Spth 365 Dysphagia and Related Disorders: Diagnosis

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Spth 365 Dysphagia and Related Disorders
Diagnosis

• Lecture Six
• Dysphagia Diagnosis

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Evaluation of Dysphagia encompasses

• case history
• clinical/bedside evaluation
• instrumental examination

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Evaluation addresses




swallowing safety




nutritional status




rehabilitation planning (if appropriate)




compensatory planning (if appropriate)




continuation/modification of diet (if needed)




additional instrumental testing (if needed)




may contribute to
differential diagnosis of


medical etiology


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What are the instrumental tests available?
Modified Barium Swallow Test (
MBS)


Flexible
Endoscopic Evaluation of Swallowing


(FEES)
Flexible
Endoscopic Evaluation of Swallowing with


Sensory Testing (
FEESST)
Manometry


Ultrasound


MRI


CT


Direct
Laryngoscopy


Esophagoscopy/
Gastroscopy


Ultrasound


Scintigraphy


pH monitoring


Electomyography (
EMG)


Pulse
Oximetry


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Introduction to VFS MBS
First dynamic fluoroscopy 1895 by Roentgen


in
Wurtzburg, Germany (very much by
accident)
The fluoroscope - a device consisting of a


fluorescent screen suitably mounted, either
separately or in conjunction with a roentgen
tube, by means of which the shadows of
objects interposed between the tube and the
screen are made visible (ML
Huckabee)
MBS VFSS cookie swallow test


Provides comprehensive instrumental


assessment of
swollowing following bedside
evaluation (Decision to carry out
MBS is
based on findings at bedside evaluation)
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The Procedure

MBS - dynamic
radiographic imaging of anatomy and physiology
of swallowing which is simultaneously recorded on
a standard
video recorder.
-

current Gold Standard for assessing swallow
function most
easily accepted by doctors.
-

uses technical instrumentation for dynamic
assessment of the
oral, pharyngeal and esophageal phases of
swallowing by
means of videofluoroscopy (
Murry
Carrou, 2001)
-

dynamic image enhanced by visualization of the
bolus to which
contrast material (BaSO
) is added. (BaSO
is dense and
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therefore provides contrast when X-rays are
absorbed)
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Comparison of Modified Barium Swallow Test to
Barium Swallow Test
Modified Barium Swallow
Barium Swallow
Speech pathologist participates in
Speech pathologist typically
procedure and translates results
not involved
into treatment plan
Focuses on oral cavity, pharynx, larynx
Focuses on esophagus
and upper esophageal sphincter
Screens esophagus
Screens
oropharynx
Uses small amounts and various
Uses large quantity of rapidly
textures of barium impregnated
ingested liquid barium
substances
Patient positioned upright
Patient positioned supine
Structure viewed laterally, then A--gtP
Structure viewed A--gtP, then
oblique
Therapeutic techniques are evaluated
No therapeutic techniques
diagnostic only
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Technical Equipment and Supplies
Quality and information is compromised if the
equipment purchased is to be least expensive.
Minimal information may be obtained and the
examinations may not be as informative and useful
as
that recorded on proper equipment.
1.

Commercial quality 4 track
SVHS recorder
Jog


Shuttle


Frame-lock


2.

Video monitor
Proper resolution for
SVHS quality


Picture reduction control


3.

Microphone
4.

Time-date generator
5.

Video printer (black white)
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• Other/Non-technical Supplies
• Spoons/cups/straws
• Puree/solid foods with BaSO4
• Pre-mixed BaSO4 liquids of varying consistencies
• BaSO4 tablet or capsule
• Lead-shielded protective apparel for patient and
  clinician

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How does it work?
The typical fluoroscope system is done with a
tilt-table fluoroscope. The x-ray
tube is located beneath the
table-top and the fluoroscope is coupled to it.
X-
rays are emitted from the x-ray tube. A
diverging beam of X-rays is projected
through the patient to the fluoroscope on the
opposite side. In passing
through the patients body, x-rays are reduced in
intensity by interacting with
the patient's tissues. Differences in tissue
absorption produce an intensity
pattern in the beam that exits the patient and
forms the radiation image. This
image is projected into the image intensifier
where it is converted to visible
form. The video camera reads the image and
transmits it electronically to the
video recorder and viewing monitor. In a typical
swallowing study, the
operator moves the fluoroscope to examine
different parts of the anatomy that
vary in thickness and density.
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What does it evaluate?
Normal
vs abnormal functional anatomy


Discreet structural movements of/in oral cavity,
pharynx larynx


Temporal coordination of anatomic movements
relative to bolus


movement
Relative speed of the swallow from start to
finish, including duration of


oral phase and onset of swallow
Efficiency of the swallow


Trajectory of the bolus through
aerodigestive pathway


Variations in physiology secondary to


- Bolus volume, consistency rate of delivery
- Positioning
- Implementation of maneuvers
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Criteria for MBS referral


The patients signs and symptoms are inconsistent
with findings on the clinical examination.


There is a need to confirm a suspected medical
diagnosis.


Confirmation and/or differential diagnosis of the
dysphagia is needed.


There is either nutritional or pulmonary
compromise
and a question of whether the oropharyngeal
dysphagia is contributing to these conditions.


The safety and efficiency of the swallow remains a
concern.


The patient is identified as a swallow
rehabilitation
candidate and specific information is needed to
guide management and treatment.
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IMPORTANT NOTE
Procedure may be indicated for
diagnosis/treatment in the presence of
medical condition or diagnosis associated
with high risk for dysphagia, change in
swallow function suspected in a previously
known
dysphagic condition, patients whose
communication/cognitive deficits affect
completion of valid bedside assessment
and/or patients with progressive disorder
needing further definition of management.
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Exclusion criteria


Patients too mentally unstable to tolerate
procedure


Patient unable to co-operate in procedure


If
SLT believes procedure would not change
medical management.
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Patient is seated as close to upright as possible


(special chairs and aids available)
Target patients normal eating posture, then


evaluate options to change
Placement of leaded skirts to protect reproductive


organs in pediatric and young adults double
check about potential pregnancy
à
abandon
procedure if positive
gown and glove yourself too leaded apron/skirt,


thyroid shield
make sure all metal jewelry, keys, coins etc are


removed prior to beginning the session
See Figure 3..
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Lateral Projection
Clear demarcation of lower pharynx, laryngeal


inlet, upper esophagus
Provides unobstructed view of
aerodigestive


path
Permits examination and measurement of oral


and pharyngeal transit times
Shows events of aspiration/penetration into


laryngeal inlet
Tracks trajectory of bolus through pharynx to


upper esophagus
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Movement patterns of the bolus and oropharyngeal


structures in oral preparatory, oral, pharyngeal
and
cervical esophageal aspects of deglutition
Observation of whether aspiration occurs before,


during or after pharyngeal swallow
Amount and etiology of any aspiration that occurs


See Figure 4
..
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See Fig.5
..
1
2 Lower rim of mandible (x2)
3 Hyoid bone
4 Epiglottis extending inferiorly to thyroid
notch/cartilage
5 Laryngeal vestibule (bound anteriorly by
epiglottis,

posteriorly by
arytenoid cartilage, laterally by
aryepiglottic

folds and inferiorly by vocal folds)
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arytenoid cartilage
7 vocal folds
8 valleculae
9 BOT
10 oral cavity and velum
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Anterior-posterior projection
Patient faces fluorescent screen


Allows better visualization of bilaterally
represented


structures
Allows view of true and false vocal folds


Vocal fold function is assessed


Symmetry of swallow is assessed


In approximately 80 of normal individuals the
bolus


divides fairly equally to pass down 2 sides of
the pharynx
and then into the esophagus. The other 20
swallow
unilaterally (
Logemann,
Kahrilas,
Kobara
Vakil, 1989)
See Figure 6..
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I.
Thin liquid barium preparation
Begin with liquid. Although this may prompt the
patient to aspirate
early in the exam, it is important to start with
this. In cases of
pharyngeal weakness where residual is a
consequence, if liquids are
given after solids, you will already have soiled
your pharynx and
won't be able to assess pure tolerance of
liquids. If they aspirate
first sip of liquid, give another. Never base
any decision on only one
swallow of anything, particularly if it is the
first swallow. As with your
clinical exam, present initially controlled,
small sips, then progress to
larger less controlled bolus size. If liquids
continue to be aspirated,
employ appropriate compensatory techniques to
evaluate
effectiveness.
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II.
Thickened barium liquid (dairy food, pudding,

custard consistency)
Proceed to semi-solids, even if they consistently
aspirate liquids.
Again following the above guidelines. Semi-solid
may consist of a
straight barium preparation or may be a nutritive
food substance
impregnated with contrast. Employ appropriate
compensatory
techniques to evaluate effectiveness.
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III.
Solids (pieces of cookie, bread, marshmallow etc.)
Proceed to solid. Again following the above
guidelines. Employ
appropriate compensatory techniques to evaluate
effectiveness.
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IV. Evaluate A P position with above
consistencies
for added information
V. Rapid liquid bolus (if all textures are
tolerated well)
VI. Screen esophagus
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• Other important observations/notes
• surgical/developmental structural deviations
• absence of known structural deviations that
  cannot be visualized
• focus on oral cavity and pharynx after each
  swallow and entire procedure
• observation of location of residue immediately
  after the swallow
• view pharynx to identify aspiration of this
  residual
• esophageal examination - after MBS procedure
• state location of barium that extends lowest
  into airway
• location extent of aspiration

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General Guidelines
MBS is not done to rule out aspiration it is
done to evaluate


swallowing physiology and plan treatment
Three trials of each texture
is optimal.


Always think of exposure time. Needs to be
limited.


You are in charge of the exam.


Watch the patient closely for positioning. Not
uncommon to have


patients on the floor.
Exams will be shorter for pediatrics and very ill
patients.


Be aware of your radiation exposure as well.
Watch your position


in respect to the radiation scatter.
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• Documentation and Rating Indexes

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The Dilemma in Outcome Measurement

• Trade off between specificity and utility
• Many scales provide some organization and
  definition of parameters of swallowing for
  evaluation
• MASA (2002)
• Typical approach binary assessment
• Presence of absence of disorder
• Most clinical checklists take this approach

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• These scales cover a lot of ground quickly, but
  provide little detail and thus little measure of
  change
• Helpful to classify and diagnose
• Tendency for these scales, however, to be unable
  to measure anything but very large increments of
  change.

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Severity Rating Scales

• Some scales have severity level rankings in
  smaller increments, thus may be able to address
  weaknesses of binary scales.
• However, definitionally these are problematic
• What is mild to an experienced clinician may be
  considered severe to an less experienced clinician

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• If there are definitions provided for severity
  level assignments, the scales tend to address
  only limited swallowing features
• Rosenbek (Aspiration-penetration scale)
• Crary (Functional Assessment of Oral Intake)

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Specific Physiological Measurement Approaches

• Some research laboratories use specifically
  defined measurements of physiological change
• Logemann OPSE oral pharyngeal swallow
  efficiency
• Robbins discrete temporal and spatial
  measurements
• Kendall hyoid tracking
• Tend to be very complicated and very limited in
  scope for clinical practice

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Patient perceptual measures

• Visual analog scale
• 1-10 scale of patient perception of dysphagia
• Quality of Life Scales
• McHorney, Robbins, Rosenbek and others
• SwalQOL
• SwalCare

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The Importance and Complications of Assessment

• ASHA Omnibus survey (1997)
• 51 of responding speech pathologists work in the
  area of dysphagia.
• Of these, dysphagia management comprises up to
  38.3 of their clinical caseload.
• Specific to medical settings, 97.4 and 95.4 of
  reporting speech pathologists in residential
  health care and hospitals, respectively, declare
  that they work with patients with swallowing
  disorders (ASHA, 1997).

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• Effective management of dysphagia is dependent
  on the accurate diagnosis of disordered
  swallowing physiology. Conversely,
  misidentification of underlying physiology can
  lead to management practices that are costly,
  ineffective and perhaps even contraindicated to
  the
• health of the patient.

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Inter-rater Reliability In Medicine

• Halvorsen, 1989
• Review of the medical literature reveals an error
  rate of 10-40 in the interpretation of still
  radiographs between experienced radiologists
• Shaw, Hendry Eden, 1990
• 3 raters evaluated 139 chest x-rays
• Total inter-rater agreement on only 29 of images
• Radiologist more accurate than MDs on validity
  (91, 62, 46)

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• Interpretation of videofluoroscopy
• may prove to be even less reliable
• than still radiographs, as videofluoroscopic
  evaluations provide an image of a rapidly
  progressing dynamic process, with required
  investigation of anatomic structure as well as
  physiologic functioning.

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Videofluoroscopy Interpretation

• Ekberg, Nylander, Fork, Sjoberg, Birch-Iensen and
  Hillarp (1988)
• 6 radiologists evaluated 12 physiologic
  parameters on 72 videofluoroscopic swallowing
  exams.
• Highest kappa coefficients were achieved for
  identification of presence of Zenkers
  diverticulum (K0.84) and aspiration (K0.83)
  both are generally static images and thus do not
  require dynamic evaluation.

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• Identification of features of normal pharyngeal
  function, defective epiglottis movement,
  laryngeal penetration, cricopharyngeal impression
  greater than 50, incomplete opening of the upper
  esophageal sphincter (UES), and crico-esophageal
  web achieved coefficients ranging between .50 and
  .70.
• The lowest concurrence was present for decreased
  or absent pharyngeal constriction, delayed
  opening of the UES, and cricopharyngeal
  prominence less than 50 (Klt0.40). The first
  three of these abnormalities require dynamic
  assessment with no persisting radiographic
  evidence of the deficit after completion of the
  swallow.

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• Telting (1991)
• Evaluated three conditions
• Experienced SLPs rated 4 VFSS with no structure
  to guide their interpretation.
• Experienced SLPs rated 4 VFSS using a prepared
  checklist of dysphagic features.
• Finally, a group of student clinicians
  interpreted the same studies after directed
  training to the checklist of features..
• These data suggest that greater structure and
  training may improve inter-rater reliability
  significantly

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• Wilcox, Liss and Siegel (1996)
• Evaluated for VFSS interpretation and reliability
  in clinical decision making.
• 10 experienced SLPs rated 3 swallowing studies,
  looking at all textures and having access to
  clinical history information.
• Clinicians instructed to complete a checklist
  that included abnormal physiologic features of
  swallowing and a checklist that identified
  treatment options based on the diagnostic exam.
• The authors established an admittedly relaxed
  agreement criteria of 70 (7/10 raters) to
  represent agreement on the presence or absence
  of a listed feature.

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• In summary, the agreement criteria of 70
  established in this research design was achieved
  on findings of
• vallecular residual pre- and post-swallow,
• pyriform sinus residual,
• impaired cricopharyngeal relaxation and
• tongue pumping across the three subjects.
• Did not reach agreement criteria on
• delayed onset of swallow,
• premature spillage,
• aspiration and penetration

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• There tended to be poorer agreement across
  subjects on selection of
• liquid modifications
• bolus control exercises
• number of swallows per bolus
• vocal adduction exercises
• bolus size.
• Greater agreement was observed for
  recommendations of
• altering food texture
• oral motor exercises
• thermal stimulation
• chin tuck posturing
• Mendelsohn maneuver and
• alternating liquids and solids.

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• Previous studies evaluated clinician reliability
  for identifying presence of absence of an
  abundance of dysphagic physiologic features,
  dysphagic symptoms or management procedures.
• No assessment of qualifying severity.

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Evaluating the little picture

• Fujiu, Logemann and Pauloski (1995)
• Oral Pharyngeal Swallow Efficiency ( of bolus
  swallowed divided by oral pharyngeal transit
  time)
• Oral swallow efficiency ( of the bolus propelled
  into the pharynx divided by oral transit time),
• Pharyngeal swallow efficiency ( of the bolus
  swallowed divided by pharyngeal transit time)
• Duration of base of tongue to posterior
  pharyngeal wall contact.

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• Measures were specifically defined by the
  research protocol and carefully executed by
  skilled researchers.
• Inter- and intra-observer variability for all
  measurements were at least 80 and 95,
  respectively.
• Although these figures are promising in that they
  suggest that high reliability can be achieved,
  the rigorous training and definitions required
  for research are not typically carried over into
  clinical practice.

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• Murray, Langmore, Ginsberg Dostie (1996)
• 4-point severity index for assessment of
  pharyngeal secretions as observed endoscopically.
• "0" no abnormality
• "4" secretions in the laryngeal vestibule
• Inter-rater reliability of 100 between one
  speech language pathologist and two
  otolaryngologists.
• This has significant clinical implications as
  further analysis revealed that all of the
  hospitalized patients with a rating of "2" or
  above were observed to aspirate food or liquid.

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• Rosenbek, Robbins, Roecker, Coyle Wood (1996)
• Aspiration Penetration Scale.
• 8-point equal appearing interval scale
• "material does not enter the airway" (rating of
  1)
• "material enters the airway, passes below the
  vocal folds and no effort is made to eject"
  (rating of 8).
• Four judges evaluated 75 swallows collected from
  the videofluoroscopic swallowing studies of 15
  dysphagic individuals.
• The study was then replicated using three judges
  evaluating a variety of swallows from both elder
  normals and oral pharyngeal cancer patients.

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• In summary, for both trials, the reliability of
  the scale proved very high.
• Data analysis included a measure of intra-class
  correlation proportion of the variability in the
  measurement that is due to true differences
  between subjects as opposed to the variability
  among judges.
• An inter-judge intra-class correlation
  coefficient of .96 was derived with an
  approximate 95 confidence interval.
• Intra-judge intra-class correlation coefficients
  for each judge ranged from .95 to .97 when
  using this scale to evaluate aspiration.

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• So what happens if we complicate things and try
  to evaluate severity across all features of
  swallowing, rather than a single feature?

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• Kuhlemeier, Yates and Palmer (1998)
• 9 raters evaluated 20 VFSS. (slp, md, rad)
• Utilized standardized evaluation sheets
• Some features rated only presence or absence of
  disorder, others rated for severity (none, min,
  mod, sev)
• Inter- and intra-rater reliability
• Evaluated reliability of food type of oral stage
  impairment, aspiration, pharyngeal retention, but
  not other functional features.

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• Inter-rater reliability
• Negative reliability ratio for aspiration was
  very high, exceeding 98
• Positive reliability ratio for aspiration was
  generally much poorer, ranging from 0 for beef
  stew to almost 85 for apple juice.
• Positive reliability ratio for functional
  swallowing components ranged from 20 for PE
  segment opening to just under 60 for onset of
  swallow.
• Intra-rater reliability not substantially
  different than inter-rater reliability.
• Reliability for normal consistently higher than
  reliability for abnormal.

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• Telting study suggests that more information is
  better. Is this true?

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New Zealand Index for the Multidisciplinary
Evaluation of Swallowing (NZIMES)

• Two Subscales
• Clinical Parameters Subscale
• Nursing Status
• Nutritional Status
• Self Feeding Ability
• Cognitive Ability
• Physiologic Parameters Subscale
• Oral Parameters
• Oral Pharyngeal Transit
• Pharyngeal Parameters
• Cricoesophageal Parameters
• Laryngeal Parameters

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NZIMES Subscale 2

• Oral Parameters
• Labial Closure, Lingual Control, Palatal Closure,
  Mastication
• Oral Pharyngeal Transit
• Position of Bolus, Timing
• Pharyngeal Parameters
• Contraction/Propulsion, Laryngeal Excursion,
  Velopharyngeal Closure
• Cricoesophageal Parameters
• Bolus Propulsion through UES, Pyriform Sinus
  Clearance
• Laryngeal Parameters
• Aspiration/Penetration, Laryngeal Valving,
  Airway Reaction

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NZIMES Subscale 2

• 5 point equal appearing interval scale
• 0 No significant impairment
• 1 Mild impairment
• 2 Moderate impairment
• 3 Severe impairment
• 4 Profound impairment
• Each severity level is associated with a detailed
  description of swallowing physiology at that
  level.
• Option to select half intervals to represent
  intermediate severity levels (ie1.5 mild to
  moderate)

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Research Participants

• 40 students in accredited speech language
  pathology masters program enrolled in graduate
  level dysphagia course.
• Three professionals with extensive experience in
  dysphagia service delivery derived consensus
  agreement ratings to use as point of comparison
  for validity assessment.

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Test Conditions

• Pre-Test Condition
• Full day swallowing lab with review of index and
  interpretation of 10 swallowing studies
• Post-test Condition
• Half day swallowing lab with inter-pretation of
  same 10 swallowing studies evaluated between 12
  and 14 days later.

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• 10 swallowing studies representing mixed
  aetiologies and severities.
  (3 cortical stroke, 3 brain stem injury,
  3 oral pharyngeal cancer, 1 normal elderly)
• Each study presented 3 times
• Normal speed
• 50 speed
• Normal speed
• No audio or clinical/history information
  provided. Interpretation for this study based
  only on visual interpretation of radiographic
  data.

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Data Analysis

• For each categorical scale and each supporting
  physiologic feature
• Intra-rater reliability Pearson Correlations
  between pre and post test student ratings.
• Inter-rater Reliability Intra-class correlations
  derived across all raters
• Validity Pearson Correlations between student
  ratings (pre and post) and validity measure.
  Median correlation across raters derived

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Intra-rater reliability Summary of Pearson
Correlation Coefficients
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Inter-rater Reliability Pre and Post Test
Conditions for Oral Parameters
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Inter-rater Reliability Pre and Post Test
Conditions for Oral Pharyngeal Transit
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Inter-rater Reliability Pre and Post Test
Conditions for Pharyngeal Parameters
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Inter-rater Reliability Pre and Post Test
Conditions for Cricoesophageal Parameters
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Inter-rater Reliability Pre and Post Test
Conditions for Laryngeal Parameters
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Validity Summary of Median Pearson Correlation
Coefficients Across all Raters Validity Ratings
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Validity Summary of Median Pearson Correlation
Coefficients Across all Raters Validity Ratings
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Validity Summary of Median Pearson Correlation
Coefficients Across all Raters Validity Ratings
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Validity Summary of Median Pearson Correlation
Coefficients Across all Raters Validity Ratings
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Validity Summary of Median Pearson Correlation
Coefficients Across all Raters Validity Ratings
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Correct Identification of Presence of Dysphagia
Across all Ten Studies
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Correct Identification of Absence of Dysphagia
Across all Ten Studies
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Summary

• Across analyses, much poorer reliability and
  validity was achieved on oral and oral pharyngeal
  transit categories and their nested physiologic
  findings.
• Poor oral phase interpretation may reflect
  methodological issues as interpretation was based
  solely on observation of videotaped studies with
  no observation of the patient and many studies do
  not emphasis oral parameters.

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• Oral phase interpretation may also be influenced
  by confusion with oral pharyngeal transit.
  Specifically differentiation of delayed swallow
  from premature spillage 2o poor oral control.
• Oral pharyngeal transit was consistency the most
  difficult area to accurately interpret. Perhaps
  due to the transient nature of the feature or the
  limited number of nested or supporting
  physiologic features.

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• Cricoesophageal and Laryngeal parameters, and
  their nested physiologic features, were
  consistently interpreted with fairly high
  reliability and validity.
• Of the nested physiologic features, laryngeal
  valving and airway reaction were among the most
  problematic.
• Laryngeal valving considered to be better
  observed with endoscopy
• Interpretation of airway reaction hindered by
  absence of audiorecording.

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• Students were able to correctly identify the
  presence of dysphagia with fairly high accuracy
  for all parameters (gt80) except oral pharyngeal
  transit.
• The ability to correctly identify normal
  swallowing (absence of dysphagia) was less
  accurate across parameters.

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• These were students trained
• to the instrument.
• What about reliability when not trained to the
  instrument?
• Does training influence reliability?

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Next Step Practicing clinicians

• 91 SLPs evaluated same 10 studies using same
  methodology as students
• 3-hr training period to learn format and
  structure of the MIMES.
• Clinicians from four diverse locations in US
• 20.9 from mid-south 28.6 from northeast
• 27.5 from southeast 23.1 from southwest
• Completed questionnaire to glean information
  about education, training and practice anatomy
  test.

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Correct Identification of Presence of Dysphagia
for Students
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Correct Identification of Absence of Dysphagia
for students
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• By appearance, it looks like the training the
  students received was somewhat beneficial in
  increasing reliability of assigning severity
  levels.
• Does this carryover to professionals?

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Which education/training features contribute to
reliability

• Stepwise regression analysis with
• Dependent variable swallowing phase or feature
• Independent variables
• Years of clinical experience
• Years of experience in dysphagia
• Graduate education in dysphagia
• CEUs in past five years
• MBS completed per week over past 12 months
• Perception of competence
• Geography

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• Overall reliability, across swallowing phases and
  features, there was one training/ educational
  variable that appeared to predict performance.
• CEUs accounted for 29.7 of variability in
  interpretation with p.005.
• of CEUs was also predicted of reliability for
  two other variables
• the categorical rating of Laryngeal parameters,
  accounting for 22 of variability in
  interpretation with p.040
• The physiologic feature of timing of onset of
  swallow, accounting for 22 of variability in
  interpretation with p.042.
• None of these are significant with Bonferroni
  corrected p value of .003.

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• Inclusion of graduate education in dysphagia also
  appeared to be predictive of reliability. This
  variable accounts for
• 25 of variability in rating feature of Lingual
  Control (within oral parameters) p.023
• Two features within the category of
  Cricoesophageal Parameters
• 36 of variability in rating the feature of bolus
  propulsion through UES p.001
• 36 of variability in rating the feature of
  pyriform sinus clearance p.001.
• Significant with Bonferroni corrected p value of
  .003.

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• Experience is not highly predictive of
  reliability
• MBS completed per week was predictive only of
  reliability in interpreting Categorical variable
  of Oral Pharyngeal Transit, accounting for 28 of
  variability, p.010.
• Years of experience in dysphagia was predictive
  only of Pharyngeal category variable, accounting
  for 26 of variability p.015.
• Year of clinical experience overall was
  predictive only of reliability for rating the
  feature of lingual-palatal closure, accounting
  for 26 of variability, p.014.
• None of these are significant with Bonferroni
  corrected p value of .003.

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• The variables of
• Geographic location
• Perception of competence
• Knowledge of radiographic anatomy
• were not predictive of interpretation of
  anything.

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So if education and training variables do not
greatly influence reliability..WHAT DOES??
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Next Step.

• Evaluated 32 student clinicians
• Validity correlation coefficients for same 10
  VFSS
• 3 hour comprehensive assessment of visual
  perception
• Are there any features of innate visual
  perception that contribute to reliability?

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Visual Perceptual Skills

• Visual Discrimination The ability to identify
  and match a specific shape within an array of
  shapes.  
• Visual Memory The ability to retain visual
  stimuli presented for a brief period of time
  (0.5 to 15 seconds).  
• Visual spatial relationship The ability to
  identify which target is presented in an altered
  directional presentation from an array of several
  identically shaped targets. Visual spatial
  relations include spatial visualization, visual
  imagery, spatial reasoning.
• Visual form constancy The ability to identify
  and match a shape that is embedded in a picture.
  The shape in the picture may be different in size
  or directionality in its presentation within the
  picture.

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• Visual sequential memory The ability to identify
  and remember a sequence of objects, words,
  letters, numbers, or symbols in the order
  originally seen.
• Visual figure ground The ability to identify and
  match a shape that is embedded in an array of
  confusing shapes. The shape in the array will be
  identical in size and directionality as the
  original to be matched.
• Visual closure The ability to identify which
  incomplete shape among an array of shapes will,
  when completed, match the target shape.

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Analysis

• Initial correlations suggest a significant
  relationship between the skills of visual memory
  (rho.337, p.030) visual figure ground
  (rho.593, plt.001) and median validity
  coefficients.
• Using stepwise regression model however, visual
  figure ground was the only variable selected as a
  predictor of reliability, accounting for
  approximately 35 of the variability in
  videofluoroscopic interpretation (R .352,
  plt.001), (alpha set at plt.007, Bonferroni
  corrected for multiple variables)
• Further regression analyses conducted on the
  specific physiologic swallowing measures.

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• Independent variables of visual perceptual skills
  were found to have no predictive value for nine
  of the swallowing measures as dependent variables
  (lingual control, palatal closure, oral
  pharyngeal transit, position of bolus at onset of
  swallow, timing of swallow, velopharyngeal
  closure, crico-esophageal parameters, bolus
  propulsion through the UES, laryngeal
  parameters).
• In addition, no significant correlations
  identified between the visual perceptual skills
  of visual discrimination, visual form constancy,
  or visual closure and accuracy in interpretation
  of any physiologic swallowing feature.
• However, many significant relationships were
  identified.

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• Visual memory
• Accounts for 48 of variability in interpretation
  of oral parameter category (Rho.486, p.005)
• Visual sequential memory
• Accounts for 39 of variability in
  interpretation of pharyngeal category (Rho.392,
  p.027)
• Visual spatial relationships
• Accounts for 52 of variability in interpretation
  of oral parameter category (Rho.521, p.002)
• Accounts for 38 of variability in interpreting
  pyriform sinus clearance (under cricoesophageal
  parameters) (Rho.384, p.030)
• Meets Bonferroni corrected p value for multiple
  variables

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• Visual figure ground was found to contribute
  significantly to interpretation of several
  physiologic features across categories
• (oral parameters category)
• Labial closure Rho.740, plt.001
• Pharyngeal parameter category Rho.538, p.002
• Contraction propulsion Rho.790, plt.001
• Laryngeal excursion Rho.553, p.001
• Laryngeal parameters category Rho.349, p.050
• Aspiration/Penetration Rho.429, p.014
• Laryngeal valving Rho.529, p.002
• Airway reaction Rho.446, p.011
• Meets Bonferroni corrected p value for multiple
  variables

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Summary

• Reliability for interpretation of static features
  of swallowing (in many cases symptoms) range from
  very good to really really rotten.
• Reliability for interpretation of dynamic
  features of swallowing (in many cases the
  physiology) is generally not very good.

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Summary

• Reliability for rating severity of isolated
  features of swallowing can be very
  good..unfortunately swallowing features dont
  happen in isolation.
• Reliability for rating severity of swallowing
  when evaluating entire swallowing process ranges
  from reasonably good to really really rotten.

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• The Development of New Zealand Standards for
  Interpretation and Documentation

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