‘Dysphagia’ is the medical term for a difficulty in swallowing, further described as any complication passing food or drink from the mouth to the stomach (Logemann, 1998). It occurs in three phases: the oral phase, the pharyngeal phase and the esophageal phase. Speech and language therapists (SLT) specialize in identifying, assessing and managing Feeding, Eating, Drinking and Swallowing disorders (FEDS) (IASLT, 2018) located in the oral and pharyngeal stages of swallowing, called oropharyngeal dysphagia. Ill-management of dysphagia can have detrimental consequences for the patient such as aspiration, malnutrition, dehydration and depression impacting pulmonary, nutritional and psychological well-being (Helldén, Bergström & Karlsson, 2018; Tanner, 2006).
The International Classification of Functioning, Disability and Health framework (ICF) put forward by the World Health Organisation (WHO, 2001) is used in the broader assessment of dysphagia to provide intervention that fulfills ethical tenets of autonomy and beneficence (Threats, 2007). The ICF boasts a ‘biopsychosocial’ design whereby aspects of the medical and social models of functioning are integrated to provide a dynamic, holistic picture of the person with dysphagia (Cichero & Murdoch, 2006). Dysphagia is described using three categories: Body Functions and Structures, Activities and Participation, and Environment and Personal factors.
Outcome measures are the used in the management of dysphagia to assist clinicians and researchers in making informed decisions regarding the most accurate intervention pathway and comparative effectiveness of dysphagia strategies (Patel et al., 2017). Dysphagia outcomes measures, however, rarely focus on the effect on the patient’s life, concentrating mainly on the direct ill-health effects of the symptom (Threats, 2007). Martino et al. (2009) support this viewpoint as while patients consider psychosocial obstacles as a direct result of their dysphagia to outweigh biomedical consequences, both clinicians and caregivers value biomedical, pulmonary and nutritional health to be of greater importance in recovery of dysphagia. The WHO’s ICF therefore, seeks to expand the SLT’s view on dysphagia and offer outcome measures that capture the patient’s experience (Penderson, Wilson, McColl, Carding & Patterson, 2016). Patient related outcome measures (PRO) provide substantial evidence directly related to the social importance of dysphagia treatment, advocating for an increased quality of life (Patel et al., 2017). This paper seeks to critically discuss available outcome measures in the management of dysphagia and how they relate to the ICF in terms of three domains.
The Clinical Bedside Examination (CBE) is often the SLT’s first step towards providing critical information relevant to the diagnostic and therapeutic processes as it is quick and readily available at bedside (Lenord & Kendall, 2008). The CBE involves gathering relevant case history from the client, medical team and carers, collation of comprehensive oro-motor assessment to examine sensory and motor aspects of the oral mechanism and clinical observation during swallow trials at bedside. Despite providing a general yet limited overview of the pharyngeal phase of the swallow, the CBE gauges the patient’s cognitive-behavioral abilities, baseline of orofacial functioning, helps determine the optimum positioning for feeding and explores of feeding options such as diet alterations or compensatory strategies (Ward & Morgan, 2009). The three ICF domains are broadly addressed during this initial assessment of the patient whereby Body Structures and Function impairments are hypothesized based on clinical impression, Activities and Participation limitations are indicated by the patients case history, and Environmental and Personal factors are observed by the clinician are reported by patient and caregivers (McAllister, Kruger, Doeltgen & Tyler-Boltrek, 2016). Moreover, the CBE results determine whether instrumental assessment is warranted (Lenoard & Kendall, 2008).
Objective, instrumental assessment techniques are used as outcome measures in dysphagia. The Video Fluoroscopic Swallowing Study (VFSS) and Fiberoptic Endoscopic Evaluation of Swallowing (FEES) are typically considered the ‘gold standard’ of dysphagia assessment, although they are not always readily available in clinical practice. VFSS, more commonly known as ‘videofluoroscopy’, is an imaging technique widely used to detect oropharyngeal dysphagia (Tomita et al., 2018). Videofluoroscopy provides a detailed, objective view of the internal anatomical structures involved in the swallow and its physiology during this process. The procedure is regarded as ‘gold standard’ as the presence or absence of aspiration can be immediately confirmed or denied, and prevented in order to avoid chronic aspiration, malnutrition and lengthy mealtimes (McNair & Reilly, 2003). VFSS is invasive as it requires food and fluid trails to be mixed with a radioactive chemical, called barium, which highlights boluses on x-ray as they travel from mouth to stomach. Patient’s mobility also has to be taken into consideration when deciding on whether VFSS is a suitable outcome measure as assessments take place the radiology department, away from the bedside.
