. It will becompletely reflected (Benson & Tuchman, 1994). Therefore, the trachea cannot be visualised as it

is an air-filled space and thus ultrasound is unable to detect penetration or aspiration of contentsinto the trachea. These factors limit its use in characterising the pharyngeal phase of the swallow,however the oral cavity is well-visualised during ultrasound. An ultrasound assessment of

swallowing is conducted by an ultrasound technician and a speech pathologist trained in itsapplication.

A.10 Videofluoroscopic swallowing study

Videofluoroscopy (also known as the Modified Barium Swallow) is the so called gold-standardagainst which many new dysphagia diagnostic techniques are compared for validity and reliabilitypurposes.





Appendix B: Working Party

The valuable contributions of the following people are acknowledged is the writing of thisdocument:

Task Force Coordinator

Monika Kaatzke-McDonald

Core Task Force:

Maria Berarducci, Julie Cichero, Nicola Clayton, Tia Croft, Cindy Dilworth, Jai Gupta, BronwynHemsley, Grainne O’Loughlin and with particular thanks to Ingrid Scholten.

Additional contributions by:

Stacey Baldac, Noni Bourke, Melita Brown, Julia Filipi-Dance, Gaye Murrills, Anne Rosten, Chris

Sheard, Sarah Starr, Chris Stone, Margaret Trzcinka and Louise Williams





References

Beck TJ & Gayler BW (1990). Image quality and radiation levels in videofluoroscopy forswallowing studies: A review. Dysphagia, 5, 118-128.

Benson JE & Tuchman D (1994). Other diagnostic tests used for evaluation of swallowing

disorders. In D.N. Tuchman & R.S. Walter (Eds). Disorders of feeding and swallowing in infants and children. San Diego: Singular Publishing Group Inc.

Bloem BR, Lagaay AM, van BeeK W, Haan J, Roos RAC, Wintzen AR (1990). Prevalence ofsubjective dysphagia in community residents aged over 87. British Medical Journal, 300, 721-722.

Brin MF & Younger D (1988). Neurologic disorders and aspiration. Otolaryngologic Clinics ofNorth America, 21(4), 691-699.

Cichero JAY & Murdoch BE (1998). The physiologic cause of swallowing sounds: Answers fromheart sounds and vocal tract acoustics. Dysphagia, 13, 39-52.

Cichero JAY & Murdoch BE (2002b). Detection of swallowing sounds: Methodology Revisted.

Dysphagia, 17, 40-49.

Cichero JAY & Murdoch BE (2002a). Acoustic signature of the normal swallow: Characterisationby age, gender and bolus volume. Annals of Otology, Rhinology and Laryngology, 111(7 pt 1),623-32.

Dantas RO, Kern MK, Massey BT, Dodds WJ, Kahrilas PJ, Brasseur JG, Cook J & Lang IM (1990).

Effect of swallowed bolus variables on oral and pharyngeal phases of swallowing. American

Journal of Physiology, 25, G675-G681.

Davalos A, Ricart W, Gonzalez-Huix F, Soler S, Marrugat J, Molins A, Suner R, Genis D (1996).Effect of malnutrition after acute stroke on clinical outcome. Stroke, 27 , 1028-1032.

DePippo KL, Holas MA & Reding MJ (1992). Validation of the 3-oz water swallow test foraspiration following stroke. Archives of Neurology , 4, 1259-1261.

Disability Services and Guardianship Act, 1987. New South Wales.

Dorland's Pocket Medical Dictionary (23rd ed.) (1982). Philadelphia: W.B. Saunders Company.

Ekberg O, Hamdy S, Woisard V, Wuttge-Hannig A & Ortega P (2002). Social and psychological

burden of dysphagia: its impact on diagnosis and treatment. Dysphagia, 17 (2), 139-46.

Feinberg MJ (1993). Radiographic techniques and interpretation of abnormal swallowing in adult

and elderly patients. Dysphagia, 8, 356-358.

Groher ME (1990). Managing dysphagia in a chronic care setting: An introduction. Dysphagia, 5,59-60

Groher ME & Bukatman R (1986). The prevalence of swallowing disorders in two teachinghospitals. Dysphagia, 1, 3-6.

Groher ME & Miller RM (1998). General treatment of neurologic swallowing disorders In Groher,M. E. (Ed.) Dysphagia: Diagnosis and Management (2nd ed.). Sydney: Butterworth-Heinemann.

Gutpa V, Reddy NE & Canilang EP (1996). Surface EMG measurements at the throat during dryand wet swallowing. Dysphagia, 11(3), 180-185.





Hamlet S, Penney DG & Formolo J (1994). Stethoscope acoustics and cervical auscultation of

swallowing. Dysphagia, 9, 63-68.

Hollshwander CH, Brenman HS & Friedman MH. (1975). Role of afferent sensors in the initiation

of swallowing in man. Journal of Dental Research, 54 (1), 83-88.

Horner J & Massey EW (1988). Silent aspiration following stroke. Neurology , 38, 317-319.

Horner J, Massey EW, Riski JE, Lathrop DL & Chase KN (1988). Aspiration following stroke:

Clinical correlates and outcome. Neurology, 38, 1359-1362.

Jones PL & Altschuler SL (1987). Dysphagia teams: A specific approach to a non-specificproblem. Dysphagia, 1, 200-205.

Kaatzke-McDonald MN, Post E & Davis PJ (1996). The effects of cold, touch, & chemical

stimulation of the anterior faucial pillar on human swallowing. Dysphagia, 11, 198-206.

Kedesdy J & Budd K (2001). Childhood feeding disorders: Behavioral assessment and intervention. Baltimore: Paul H. Brookes

Kennedy I & Grubb A (Eds) (1998) Principles of Medical Law. Oxford: Oxford University Press.

Kerridge I, Lowe M, & McPhee J. (1998). Ethics and Law for the Health Professions. Katoomba,

Aust.: Social Science Press.

Kidder TM, Langmore SE & Martin BJW (1994). Indications and techniques of endoscopy in

evaluation of cervical dysphagia with radiographic techniques. Dysphagia, 9, 256-261.

Langmore SE, Schatz K & Olso, N (1991). Endoscopic and videofluoroscopic evaluations of

swallowing and aspiration. Annals of Otology, Rhinology and Laryngology, 100, 678-681.

Langmore S, Terpenning M, Schork A, Chen Y, Murray, J, Lopatin D, Loesche W (1998).

Predictors of Aspiration Pneumonia: How Important is Dysphagia? Dysphagia, 13, 69-81.

Layne KA, Losinski DS, Zenner PM, Ament JA (1989). Using the Fleming index of dysphagia toestablish prevalence. Dysphagia, 4, 39-42.

Lee A, Sitoh YY, Lieu PK, Phua SY, Chin JJ (1999). Swallowing impairment and feedingdependency in the hospitalised elderly. Ann Acad Med Singapore, 28 (3), 371-6.

Lin LC, Wu SC, Chen HS, Wang TG, Chen MY (2002). Prevalence of impaired swallowing ininstitutionalized older people in Taiwan. Journal of the American Geriatrics Society. 50 (6), 1118-

23.

Linden P, Kuhlemeier KV & Patterson C. (1993). The probability of correctly predicting subglottic

penetration from clinical observations. Dysphagia, 8, 170-179.

Logemann J (1998). Evaluation and treatment of swallowing disorders. (2nd ed.) Texas: Pro-ed,Inc.

Logemann JA (1994). Management of dysphagia poststroke. In Chapey, R (Ed). LanguageIntervention Strategies in Adult Aphasia (3rd ed.). Sydney: Williams & Wilkins.

Logemann JA (1993). Manual for the videofluoroscopic study of swallowing. (2nd ed.) Texas:

Pro-Ed.

Lucas C & Rodgers H (1998). Variation in management of dysphagia after stroke: Does SLT makea difference? International Journal of Language and Communication Disorders, 3, 284-289.





Martens L, Cameron T, & Simonsen M, (1990). Effects of a multidisciplinary managementprogram on neurologically impaired patients with dysphagia. Dysphagia, 5, 147-151.

McConnel FMS, Cerenko D, Jackson RT & Guffin TN (1988). Timing of major events of pharyngeal

swallowing. Archives of Otolaryngology Head and Neck Surgery, 114, 1413-1418.

Miller RM, & Languor SE (1994). Treatment efficacy for adults with oropharyngeal dysphagia. Archives of Physical Medicine Rehabilitation, 75, 1256-1262.

Miller RM (1992). Clinical examination for dysphagia. In M.E. Groher (Ed.) Dysphagia: Diagnosis

and management (2nd ed.). Boston: Butterworth-Heinemann.

Morris, S. E. (1985). Developmental implications for the management of feeding problems inneurologically impaired infants. Seminars in Speech and Language. 6:4, 293-314.

Natural Death Act, 1983 number 121. DB Dunstan, Governor, South Australia.

New South Wales - proposed legislation (1990) which has been debated and discussed at Forum

(1991) regarding “Legal Effect to Directions Against Artificial Prolongation of the Dying Process".

Ohliger PC (1997). Legal implications in dysphagia practice. In BC Sonies (Ed.), Dysphagia: Acontinuum of care (pp. 77-89). Maryland: Aspen Publishers Inc.

Pelly JE, Newby L, Tito F, Redman S, & Adrian A. (1998). Clinical practice guidelines before thelaw: sword or shield? Medical Journal of Australia, 169, 330-333.

Perlman AL & Liang H. (1991). Frequency response of the fourcin electroglottograph and

measurement of temporal aspects of laryngeal movement during swallowing. Journal of Speech

and Hearing Research, 34, 791-795.

Preiksaitis HG, Mayrand S, Robins K. & Diamant NE. (1992). Coordination of

Prevalence of swallowing complaints and clinical findings among 50-79-year-old men and womenin an urban population. Dysphagia,1991, 6:187-92.

Ruf JM & Stevens JH. (1995). Accuracy of bedside versus videofluoroscopy swallowing

evaluation. (Abstract). Dysphagia, 10, 63.

Siebens H, Trupe E, Siebens A, Cook F, Anshen Shanauer R, Oster G (1986). Correlates andconsequences of eating dependency in the institutionalised elderly. J Am Geriatr Soc 34, 192-

198.

Silver KH, Van Nostrand D, Kuhlemeier K. & Siebens AA (1991). Scintigraphy for the detection and

quantification of subglottic aspiration: Preliminary observations. Archives of Physical Medicine

and Rehabilitation, 72, 902-910.

Sonies BC & Baum BJ (1988). Evaluation of swallowing pathophysiology. Otolaryngologic Clinics

of North America, 21(4), 637-648.

Sonies BC (1991). Instrumental procedures for dysphagia diagnosis. Seminars in Speech andLanguage, 12(3), 185-197.

Sonies BC (2000). The role of the speech pathologist in the management of dysphagia. In JS

Rubin, M Broniatowski & JH Kelly (Eds). The swallowing manual. (chapter 7). San Diego: Singular

Publishing Group.




Sorin R, Somers S, Austin W & Bester A. (1987). The influence of videofluoroscopy on the

management of the dysphagic patient. Dysphagia, 2, 127-135.

Speech Pathology Australia (2000). Code of Ethics.

Speech Pathology Australia (1994). Position paper on invasive procedures 1: Endoscopic

evaluation of the vocal tract.

Speech Pathology Australia (2001). Competency-Based Occupational Standards (CBOS) for

Speech Pathologists.

Speech Pathology Australia (2001). Principles of Practice.

Speech Pathology Australia (2003). Speech Pathology Services in Schools.

Speech Pathology Australia (2002). Ethics Education Package.

Splaingard ML, Hutchins B, Sulton LD & Chaudhuri G (1988). Aspiration in rehabilitation patients:

Videofluoroscopy vs. bedside clinical assessment. Archives of Physical Medicine and

Rehabilitation, 69, 637-640.

Swigert, N. B. (2000). The source for dysphagia: updated & expanded . Illinois: Linguisystems.

Takahashi, K., Groher. M.E. & Michi, K-I. (1994a). Methodology for detecting swallowing sounds.

Dysphagia, 9, 54-62

Thompson-Henry & Braddock B (1995). The modified Evan's blue dye procedure fails to detect

aspiration in the tracheotomized patient: Five case reports. Dysphagia, 10, 172-174.

Tibbling L, Gustafsson B (1991). Dysphagia and its consequences in the elderly. Dysphagia, 6,200-2.

World Health Organization (WHO) classifications. http://www.aihw.gov.au/disability/icf

Wilkinson T, de Picciotto J (1999). Swallowing problems in the normal ageing population. S Afr JCommun Disord, 46, 55-64.

Wilson DJ (1992). The reliability of the methylene blue test to detect aspiration in patients with a

tracheostomy tube. (CD-ROM) Abstract from: ProQuest File: Dissertation Abstracts Item: AAC

1348204.

Winstein CJ (1983). Neurogenic dysphagia: Frequency, progression, and outcome in adultsfollowing head injury. Phys Ther, 63(12), 1992-7.

dysphagia general

Documents