Hans Bogaardt

Quality of life in oncological patients with oropharyngeal dysphagia: validity and reliability of the Dutch version of the MD Anderson Dysphagia Inventory and the Deglutition Handicap Index.

Quality of life is an important outcome measurement in objectifying the current health status or therapy effects in patients with oropharyngeal dysphagia. In this study, the validity and reliability of the Dutch version of the Deglutition Handicap Index (DHI) and the MD Anderson Dysphagia Inventory (MDADI) have been determined for oncological patients with oropharyngeal dysphagia. At Maastricht University Medical Center, 76 consecutive patients were selected and asked to fill in three questionnaires on quality of life related to oropharyngeal dysphagia (the SWAL-QOL, the MDADI, and the DHI) as well as a simple one-item visual analog Dysphagia Severity Scale. None of the quality-of-life questionnaires showed any floor or ceiling effect. The test-retest reliability of the MDADI and the Dysphagia Severity Scale proved to be good. The test-retest reliability of the DHI could not be determined because of insufficient data, but the intraclass correlation coefficients were rather high. The internal consistency proved to be good. However, confirmatory factor analysis could not distinguish the underlying constructs as defined by the subscales per questionnaire. When assessing criterion validity, both the MDADI and the DHI showed satisfactory associations with the SWAL-QOL (reference or gold standard) after having removed the less relevant subscales of the SWAL-QOL. In conclusion, when assessing the validity and reliability of the Dutch version of the DHI or the MDADI, not all psychometric properties have been adequately met. In general, because of difficulties in the interpretation of study results when using questionnaires lacking sufficient psychometric quality, it is recommended that researchers strive to use questionnaires with the most optimal psychometric properties.

Use of Neuromuscular Electrostimulation in the Treatment of Dysphagia in Patients with Multiple Sclerosis

Objectives: We explored the possible effects of neuromuscular electrostimulation on the swallowing function of patients with multiple sclerosis and swallowing problems. Methods: Twenty-five patients (average age, 53.1 years; SD, 9.8 years) with multiple sclerosis and swallowing problems were treated for 3 weeks with 2 sessions per week of neuromuscular electrostimulation. The average time since the onset of multiple sclerosis was 16.5 years (SD, 10.2 years). Seventeen patients were examined with transnasal flexible endoscopy 1 week before treatment and 1 week after treatment. Results: After treatment, a significant decrease in pooling of saliva in the pyriform sinuses was seen in 6 patients (p = 0.03), and significantly less aspiration during swallowing of thin liquids (p < 0.01) was seen in 9 patients. Overall, the 25 patients reported that their swallowing had improved (p < 0.01), and in 20% of the patients, it had become less strenuous. No adverse effects of the treatment were reported. Conclusions: Our study showed that the treatment of swallowing problems with neuromuscular electrostimulation in patients with multiple sclerosis in this sample was successful in the reduction of pooling of saliva and in the reduction of aspiration.

The Use of Biofeedback in the Treatment of Chronic Dysphagia in Stroke Patients

Objective: To evaluate the efficacy of the use of surface electromyographic feedback in the treatment of stroke patients with chronic dysphagia. Patients and Methods: Data of 11 consecutive patients with chronic dysphagia after stroke were analyzed. Our patients were treated for dysphagia with surface electromyography as biofeedback as adjunct to normal exercises. All patients suffered from dysphagia after stroke. The average time after onset was 31.1 months. All patients had been previously treated by speech therapists without success. Functional swallowing was estimated using the Functional Oral Intake Scale (FOIS). At the start of the treatment 8 patients were tube dependent (FOIS ≤4). Three patients were on an oral diet, but with restrictions (FOIS ≥5). Results: The patients were treated on average seven 7 times. The time between the first and last treatment session was on average 76.1 days (SD ± 44.0; range = 29–168). Before treatment the average FOIS was 2.6 (SD ±2.3) and after treatment 5.6 (SD ±1.6). The median scores improved from 1 to 6, showing a significant and clinically relevant improvement (z = –2.820: p < 0.01) in swallowing function. In 6 of initially 8 patients with percutaneous enteral gastrostomy tubes, the feeding tube could be removed after treatment. Conclusion: Our data suggest that the use of surface electromyography as biofeedback in the treatment of chronic dysphagia after stroke could be an effective adjunct to standard therapy for swallowing disorders in 11 patients.

Viscosity is not a parameter of postdeglutitive pharyngeal residue: quantification and analysis with scintigraphy.

The aim of this study was to explore the influence of viscosity on pharyngeal residue in normal healthy volunteers. Scintigraphy was used to measure pharyngeal residue in 11 healthy volunteers after swallowing three different substances (age = 20.2–48.3 years). The first substance was a 10-ml solution of tap water with 0.5% xanthan with a viscosity of 4500 mPa s, comparable to a yogurt drink. The second and third substances were a 0.75% xanthan and a 1.00% xanthan solution, with viscosities of 10,500 and 21,000 mPa s, comparable to low-fat yogurt and 3% fat yogurt, respectively. Tap water was used as the control substance. Mean pharyngeal residue after swallowing tap water was 2.3% (SD = 1.2) of the initial volume in the oral cavity. Pharyngeal residue after swallowing 0.5% xanthan solution was 1.8% (SD = 0.8), after swallowing 0.75% xanthan solution 2.6% (SD = 2.2), and after swallowing 1.00% xanthan solution 2.8% (SD = 1.7). No significant correlation between increase of viscosity and pharyngeal residue was found. In healthy persons viscosity does not seem to be a significant parameter for pharyngeal residue for boluses with viscosities ranging from tap water to solutions having a viscosity comparable to 3% fat yogurt.

Treatment Effects for Dysphagia in Adults with Multiple Sclerosis: A Systematic Review.

Dysphagia or swallowing difficulties have been reported to be a concern in adults with multiple sclerosis (MS). This problem can result in several complications including aspiration pneumonia, reduced quality of life and an increase in mortality rate. No previous systematic reviews on treatment effects for dysphagia in MS have been published. The main objective of this study is to summarise and qualitatively analyse published studies on treatment effects for dysphagia in MS. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were applied to conduct a systematic search of seven databases, using relevant key words, and subsequent analysis of the identified studies. The studies were required to meet all three inclusion criteria of including a statement on intention to treat, or measure the effects of treatment for dysphagia in adults with MS and data on treatment outcomes for at least one adult diagnosed with MS. Retained studies were evaluated by two independent reviewers using a critical appraisal tool. This study has not been registered. A total of 563 studies were identified from the database searches. After screening and assessment of full articles for eligibility, five studies were included in the review. Three examined electrical stimulation and two examined the use of botulinum toxin. One study testing electrical stimulation was a randomised controlled trial, two were well-designed case series and two were case series lacking experimental control. All studies reported some positive effects on dysphagia; however, treatments that involved the use of electrical stimulation showed larger effect sizes. There is a paucity of evidence to guide treatment of dysphagia in MS, with only electrical stimulation and botulinum toxin treatment represented in the literature search conducted here. While both treatments show initial promise for reducing the swallowing impairment, they require further research using well-controlled experimental designs to determine their clinical applicability and long-term treatment effects for dysphagia across different types and severity of MS.

Pulmonary Rehabilitation After Total Laryngectomy A Multicenter Time-Series Clinical Trial Evaluating the Provox XtraHME in HME-Naïve Patients

Background: Both the immediate beneficial physiological changes in a laboratory setting and the long-term clinical outcomes of heat and moisture exchanger (HME) use are well described. So far, there has not been any research published that provides detailed insight in the pattern of changes in both respiratory function and patients’ experiences with HMEs in the first weeks of use. Methods: A multicenter time-series study design with a 2-week double baseline period. All patients used the XtraHME for 12 weeks afterward. Data were collected 2 weeks, 6 weeks, and 12 weeks after the start of HME use. Results: Data of 30 patients were analyzed. Pulmonary symptoms decreased significantly during the 12 weeks of HME use. After 2 weeks, a significant decrease in daily coughs and daily forced expectorations was seen. The general quality of life showed a significant increase throughout the study. More general physical complaints also significantly decreased with HME use. Patient satisfaction with the HME was high. Conclusions: This study shows that there is a significant influence of the XtraHME on pulmonary status that can already be observed after 2 weeks of using the XtraHME and continues to improve further after 6 weeks of XtraHME use.

Long-term use of heat and moisture exchangers among laryngectomees: medical, social, and psychological patterns.

Objectives: After laryngectomy, pulmonary protection is mostly acquired by means of a heat and moisture exchanger (HME) that is placed on an airtight seal around the stoma. The effects of HMEs on the tracheal climate have been well described, and the filtration effect of an HME with an electrostatic filter has been described in vitro. The effects of HME use in patients have been documented in several trials in different countries. The follow-up time of the patients in these trials, however, is limited. Less is known about long-term use of HMEs, and studies describing long-term compliance with HME use are scarce. This study investigated the long-term use of HMEs in laryngectomees. Methods: Questionnaires were sent to 195 laryngectomees, and 75 questionnaires were returned. Results: More than 85% of the respondents used an HME, of whom 77% were compliant users (ie, use for more than 20 hours per day). The incidence of pulmonary illnesses (either before or after surgery) was about 25%. More than 90% of the respondents were heavy smokers before laryngectomy. One third of the respondents are regularly exposed to dusty environments. Compliant HME users tend to make less use of external humidifiers and vaporizers, and have better pulmonary status and lower health-care costs. Regarding quality of life, patients who use a FreeHands device tended to have more frequent social contacts (r = 0.251; p = 0.030). The prevalence of depression is high, pointing to an urgent need to recognize and treat psychiatric problems such as depression and suicidal ideation in this patient group. Conclusions: These findings have implications for any postlaryngectomy research that uses pulmonary parameters.

Dysphagia, Speech, Voice, and Trismus following Radiotherapy and/or Chemotherapy in Patients with Head and Neck Carcinoma: Review of the Literature.

Introduction. Patients with head and neck cancer suffer from various impairments due to the primary illness, as well as secondary consequences of the oncological treatment. This systematic review describes the effects of radiotherapy and/or chemotherapy on the functions of the upper aerodigestive tract in patients with head and neck cancer. Methods. A systematic literature search was performed by two independent reviewers using the electronic databases PubMed and Embase. All dates up to May 2016 were included. Results. Of the 947 abstracts, sixty articles met the inclusion criteria and described one or more aspects of the sequelae of radiotherapy and/or chemotherapy. Forty studies described swallowing-related problems, 24 described voice-related problems, seven described trismus, and 25 studies described general quality of life. Only 14 articles reported that speech pathologists conducted the interventions, of which only six articles described in detail what the interventions involved. Conclusion. In general, voice quality improved following intervention, whereas quality of life, dysphagia, and oral intake deteriorated during and after treatment. However, as a consequence of the diversity in treatment protocols and patient characteristics, the conclusions of most studies cannot be easily generalised. Further research on the effects of oncological interventions on the upper aerodigestive tract is needed.

The role of speech-language pathologists in palliative care: Where are we now? A review of the literature

Introduction: Dysphagia and communication changes are common in life-limiting conditions and Speech-Language Pathology (SLP) involvement to facilitate effective communication, eating and drinking contributes to the goals of comprehensive palliative care. Aim: To examine the existing literature around the role of SLPs in palliative care to define the best practice role for SLPs in this area, identify current services and interventions provided by SLPs to patients with life-limiting conditions, assess for potential gaps between best practice in the literature and everyday SLP practice and opportunities for improvement. Methods: The methods used were electronic literature searches within MEDLINE, EMBASE and CINAHL, and manual searching. Papers were classified according to type. Meta-analysis was not appropriate due to the nature of the papers, and so a narrative exploration of themes was conducted. Results: Thirty-two papers were included (eight research, twenty-four non-research). Discussion: Specific roles for SLPs in dysphagia, communication, and holistic professional practice were identified. There is insufficient research to determine whether this is reflected in everyday SLP practice. Potential challenges to providing services include the impact of working with people who are dying, limited professional preparation, ongoing education constraints, and legal and ethical considerations. Further research into SLP activities with patients with life-limiting conditions is required to explore the valuable contributions already being made by SLPs to the care of patients with life-limiting illnesses and to identify opportunities to develop and improve evidence-based services in this area.

Getting comfortable with “comfort feeding”: An exploration of legal and ethical aspects of the Australian speech-language pathologist’s role in palliative dysphagia care

Abstract Purpose: With an ageing population, speech-language pathologists (SLPs) can expect to encounter legal and ethical challenges associated with palliative and end-of-life care more frequently. An awareness of the medico-legal and ethical framework for palliative dysphagia management will better equip SLPs to work effectively in this area. Method: This narrative review examines a range of legislation, legal, ethical and SLP literature that is currently available to orient SLPs to legal and ethical palliative dysphagia management in the Australian context. Result: Relevant legal and ethical considerations in palliative and end-of-life care are described. Conclusion: SLPs have a role in palliative dysphagia management, however, this can involve unique legal and ethical challenges. The legal position on provision and cessation of nutrition and hydration differs between Australian States and Territories. Decisions by the courts have established a body of relevant case law. This article introduces SLPs to some of the important considerations for legal and ethical palliative care, but is not intended to be directive. SLPs are encouraged to explore their local options for ethical and medico-legal guidance. It is hoped that increasing SLPs awareness of many of the concepts discussed in this article enhances the provision of high-quality patient-centred care.