This White Paper by the European Society for Swallowing Disorders (ESSD) reports on the current state of screening and non-instrumental assessment for dysphagia in adults. An overview is provided... Show moreThis White Paper by the European Society for Swallowing Disorders (ESSD) reports on the current state of screening and non-instrumental assessment for dysphagia in adults. An overview is provided on the measures that are available, and how to select screening tools and assessments. Emphasis is placed on different types of screening, patient-reported measures, assessment of anatomy and physiology of the swallowing act, and clinical swallowing evaluation. Many screening and non-instrumental assessments are available for evaluating dysphagia in adults; however, their use may not be warranted due to poor diagnostic performance or lacking robust psychometric properties. This white paper provides recommendations on how to select best evidence-based screening tools and non-instrumental assessments for use in clinical practice targeting different constructs, target populations and respondents, based on criteria for diagnostic performance, psychometric properties (reliability, validity, and responsiveness), and feasibility. In addition, gaps in research that need to be addressed in future studies are discussed. The following recommendations are made: (1) discontinue the use of non-validated dysphagia screening tools and assessments; (2) implement screening using tools that have optimal diagnostic performance in selected populations that are at risk of dysphagia, such as stroke patients, frail older persons, patients with progressive neurological diseases, persons with cerebral palsy, and patients with head and neck cancer; (3) implement measures that demonstrate robust psychometric properties; and (4) provide quality training in dysphagia screening and assessment to all clinicians involved in the care and management of persons with dysphagia. Show less
The management of dysphagia may differ by country and clinical setting. The purpose of this study was to describe the management and care pathways for elderly people with dysphagia in nursing homes... Show moreThe management of dysphagia may differ by country and clinical setting. The purpose of this study was to describe the management and care pathways for elderly people with dysphagia in nursing homes across Norway using an online survey. A national survey was developed that consisted of 23 questions covering various areas related to dysphagia care in nursing homes: background information of respondents, nursing homes, and residents and staff; screening and assessment of dysphagia including use of specialist consultation; management, practice patterns, and interventions targeting residents with dysphagia; training of staff; and perceived quality of current clinical practices in their nursing home. A total of 121 respondents completed the online survey, resulting in an overall response rate of 23.2%. Substantial discrepancies in dysphagia management were identified between nursing homes. In approximately 75% of nursing homes, residents were not routinely screened or assessed for swallowing problems. Although nursing homes used a broad range of strategies and routines for people with eating and swallowing difficulties, bolus modification seemed standard practice. Oral hygiene strategies were lacking in over 80% of nursing homes, and almost 50% did not have access to external experts, including speech therapists. Although nursing home staff rated the overall quality of care for people with eating and swallowing problems as high, their rating seemed mainly based on care for malnutrition and not directly aimed at dysphagia. The survey identified an evident need for training and upskilling staff in Norwegian nursing homes and raising awareness of the serious consequences and comorbidities that can result from dysphagia. Show less
The Deglutition Handicap Index (DHI) is a self-report measure for patients at risk of oropharyngeal dysphagia on deglutition-related aspects of functional health status (FHS) and health-related... Show moreThe Deglutition Handicap Index (DHI) is a self-report measure for patients at risk of oropharyngeal dysphagia on deglutition-related aspects of functional health status (FHS) and health-related quality of life (HR-QoL). The DHI consists of 30 items which are subsumed within the Symptom, Functional and Emotional subscales. The purpose of this study was to evaluate the psychometric properties of the DHI using Classic Test Theory according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria. A total of 453 patients with dysphagia with different aetiologies were recruited concurrently at two academic hospitals. Dysphagia was confirmed by fiberoptic endoscopic and/or videofluoroscopic evaluation of swallowing. In addition, a healthy control group of 132 participants were recruited. Structural validity was determined using exploratory and confirmatory factor analyses and internal consistency by calculating Cronbach's alpha coefficients. Hypothesis testing was evaluated using Mann-Whitney U-tests, linear regression analysis and correlations analysis. Diagnostic performance and receiver operating characteristic curves analysis were calculated. Factor analyses indicated that the DHI is a unidimensional measure. The DHI has good internal consistency with some indication of item redundancy, weak to moderate structural validity and strong hypothesis testing for construct validity. The DHI shows high diagnostic performance as part of criterion validity. These findings support that the DHI is an appropriate choice as a patient self-report measure to evaluate FHS and HR-QoL in dysphagia. Ongoing validation to assess the measure for possible item redundancy and to examine the dimensionality of the DHI using item response theory is recommended. Show less
Introduction The Videofluoroscopic Swallow Study (VFSS) is a commonly used dysphagia assessment that is routinely analysed visuoperceptually. However, no consensus exists regarding which... Show moreIntroduction The Videofluoroscopic Swallow Study (VFSS) is a commonly used dysphagia assessment that is routinely analysed visuoperceptually. However, no consensus exists regarding which visuoperceptual measures should be used to analyse VFSSs. Current visuoperceptual measures for VFSSs are limited by poor quality and incomplete or indeterminate psychometric properties. Objective This study aimed to establish the content validity for a new visuoperceptual VFSS measure for oropharyngeal dysphagia in adults, by identifying relevant domains of the construct and generating items and corresponding response scales. Methods Consensus among experts in dysphagia and VFSS from over 20 countries was achieved across three rounds of anonymous online surveys, using the Delphi technique. Participants judged relevance and comprehensiveness of definitions of visuoperceptual domains of VFSS and the relevance of various domains to the overall construct. After reaching consensus on definitions of relevant domains, consensus on items were established using the same process. Results Participants achieved consensus on definitions of 32 domains recommended for analysis, and at least one item per domain (range 1-4). Domains selected by participants included both those which occur in existing measures and domains which have not been included in any measures to date. This study will form the basis for content validity of a new measure for VFSS. Conclusions This first phase of developing a visuoperceptual measure of VFSS resulted in the identification of 32 domains and 60 items for oropharyngeal dysphagia. Developers can now advance to the next phase of measure construction; prototype development and psychometric testing. Show less
Fibreoptic Endoscopic Evaluation of Swallowing (FEES) and Videofluoroscopic Swallow Studies (VFSS) are instrumental assessments of dysphagia which provide videos of the internal structures of... Show moreFibreoptic Endoscopic Evaluation of Swallowing (FEES) and Videofluoroscopic Swallow Studies (VFSS) are instrumental assessments of dysphagia which provide videos of the internal structures of swallowing. They are commonly regarded as gold-standard' assessments; however, there is no consensus regarding a gold-standard measure to analyse the video recordings that they produce. Measures require sound psychometric properties to be suitable for clinical or research purposes. To date, no review of psychometric properties of FEES and VFSS measures has been undertaken or formally reported. This review assessed the quality of the psychometric properties of visuoperceptual measures of FEES and VFSS. Electronic databases were searched for studies reporting on psychometric qualities of visuoperceptual measures which are used to analyse recordings from FEES and VFSS. All dates until February 2017 were included. The Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist was used to evaluate the methodical quality of studies. The measures' overall quality was then assessed by combining COSMIN ratings with quality criteria. Forty-five studies, reporting on 39 measures, met the inclusion criteria for this review. Data about the measures' psychometric properties were very limited. Twenty-one measures had information available about reliability only, while 18 had information on up to five of the possible nine psychometric properties categorised within the COSMIN framework. The majority of the FEES and VFSS measures' psychometric properties were rated as indeterminate' overall, due to the small number of studies, issues with design, statistical analyses, and reporting practices of extant studies. There is insufficient evidence to recommend any individual measure included in this review as valid and reliable to interpret VFSS and FEES recordings. Further research, which utilises robust methodological design and reporting, is needed to examine the psychometric properties of measures for FEES and VFSS. Show less
The Swallowing Quality of Life questionnaire (SWAL-QOL) is widely used clinically and in research to evaluate quality of life related to swallowing difficulties. It has been described as a valid... Show moreThe Swallowing Quality of Life questionnaire (SWAL-QOL) is widely used clinically and in research to evaluate quality of life related to swallowing difficulties. It has been described as a valid and reliable tool, but was developed and tested using classic test theory. This study describes the reliability and validity of the SWAL-QOL using item response theory (IRT; Rasch analysis). SWAL-QOL data were gathered from 507 participants at risk of oropharyngeal dysphagia (OD) across four European countries. OD was confirmed in 75.7% of participants via videofluoroscopy and/or fiberoptic endoscopic evaluation, or a clinical diagnosis based on meeting selected criteria. Patients with esophageal dysphagia were excluded. Data were analysed using Rasch analysis. Item and person reliability was good for all the items combined. However, person reliability was poor for 8 subscales and item reliability was poor for one subscale. Eight subscales exhibited poor person separation and two exhibited poor item separation. Overall item and person fit statistics were acceptable. However, at an individual item fit level results indicated unpredictable item responses for 28 items, and item redundancy for 10 items. The item-person dimensionality map confirmed these findings. Results from the overall Rasch model fit and Principal Component Analysis were suggestive of a second dimension. For all the items combined, none of the item categories were 'category', 'threshold' or 'step' disordered; however, all subscales demonstrated category disordered functioning. Findings suggest an urgent need to further investigate the underlying structure of the SWAL-QOL and its psychometric characteristics using IRT. Show less
The negative impact of increased bolus modification on health-related quality of life (HRQoL) in persons with oropharyngeal dysphagia (OD) has been described in previous literature; however,... Show moreThe negative impact of increased bolus modification on health-related quality of life (HRQoL) in persons with oropharyngeal dysphagia (OD) has been described in previous literature; however, findings may have been influenced by the severity of OD and underlying etiology. The current systematic review therefore aims to investigate the relationships between HRQoL and OD and to report on changes in HRQoL and OD following intervention. This review was conducted in accordance with the PRISMA statement. A systematic search of the literature was performed using PubMed and Embase. All available English publications up to February 2016 that reported on OD and HRQoL were included. Articles that studied OD arising from esophageal dysfunction or included less than 15 participants with OD, were excluded. Thirty-five studies met the inclusion criteria. Inverse bidirectional relationships were found between decreased HRQoL and increased OD severity. Following intervention, changes were evident through improved HRQoL with decreased OD severity. The findings of this paper highlight the importance of targeting HRQoL in patients with OD. However, because of the heterogeneity in methodology, terminology, and assessment procedures used in the retrieved articles, the generalization of study results is limited. More research investigating the relationships between HRQoL and OD is needed. Future studies should implement study designs that lead to stronger levels of evidence, quantify the severity of OD and underlying diseases, use validated measures and less ambiguous terminology. Show less
As early diagnosis of swallowing and feeding difficulties in infants and children is of utmost importance, there is a need to evaluate the quality of the psychometric properties of pediatric... Show moreAs early diagnosis of swallowing and feeding difficulties in infants and children is of utmost importance, there is a need to evaluate the quality of the psychometric properties of pediatric assessments of swallowing and feeding. A systematic review was performed summarizing the psychometric properties of non-instrumental assessments for swallowing and feeding difficulties in pediatrics; no data were identified for the remaining twelve assessments. The COSMIN taxonomy and checklist were used to evaluate the methodological quality of 23 publications on psychometric properties. For each assessment, an overall quality score for each measurement property was determined. As psychometric data proved incomplete, conflicting or indeterminate for all assessments, only preliminary conclusions could be drawn; the most robust assessment based on current data is the dysphagia disorder survey (DDS). However, further research is needed to provide additional information on all psychometric properties for all assessments. Show less
Cordier, R.; Joosten, A.; Clave, P.; Schindler, A.; Bulow, M.; Demir, N.; ... ; Speyer, R. 2017
Early and reliable screening for oropharyngeal dysphagia (OD) symptoms in at-risk populations is important and a crucial first stage in effective OD management. The Eating Assessment Tool (EAT-10)... Show moreEarly and reliable screening for oropharyngeal dysphagia (OD) symptoms in at-risk populations is important and a crucial first stage in effective OD management. The Eating Assessment Tool (EAT-10) is a commonly utilized screening and outcome measure. To date, studies using classic test theory methodologies report good psychometric properties, but the EAT-10 has not been evaluated using item response theory (e.g., Rasch analysis). The aim of this multisite study was to evaluate the internal consistency and structural validity and conduct a preliminary investigation of the cross-cultural validity of the EAT-10; floor and ceiling effects were also checked. Participants involved 636 patients deemed at risk of OD, from outpatient clinics in Spain, Turkey, Sweden, and Italy. The EAT-10 and videofluoroscopic and/or fiberoptic endoscopic evaluation of swallowing were used to confirm OD diagnosis. Patients with esophageal dysphagia were excluded to ensure a homogenous sample. Rasch analysis was used to investigate person and item fit statistics, response scale, dimensionality of the scale, differential item functioning (DIF), and floor and ceiling effect. The results indicate that the EAT-10 has significant weaknesses in structural validity and internal consistency. There are both item redundancy and lack of easy and difficult items. The thresholds of the rating scale categories were disordered and gender, confirmed OD, and language, and comorbid diagnosis showed DIF on a number of items. DIF analysis of language showed preliminary evidence of problems with cross-cultural validation, and the measure showed a clear floor effect. The authors recommend redevelopment of the EAT-10 using Rasch analysis. Show less
Heijnen, B.J.; Speyer, R.; Bulow, M.; Kuijpers, L.M.F. 2016
This study compares the effects of traditional logopedic dysphagia treatment with those of neuromuscular electrical stimulation (NMES) as adjunct to therapy on the quality of life in patients with... Show moreThis study compares the effects of traditional logopedic dysphagia treatment with those of neuromuscular electrical stimulation (NMES) as adjunct to therapy on the quality of life in patients with Parkinson's disease and oropharyngeal dysphagia. Eighty-eight patients were randomized over three treatment groups. Traditional logopedic dysphagia treatment and traditional logopedic dysphagia treatment combined with NMES at sensor or motor level stimulation were compared. At three times (pretreatment, post-treatment, and 3 months following treatment), two quality-of-life questionnaires (SWAL-QOL and MD Anderson Dysphagia Inventory) and a single-item Dysphagia Severity Scale were scored. The Functional Oral Intake Scale was used to assess the dietary intake. After therapy, all groups showed significant improvement on the Dysphagia Severity Scale and restricted positive effects on quality of life. Minimal group differences were found. These effects remained unchanged 3 months following treatment. No significant correlations were found between dietary intake and quality of life. Logopedic dysphagia treatment results in a restricted increased quality of life in patients with Parkinson's disease. In this randomized controlled trial, all groups showed significant therapy effects on the Dysphagia Severity Scale and restricted improvements on the SWAL-QOL and the MDADI. However, only slight nonsignificant differences between groups were found. Show less
Molen, L. van der; Rossum, M.A. van; Burkhead, L.M.; Smeele, L.E.; Rasch, C.R.N.; Hilgers, F.J.M. 2011
The aim of this study was to assess the effect of (preventive) rehabilitation on swallowing and mouth opening after concomitant chemoradiotherapy (CCRT). Forty-nine patients with advanced oral... Show moreThe aim of this study was to assess the effect of (preventive) rehabilitation on swallowing and mouth opening after concomitant chemoradiotherapy (CCRT). Forty-nine patients with advanced oral cavity, oropharynx, hypopharynx and larynx, or nasopharynx cancer treated with CCRT were randomized into a standard (S) or an experimental (E) preventive rehabilitation arm. Structured multidimensional assessment (i.e., videofluoroscopy, mouth-opening measurement, structured questionnaires) was performed before and 10 weeks after CCRT. In both S and E arms, feasibility was good (all patients could execute the exercises within a week) and compliance was satisfactory (mean days practiced per week was 4). Nevertheless, mouth opening, oral intake, and weight decreased significantly. Compared to similar CCRT studies at our institute, however, fewer patients were still tube-dependent after CCRT. Furthermore, some functional outcomes seemed less affected than those of studies in the literature that did not incorporate rehabilitation exercises. Patients in the E arm practiced significantly fewer days in total and per week, but they obtained results comparable to the S arm patients. Preventive rehabilitation (regardless of the approach, i.e., experimental or standard) in head and neck cancer patients, despite advanced stage and burdensome treatment, is feasible, and compared with historical controls, it seems helpful in reducing the extent and/or severity of various functional short-term effects of CCRT. Show less
