Nature, severity, and impact of chronic oropharyngeal dysphagia following curative resection for esophageal cancer: a cross-sectional study.

Chronic oropharyngeal dysphagia (COD) and aspiration after esophageal cancer surgery may have clinical significance; however, it is a rarely studied topic. In a prospective cross-sectional observational study we comprehensively evaluated the nature, severity, and impact of COD, its predictors, and the impact of the surgical approach and site of anastomosis. Forty participants were recruited via purposive sampling from the (Irish) National Center between November 2021 and August 2022. Swallow evaluations included videofluoroscopy [Dynamic Imaging Grade of Swallowing Toxicity v2 (DIGESTv2), MBS Impairment Profile, Penetration-Aspiration Scale)]. Functional Oral Intake Scale (FOIS) identified oral intake status. The patient reported outcome measures of swallowing, and Quality of Life (QL) included EAT-10 and MD Anderson Dysphagia Inventory (MDADI). Fourteen (35%) participants presented with COD on DIGESTv2 and 10% had uncleared penetration/aspiration. Avoidance or modification of diet on FOIS was observed in 17 (42.5%). FOIS was associated with pharyngeal dysphagia (OR = 4.05, P = 0.046). Median (range) EAT-10 and MDADI Composite results were 3(0-30) and 77.9(60-92.6), respectively. Aspiration rates significantly differed across surgical groups (P = 0.029); only patients undergoing transhiatal surgery aspirated. Survivors of esophageal cancer surgery may have COD that is undiagnosed, potentially impacting swallow-related QL. Given the small number of aspirators, further research is required to determine whether aspiration risk is associated with surgical approach. A FOIS score below 7 may be a clinically useful prompt for the MDT to refer for evaluation of COD following curative intent surgery. These data present findings that may guide preventive and rehabilitative strategies toward optimizing survivorship.

Dysphagia Prevalence in Progressive Supranuclear Palsy: A Systematic Review and Meta-Analysis.

The objective of this systematic review was to determine the prevalence of dysphagia and aspiration in people with progressive supranuclear palsy (PSP). A search of six electronic databases was performed from inception to April 2022. No context restrictions were set. All primary research comprising figures to derive a prevalence rate were included. Two independent reviewers screened search results. Data were extracted by one reviewer. Conflicts were resolved by discussion with a third reviewer. The quality of included studies was assessed using the JBI Checklist for Prevalence Studies. From 877 studies, 12 were eligible for inclusion. Dysphagia had to be confirmed using instrumental assessments, clinical swallowing evaluation, screening, and patient-reported outcome measures (PROM). A random-effects meta-analysis calculated a pooled dysphagia prevalence in 78-89% (95% CI [60.6, 89.1], [78.9, 95.0]). depending on the chosen assessment method, and a pooled aspiration prevalence of 23.5% (95% CI [14.5, 33.7]). The included studies were of moderate quality, with high risk of selection and coverage bias and low to moderate risk of measurement bias. Dysphagia is highly prevalent in a sample of participants with mostly moderately severe PSP. Aspiration occurs in a quarter of this sample and is likely to increase as the disease progresses. Given the low general prevalence of PSP, studies remain at high risk for selection bias. Prospective research should focus on the development of dysphagia in the course of PSP and its subcategories using instrumental assessment and consider all phases of swallowing. REGISTRATION: The protocol of this systematic review was registered on the International Prospective Register of Systematic Reviews (PROSPERO) in April 2021 (registration number: CRD42021245204).

Oral stimulation for promoting oral feeding in preterm infants.

BACKGROUND: Preterm infants (< 37 weeks' post-menstrual age (PMA)) are often delayed in attaining oral feeding. Normal oral feeding is suggested as an important outcome for the timing of discharge from the hospital and can be an early indicator of neuromotor integrity and developmental outcomes. A range of oral stimulation interventions may help infants to develop sucking and oromotor co-ordination, promoting earlier oral feeding and earlier hospital discharge. This is an update of our 2016 review. OBJECTIVES: To determine the effectiveness of oral stimulation interventions for attainment of oral feeding in preterm infants born before 37 weeks' PMA. SEARCH METHODS: Searches were run in March 2022 of the following databases: CENTRAL via CRS Web; MEDLINE and Embase via Ovid. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-randomised trials. Searches were limited by date 2016 (the date of the search for the original review) forward. Note: Due to circumstances beyond our control (COVID and staffing shortages at the editorial base of Cochrane Neonatal), publication of this review, planned for mid 2021, was delayed. Thus, although searches were conducted in 2022 and results screened, potentially relevant studies found after September 2020 have been placed in the section, Awaiting Classification, and not incorporated into our analysis. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials comparing a defined oral stimulation intervention with no intervention, standard care, sham treatment or non-oral intervention (e.g. body stroking protocols or gavage adjustment protocols) in preterm infants and reporting at least one of the specified outcomes. DATA COLLECTION AND ANALYSIS: Following the updated search, two review authors screened the titles and abstracts of studies and full-text copies when needed to identify trials for inclusion in the review. The primary outcomes of interest were time (days) to exclusive oral feeding, time (days) spent in NICU, total hospital stay (days), and duration (days) of parenteral nutrition. All review and support authors contributed to independent extraction of data and analysed assigned studies for risk of bias across the five domains of bias using the Cochrane Risk of Bias assessment tool. The GRADE system was used to rate the certainty of the evidence. Studies were divided into two groups for comparison: intervention versus standard care and intervention versus other non-oral or sham intervention. We performed meta-analysis using a fixed-effect model. MAIN RESULTS: We included 28 RCTs (1831 participants). Most trials had methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel. Oral stimulation compared with standard care Following meta-analysis, it is uncertain whether oral stimulation reduces the time to transition to oral feeding compared with standard care (mean difference (MD) -4.07 days, 95% confidence interval (CI) -4.81 to -3.32 days, 6 studies, 292 infants; I2 =85%, very low-certainty evidence due to serious risk of bias and inconsistency). Time (days) spent in the neonatal intensive care unit (NICU) was not reported. It is uncertain whether oral stimulation reduces the duration of hospitalisation (MD -4.33, 95% CI -5.97 to -2.68 days, 5 studies, 249 infants; i2 =68%, very low-certainty evidence due to serious risk of bias and inconsistency). Duration (days) of parenteral nutrition was not reported. Oral stimulation compared with non-oral intervention Following meta-analysis, it is uncertain whether oral stimulation reduces the time to transition to exclusive oral feeding compared with a non-oral intervention (MD -7.17, 95% CI -8.04 to -6.29 days, 10 studies, 574 infants; I2 =80%, very low-certainty evidence due to serious risk of bias, inconsistency and precision). Time (days) spent in the NICU was not reported. Oral stimulation may reduce the duration of hospitalisation (MD -6.15, 95% CI -8.63 to -3.66 days, 10 studies, 591 infants; I2 =0%, low-certainty evidence due to serious risk of bias). Oral stimulation may have little or no effect on the duration (days) of parenteral nutrition exposure (MD -2.85, 95% CI -6.13 to 0.42, 3 studies, 268 infants; very low-certainty evidence due to serious risk of bias, inconsistency and imprecision). AUTHORS' CONCLUSIONS: There remains uncertainty about the effects of oral stimulation (versus either standard care or a non-oral intervention) on transition times to oral feeding, duration of intensive care stay, hospital stay, or exposure to parenteral nutrition for preterm infants. Although we identified 28 eligible trials in this review, only 18 provided data for meta-analyses. Methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel and caregivers, inconsistency between trials in effect size estimates (heterogeneity), and imprecision of pooled estimates were the main reasons for assessing the evidence as low or very low certainty. More well-designed trials of oral stimulation interventions for preterm infants are warranted. Such trials should attempt to mask caregivers to treatment when possible, paying particular attention to blinding of outcome assessors. There are currently 32 ongoing trials. Outcome measures that reflect improvements in oral motor skill development as well as longer term outcome measures beyond six months of age need to be defined and used by researchers to capture the full impact of these interventions.

Patient Reported Outcome Measures in Dysphagia Research Following Stroke: A Scoping Review and Qualitative Analysis.

Patient reported outcome measures (PROMs) are commonly used to evaluate the impact of a health condition on quality of life (QOL). This study aimed to identify the range of PROMs that are currently in common use in clinical trials in dysphagia following stroke and to qualitatively analyse these PROMs by mapping the content to both the International Classification of Functioning and Disability Framework (ICF) and the Core Outcome Measures in Effectiveness Trials (COMET) Taxonomy for outcome classification. With consideration for the PRISMA-ScR checklist, a scoping review was conducted to identify commonly used PROMs in randomised controlled trials reported in persons with dysphagia stroke. A search of five databases was conducted. Studies were excluded if they included pediatric participants i.e. < 18 years of age, or if the text was not available in the English language. 110 papers met the inclusionary criteria. Twelve of these 110 papers included a dysphagia PROM. Two PROMs were identified as being in common use-the SWAL-QOL and the EAT-10. These two tools consisted of 47 items and 78 meaningful concepts, which were subsequently mapped to the ICF and the COMET Taxonomy. Mapping to the ICF showed that neither tool directly assessed the impact of 'Environmental Factors' on the experience of dysphagia. Mapping to the COMET Taxonomy showed that neither tool considered the impact of 'Role Functioning' on the person's experience of dysphagia. The development of a suitable and appropriate patient-reported assessment tool for use in those with dysphagia following stroke is warranted.

An intensive neurorehabilitation programme with sEMG biofeedback to improve swallowing in idiopathic Parkinson's disease (IPD): A feasibility study.

BACKGROUND: Studies suggest swallow intervention programmes that incorporate visual biofeedback and motor programming principles can improve swallowing and quality of life for people with idiopathic Parkinson's disease (IPD) and dysphagia. Few studies have examined outcomes using instrumentation. AIMS: Using fibreoptic endoscopic examination of swallowing (FEES), this study examines the effectiveness of a neurorehabilitation intervention involving biofeedback via surface electromyography (sEMG) to improve swallowing in people with IPD, and to explore the feasibility of the intervention approach. METHODS & PROCEDURES: We recruited 12 participants with IPD and dysphagia. A total of 10 completed the study. Intervention was delivered for 1 h per day, 5 days per week, for 4 weeks (20 h). Swallowing tasks using sEMG biofeedback incorporated principles of motor learning and neuroplasticity. Instrumental and non-instrumental assessment, including quality-of-life measures carried out at four different time points (two pre-treatment and two post-treatment). The final assessment was at 3 months post-intervention. OUTCOME & RESULTS: Statistically significant improvement (p < 0.05) in oral intake methods (95% confidence interval (CI) = 4.70-5.50) and in pharyngeal residue from saliva (95% CI = 2.14-3.15) and solids (95% CI = 2.4-3.5) post-intervention were confirmed using FEES with improvements at 3 months. The intervention protocol was well tolerated. Participants reported positive change in saliva control and duration of mealtimes as well as unanticipated improvements in voice and cognitive attention. CONCLUSIONS & IMPLICATIONS: An intensive neurorehabilitation with biofeedback shows positive effects in improving swallow function in IPD. This protocol is feasible with amendments to inform a larger clinical trial. WHAT THIS PAPER ADDS: What is already known on the subject Biofeedback has positive effects on increasing swallowing function and quality of life in people with IPD and dysphagia. sEMG is the most common method used to deliver swallowing biofeedback in this population. The quality of the evidence on the intervention, based on findings from a recent systematic review, is low. Included studies in this review were heterogeneous in terms of type and frequency of biofeedback, study design and outcome measures. The majority of outcome measures were subjective and higher quality studies to examine the efficacy of biofeedback using sEMG are needed. What this study adds Recognizing the limitations of earlier studies, this within-subject feasibility study examined the efficacy and effectiveness of an intensive biofeedback intervention using sEMG in a sample of people with dysphagia and IPD. Valid and reliable outcome measures were used and repeated after a 3-month period. The feasibility of the methodological approach was also tested and a qualitative component was included in the study. Positive findings were evident. Qualitative information added new perspectives and provided direction for new outcomes to be included in future studies. This study helps to inform further research trials as well as clinical practice. Clinical implications of this study This intensive intervention using principles of neuroplasticity and motor programming with sEMG biofeedback led not only to positive swallowing outcomes but also to unexpected benefits such as improved voice production and general attention skills. No adverse events were reported. Improvement in function was retained at 3 months post-intervention. Despite the small sample size, participants described the benefits of the treatment, and enjoyed sEMG biofeedback tasks, especially using an sEMG game mode. This suggests that intensive biofeedback not only improved swallowing but also was acceptable to these participants. This intensive protocol has merit and is worth considering further in clinical practice.

Exercise-based dysphagia rehabilitation for adults with oesophageal cancer: a systematic review.

BACKGROUND: Dysphagia is prevalent in oesophageal cancer with significant clinical and psychosocial complications. The purpose of this study was i) to examine the impact of exercise-based dysphagia rehabilitation on clinical and quality of life outcomes in this population and ii) to identify key rehabilitation components that may inform future research in this area. METHODS: Randomised control trials (RCT), non-RCTs, cohort studies and case series were included. 10 databases (CINAHL Complete, MEDLINE, EMBASE, Web of Science, CENTRAL, and ProQuest Dissertations and Theses, OpenGrey, PROSPERO, RIAN and SpeechBITE), 3 clinical trial registries, and relevant conference abstracts were searched in November 2020. Two independent authors assessed articles for eligibility before completing data extraction, quality assessment using ROBINS-I and Downs and Black Checklist, followed by descriptive data analysis. The primary outcomes included oral intake, respiratory status and quality of life. All comparable outcomes were combined and discussed throughout the manuscript as primary and secondary outcomes. RESULTS: Three single centre non-randomised control studies involving 311 participants were included. A meta-analysis could not be completed due to study heterogeneity. SLT-led post-operative dysphagia intervention led to significantly earlier start to oral intake and reduced length of post-operative hospital stay. No studies found a reduction in aspiration pneumonia rates, and no studies included patient reported or quality of life outcomes. Of the reported secondary outcomes, swallow prehabilitation resulted in significantly improved swallow efficiency following oesophageal surgery compared to the control group, and rehabilitation following surgery resulted in significantly reduced vallecular and pyriform sinus residue. The three studies were found to have 'serious' to 'critical' risk of bias. CONCLUSIONS: This systematic review highlights a low-volume of low-quality evidence to support exercise-based dysphagia rehabilitation in adults undergoing surgery for oesophageal cancer. As dysphagia is a common symptom impacting quality of life throughout survivorship, findings will guide future research to determine if swallowing rehabilitation should be included in enhanced recovery after surgery (ERAS) programmes. This review is limited by the inclusion of non-randomised control trials and the reliance on Japanese interpretation which may have resulted in bias. The reviewed studies were all of weak design with limited data reported.

Fidelity in Behavioral Interventions for Oropharyngeal Dysphagia in Parkinson's Disease: A Systematic Review.

Measuring fidelity of delivery and engagement in the methods of a trial helps us to understand whether planned interventions were effective. Treatment fidelity is critical in proving that change in study outcomes is due to the intervention itself and not to variability in its implementation or measurement. Existing reviews of oropharyngeal dysphagia (OD) interventions for Parkinson's disease (PD) have not systematically scrutinized fidelity within clinical trials. This study aimed to examine treatment fidelity in behavioral interventions for OD in PD and provide information about the reliability of existing study findings on behavioral interventions. All published and unpublished randomized controlled trials (RCTs) regarding behavioral interventions for OD in PD were sought. A comprehensive search of eight electronic databases was performed from inception to January 2019 and updated in April 2020. Gray literature was explored to minimize publication bias. No language or date restrictions were applied. Data were extracted by two independent reviewers with a third mediator. The National Institutes of Health Behavior Change Consortium Treatment Fidelity checklist was used to assess fidelity. From the 4998 references identified, eight studies met the inclusion criteria. Behavioral interventions in the included studies varied. The level of treatment fidelity was rated as low across all studies included in the review. The review concluded that low levels of treatment fidelity adherence in RCTs on dysphagia interventions in PD undermine the interpretation of the validity and reliability of study findings along with successful replication of these interventions in research and clinical practice.

White Paper by the European Society for Swallowing Disorders: Screening and Non-instrumental Assessment for Dysphagia in Adults.

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 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.

Interventions Involving Biofeedback to Improve Swallowing in People With Parkinson Disease and Dysphagia: A Systematic Review.

OBJECTIVES: To examine the effectiveness of biofeedback used in the treatment of adults with Parkinson disease (PD) and dysphagia, define the factors associated with biofeedback treatment outcomes, and inform a theory to guide the implementation of biofeedback in future dysphagia interventions. DATA SOURCES: A systematic review using a narrative synthesis approach of all published and unpublished studies were sought with no date or language restrictions. Ten electronic databases (EMBASE, PubMed, CINAHL, Web of Science, Scopus, Science Direct, AMED, The Cochrane Database of Systematic Reviews, ProQuest Dissertations and Theses A & I, Google Scholar) were searched from inception to April 2019. This search was updated in January 2020. The methodological quality of included studies was assessed using Downs and Black checklist. STUDY SELECTION: Four studies were included. The methodological quality of the included studies was low with a high risk of bias. Data were analyzed narratively and descriptively. Despite the heterogeneity of the included studies, the findings suggest that interventions incorporating visual biofeedback may have positive effects on swallowing-related quality of life. CONCLUSIONS: Based on these preliminary findings, we provide directions for further research and clinical interventions that incorporate an augmentative biofeedback component of swallowing interventions in people with PD. Future studies should be rigorously designed and set appropriate biofeedback treatment in terms of types, schedules, and timing.

A Consensus Statement for the Management and Rehabilitation of Communication and Swallowing Function in the ICU: A Global Response to COVID-19.

OBJECTIVE: To identify core practices for workforce management of communication and swallowing functions in coronavirus disease 2019 (COVID-19) positive patients within the intensive care unit (ICU). DESIGN: A modified Delphi methodology was used, with 3 electronic voting rounds. AGREE II and an adapted COVID-19 survey framework from physiotherapy were used to develop survey statements. Sixty-six statements pertaining to workforce planning and management of communication and swallowing function in the ICU were included. SETTING: Electronic modified Delphi process. PARTICIPANTS: Speech-language pathologists (SLPs) (N=35) from 6 continents representing 12 countries. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The main outcome was consensus agreement, defined a priori as ≥70% of participants with a mean Likert score ≥7.0 (11-point scale: 0=strongly disagree, 10=strongly agree). Prioritization rank order of statements in a fourth round was also conducted. RESULTS: SLPs with a median of 15 years of ICU experience, working primarily in clinical (54%), academic (29%), or managerial positions (17%), completed all voting rounds. After the third round, 64 statements (97%) met criteria. Rank ordering identified issues of high importance. CONCLUSIONS: A set of global consensus statements to facilitate planning and delivery of rehabilitative care for patients admitted to the ICU during the COVID-19 pandemic were agreed by an international expert SLP group. Statements focused on considerations for workforce preparation, resourcing and training, and the management of communication and swallowing functions. These statements support and provide direction for all members of the rehabilitation team to use for patients admitted to the ICU during a global pandemic.

ESSD Commentary on Dysphagia Management During COVID Pandemia.

Since the World Health Organization declared the COVID-19 pandemic a Global Public Health Emergency, experts in swallowing are seeking guidance on service delivery and clinical procedures. The European Society for Swallowing Disorders provides considerations to support experts in swallowing disorders in clinical practice. During the COVID-19 pandemic, assessment and treatment of patients with oropharyngeal dysphagia should be provided, while at the same time balancing risk of oropharyngeal complications with that of infection of patients and healthcare professionals involved in their management. Elective, non-urgent assessment may be temporarily postponed and patients are triaged to decide whether dysphagia assessment is necessary; instrumental assessment of swallowing is performed only if processing of the instruments can be guaranteed and clinical assessment has not provided enough diagnostic information for treatment prescription. Assessment and management of oropharyngeal dysphagia is a high-risk situation as it must be considered an aerosol-generating procedure. Personal protective equipment (PPE) should be used. Telepractice is encouraged and compensatory treatments are recommended.

European white paper: oropharyngeal dysphagia in head and neck cancer.

PURPOSE: To develop a European White Paper document on oropharyngeal dysphagia (OD) in head and neck cancer (HNC). There are wide variations in the management of OD associated with HNC across Europe. METHODS: Experts in the management of specific aspects of OD in HNC across Europe were delegated by their professional medical and multidisciplinary societies to contribute to this document. Evidence is based on systematic reviews, consensus-based position statements, and expert opinion. RESULTS: Twenty-four sections on HNC-specific OD topics. CONCLUSION: This European White Paper summarizes current best practice on management of OD in HNC, providing recommendations to support patients and health professionals. The body of literature and its level of evidence on diagnostics and treatment for OD in HNC remain poor. This is in the context of an expected increase in the prevalence of OD due to HNC in the near future. Contributing factors to increased prevalence include aging of our European population (including HNC patients) and an increase in human papillomavirus (HPV) related cancer, despite the introduction of HPV vaccination in various countries. We recommend timely implementation of OD screening in HNC patients while emphasizing the need for robust scientific research on the treatment of OD in HNC. Meanwhile, its management remains a challenge for European professional associations and policymakers.

Post-extubation dysphagia and dysphonia amongst adults with COVID-19 in the Republic of Ireland: A prospective multi-site observational cohort study.

OBJECTIVES: This study aims to (i) investigate post-extubation dysphagia and dysphonia amongst adults intubated with SARS-COV-2 (COVID-19) and referred to speech and language therapy (SLT) in acute hospitals across the Republic of Ireland (ROI) between March and June 2020; (ii) identify variables predictive of post-extubation oral intake status and dysphonia and (iii) establish SLT rehabilitation needs and services provided to this cohort. DESIGN: A multi-site prospective observational cohort study. PARTICIPANTS: One hundred adults with confirmed COVID-19 who were intubated across eleven acute hospital sites in ROI and who were referred to SLT services between March and June 2020 inclusive. MAIN OUTCOME MEASURES: Oral intake status, level of diet modification and perceptual voice quality. RESULTS: Based on initial SLT assessment, 90% required altered oral intake and 59% required tube feeding with 36% not allowed oral intake. Age (OR 1.064; 95% CI 1.018-1.112), proning (OR 3.671; 95% CI 1.128-11.943) and pre-existing respiratory disease (OR 5.863; 95% CI 1.521-11.599) were predictors of oral intake status post-extubation. Two-thirds (66%) presented with dysphonia post-extubation. Intubation injury (OR 10.471; 95% CI 1.060-103.466) and pre-existing respiratory disease (OR 24.196; 95% CI 1.609-363.78) were predictors of post-extubation voice quality. Thirty-seven per cent required dysphagia intervention post-extubation, whereas 20% needed intervention for voice. Dysphagia and dysphonia persisted in 27% and 37% cases, respectively, at hospital discharge. DISCUSSION: Post-extubation dysphagia and dysphonia were prevalent amongst adults with COVID-19 across the ROI. Predictors included iatrogenic factors and underlying respiratory disease. Prompt evaluation and intervention is needed to minimise complications and inform rehabilitation planning.

Interventions for Feeding and Swallowing Disorders in Adults with Intellectual Disability: A Systematic Review of the Evidence.

Feeding and swallowing disorders are prevalent in adults with Intellectual Disability (ID) and can potentially lead to discomfort, malnutrition, dehydration, aspiration, and choking. Most common interventions include: diet modification, compensatory strategies, swallowing therapy, and non-oral feeding. Despite their common use, the research evidence for these interventions is lacking. The current study aimed to systematically review the evidence for the safety and the effectiveness of interventions for feeding and swallowing disorders in adults with ID. Seven electronic databases, conference proceedings, and reference lists of relevant studies were reviewed from online availability to March 2019, with no language restrictions. Eligibility criteria encompassed experimental or non-experimental study design, adults (> 18 years) with ID and feeding and/or swallowing disorders (any etiology and severity) and any intervention for feeding and/or swallowing disorders. Methodological quality was assessed by two independent reviewers using the Downs and Black checklist. Four articles met the inclusion criteria. All included studies considered enteral feeding as an intervention strategy and had a retrospective observational design. Overall, included studies reported positive change in nutritional status and a high incidence of adverse events following enteral feeding initiation. Risk of bias was high with variability in methodological quality. The safety and effectiveness of interventions for feeding and swallowing in adults with ID is unclear. This review highlights the lack of evidence-based practice in this area. Directions for further research are provided. Before enteral feeding initiation, risks and benefits should be appropriately balanced on an individual basis, and caregivers should be involved in the decision-making process.

Managing and supporting quality-of-life issues in dysphagia: A survey of clinical practice patterns and perspectives in the UK, Ireland and South Africa.

BACKGROUND: There is increasing recognition that dysphagia has significant implications for a person's psychological well-being, social participation and quality of life (QOL). However, a paucity of research exists regarding the clinical management of this area. To inform future research and the development of appropriate and beneficial resources and guidelines, a better understanding of the current practice of speech and language therapists (SLTs) in this area would be useful. This information will highlight current challenges to clinical practice and the ongoing development needs of the profession, which are, as of yet, undocumented. AIMS: To determine the practices of SLTs when addressing QOL issues in individuals with dysphagia, the beliefs of SLTs regarding the impact of dysphagia on QOL, the current trends in assessing and managing QOL in dysphagia, and if variations in beliefs and practices in this area exist. METHODS & PROCEDURES: An anonymous cross-sectional, non-experimental survey study was used. The survey consisted of 18 questions exploring participants' beliefs and opinions regarding dysphagia and QOL, current clinical practice in the area, perceived facilitators and barriers, and education, training and development needs. The survey was created on Survey Monkey and disseminated by e-mail link to SLT professional bodies. Purposive and snowball sampling were used and participants self-selected based on the information provided alongside the e-mail link. Inclusion criteria for the study were a qualification in speech and language therapy, proficiency in the English language, and access to a computer with the internet. OUTCOMES & RESULTS: A total of 148 SLTs working across the UK, Ireland and South Africa completed the survey. Over 90% of respondents believe that dysphagia has a negative impact on QOL, but only 25% are currently satisfied with the amount of clinical time they can dedicate to this area. Staffing, resources, a lack of best-practice guidelines and disease-specific QOL assessment tools were cited as contributing factors. A number of facilitators and barriers to best practice were also highlighted. Based on these findings, professional development actions for the future are suggested. CONCLUSIONS & IMPLICATIONS: SLTs believe they have an important role to play in supporting QOL issues in dysphagia. However, it is reported that the area is currently under-developed, under-resourced and under-supported. Increased awareness raising of the role of SLT, alongside the development of best-practice guidelines and disease-specific QOL assessment tools, will enhance the quality of care that can be offered in this area.

Assessing cognitive communication skills in dementia: a scoping review.

BACKGROUND: Cognitive communication difficulties are a characteristic feature of dementia. These deficits have negative effects on all aspects of daily life. Yet, there are few options for standardized assessment of cognitive communication skills in people with dementia. AIMS: To review published cognitive-communication assessments to determine what psychometrically sound assessments exist that are applicable to all people with dementia. METHODS & PROCEDURES: A scoping review of the literature was conducted using an established scoping review model. Cognitive-communication assessments validated in English with people with dementia were sought. A comprehensive search of eight relevant electronic databases was undertaken. Two reviewers independently analysed and assessed the psychometric quality of instruments that met inclusion criteria. OUTCOMES & RESULTS: Four cognitive-communication assessments were included in the review. Although psychometrically sound, none was suitable for administration at all stages of dementia. Only one was validated for different dementia types. None included subtests for evaluation of conversation ability, and none involved the evaluation of communication partners' communication. CONCLUSIONS & IMPLICATIONS: There are limited options for standardized communication assessment for individuals with dementia and their communication partners. Directions for the development of new measures are provided to facilitate research and improve clinical practice.

Modifying the consistency of food and fluids for swallowing difficulties in dementia.

BACKGROUND: People with dementia can have feeding and swallowing difficulties (dysphagia). Modification of the consistency of food or fluids, or both, is a common management strategy. However, diet modification can affect quality of life and may lead to dehydration and malnutrition. Evidence on the benefits and risks of modifying food and fluids is mandatory to improve the care of people with dementia and dysphagia. OBJECTIVES: To determine the effectiveness and adverse effects associated with modifying the consistency of food and fluids in improving oral intake and eliminating aspiration in adults with dysphagia and dementia. SEARCH METHODS: We searched ALOIS (the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group), the Cochrane Library, MEDLINE via Ovid SP, Embase via Ovid SP, PsycINFO via Ovid SP, CINAHL via EBSCOhost, LILACS via BIREME, ClinicalTrials.gov and the World Health Organization (WHO) Portal on 9 May 2018. We also checked the reference lists of relevant articles to identify any additional studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs), quasi-RCTs and cluster-RCTs published in any language that measured any of the outcomes of interest. We included trials with adults with a clinical diagnosis of dementia with symptoms and signs of dysphagia confirmed on instrumental assessment. We included participants with all types, stages and severities of dementia. Control groups received either no intervention or interventions not involving diet modification or modification to sensory properties of food. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed for inclusion all potential studies identified. Data were extracted independently along with assessment of methodological quality using standard Cochrane methods. We contacted study authors for additional unpublished information. MAIN RESULTS: No trials on modification of food met the inclusion criteria. We included two studies that examined modification to fluids. Both were part of the same large multicentre trial and included people with dementia and people with or without dementia and Parkinson's disease. Participation in the second trial was determined by results from the first trial. With unpublished data supplied by study authors, we examined data from participants with dementia only. The first study, a cross-over trial, investigated the immediate effects on aspiration of two viscosities of liquids (nectar thick and honey thick) compared to regular liquids in 351 participants with dementia using videofluoroscopy. Regular liquids with a chin down head posture, as well as regular liquids without any intervention were also compared. The sequence of interventions during videofluoroscopy may have influenced response to intervention. The second study, a parallel designed RCT, compared the effect of nectar and honey thick liquids with a chin down head posture over a three-month period in a subgroup of 260 participants with dementia. Outcomes were pneumonia and adverse intervention effects. Honey thick liquids, which are more consistent with descriptors for 'spoon thick' or 'extremely thick' liquids, showed a more positive impact on immediate elimination of aspiration during videofluoroscopy, but this consistency showed more adverse effects in the second follow-up study. During the second three-month follow-up trial, there were a greater number of incidents of pneumonia in participants receiving honey thick liquids than those receiving nectar thick liquids or taking regular liquids with a chin down posture. There were no deaths classified as 'definitely related' to the type of fluids prescribed. Neither trial addressed quality of life. Risk of bias for both studies is high. The overall quality of evidence for outcomes in this review is low. AUTHORS' CONCLUSIONS: We are uncertain about the immediate and long-term effects of modifying the consistency of fluid for swallowing difficulties in dementia as too few studies have been completed. There may be differences in outcomes depending on the grade of thickness of fluids and the sequence of interventions trialled in videofluoroscopy for people with dementia. Clinicians should be aware that while thickening fluids may have an immediate positive effect on swallowing, the long-term impact of thickened fluids on the health of the person with dementia should be considered. Further high-quality clinical trials are required.

Prevalence, Nature, and Management of Oral Stage Dysphagia in Adults With Temporomandibular Joint Disorders: Findings From an Irish Cohort.

PURPOSE: Temporomandibular disorders (TMDs) are caused by changes in the structure and/or function of the temporomandibular joint, masticatory muscles, and/or osseous components. TMDs can result in oral stage dysphagia (OD) with potential effects on function and patient well-being. Little is known about the prevalence, nature, and management of TMD-related OD. The aims of the present study were to estimate the prevalence and nature of OD in adult TMD patients and to identify the common management techniques used to manage the signs and symptoms of TMD-related OD. PATIENTS AND METHODS: An 18-item subjective questionnaire was adapted from existing tools and used to investigate TMD etiology, the symptoms and signs of TMD-related OD, and the intervention techniques used to manage these symptoms. This was disseminated to 178 TMD patients consecutively recruited over 6 months in 2016. Descriptive and statistical methods were used to analyze the data. RESULTS: Of the 178 TMD participants, 99% reported at least one symptom or sign of OD. Individuals presenting with subluxation of the jaw (80%), degenerative joint disorder (67%), and myofascial pain disorder (40%) reported OD most frequently. Common symptoms included painful mastication (90%), masticatory fatigue (78%), difficulties swallowing (33%), and difficulties drinking liquids (28%). The use of a broad range of management techniques was reported, with these including both OD-specific techniques (eg, diet modifications [81%]), and non-OD specific techniques (eg, analgesia [79%] and oral splints [75%]). CONCLUSIONS: OD is prevalent, and difficulties with mastication are common in those with TMDs. The interventions used were diverse, with varying objectives and disparate levels of evidence supporting their efficacy within this cohort. Further research should address the epidemiology of TMD-related OD, evidence-based interventions, and the promotion of collaboration across the disciplines responsible for managing TMD-related OD (eg, speech and language therapy, oral and maxillofacial surgery, dentistry, restorative dentistry, orthodontics, oral medicine).

Exercise, orthoses and splinting for treating Achilles tendinopathy: a systematic review with meta-analysis.

OBJECTIVES: To assess the efficacy of exercise, orthoses and splinting on function, pain and quality of life (QoL) for the management of mid-portion and insertional Achilles tendinopathy, and to compare different types, applications and modes of delivery within each intervention category. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Medline, CINAHL, Embase, AMED, WHO ICTRP, Web of Science, PEDro and Cochrane Library from inception to October 2017. Citation tracking of published studies and conference proceedings and contacting experts in the field. STUDY ELIGIBILITY CRITERIA: Controlled clinical trials evaluating either exercise, orthoses or splinting for the management of Achilles tendinopathy. METHODS: Independent reviewers undertook searches, screening and risk of bias appraisal. Primary outcomes of interest were function, pain and QoL. RESULTS: Twenty-two studies were included (1137 participants). Moderate level evidence favoured eccentric exercise over control for improving pain and function in mid-portion tendinopathy. Moderate level evidence favoured eccentric exercise over concentric exercise for reducing pain. There was moderate level evidence of no significant difference in pain or function between eccentric exercise and heavy slow resistance exercise. There was low level evidence that eccentric exercise was not superior to stretching for pain or QoL. There was moderate level evidence that a combined exercise protocol was not superior to a lower dosage protocol for improving functional performance. There was moderate to low level evidence of a significant difference in pain (mean difference (MD) 6.3 mm, 95% CI -4.45 to 17.04, moderate) or function (MD 1.83 Victoria Institute of Sport Assessment points, 95% CI -7.47 to 11.12, low) between high-dose and low-dose eccentric training. There was high to moderate level evidence of no difference in pain (moderate) or function (high) between orthoses and control. There was low level evidence of no significant benefit in adding a night splint to an eccentric exercise programme for function, and moderate level evidence for no reduction in pain (MD -3.50, 95% CI -10.49 to 3.48). Eccentric exercise was not superior to splinting for pain (moderate evidence) or function (low level evidence). SUMMARY: We conditionally recommend exercise for improving pain and function in mid-portion Achilles tendinopathy. The balance of evidence did not support recommendation of one type of exercise programme over another. We conditionally recommend against the addition of a splint to an eccentric exercise protocol and we do not recommend the use of orthoses to improve pain and function in Achilles tendinopathy.