Hybrid SPEAK OUT! protocol improves aerodynamic measurements and PROMs in Parkinson's disease.

BACKGROUND: SPEAK OUT! has been shown to enhance various aspects of voice such as intensity, prosody, voice quality and perception of voice. However, their impacts on expiration and communication effectiveness have not yet been evaluated. This study aimed to evaluate the effectiveness of the Hybrid SPEAK OUT! method on aerodynamic measurements and patient-reported outcome measures (PROMs) in individuals with Parkinson's disease (PD). METHODS: This study included 157 participants with PD who underwent an intensive 8-week multidisciplinary treatment program. The Hybrid SPEAK OUT! method consisted of three sessions per week, including two group sessions and one individual treatment session. Voice-related aerodynamic measures included maximum phonation time (MPT), vocal cord function using the S/Z ratio, and expiratory flow measures including peak expiratory flow (PEF) and peak cough flow (PCF). Two PROMs were included: the Hebrew version of the voice handicap index-10 and communication effectiveness questionnaire. RESULTS: The results of 111 participants were analysed. MPT duration increased, PEF and PCF increased, and better scores were found in PROMs. CONCLUSION: These findings would appear to support the effectiveness of the Hybrid SPEAK OUT! methods improving function, activity and participation in individuals with PD. However, further research is needed. WHAT THIS PAPER ADDS: What is already known on the subject Prior research has demonstrated the effectiveness of behavioral therapies, including the SPEAK OUT! program, in managing speech symptoms in individuals with Parkinson's disease (PD). These therapies have shown improvements in voice intensity, fundamental frequency, voice quality, and voice perception. However, the impact on aerodynamic measures, expiratory flow, and patient-reported outcome measures has not been extensively studied. What this paper adds to existing knowledge This study adds to the existing knowledge by demonstrating that a Hybrid SPEAK OUT! approach, can lead to improvements in aerodynamic measures, including maximum phonation time (MPT), expiratory and cough peak flow. In terms of motor learning, we found that two non-speech exhalation-related tasks that were not directly trained improved following the intensive speech training protocol. Furthermore, it shows positive changes in patient-reported outcome measures, with reduced voice-related disability and improved communication efficiency. What are the potential or actual clinical implications of this work? The findings of this study have important clinical implications for the management of speech symptoms in individuals with PD. The Hybrid SPEAK OUT! program, which combines group and individual sessions, can effectively improve voice, aerodynamic measurements and patient-reported outcome measures (PROMs), ultimately enhancing the overall quality of life for patients. These findings support the effectiveness of the Hybrid SPEAK OUT! methods for improving function, activity, and participation in individuals with PD.

The Test of Mastication and Swallowing Solids and the Timed Water Swallow Test: Reliability, associations, age and gender effects, and normative data.

BACKGROUND: Quantitative measures can increase precision in describing swallowing function, improve interrater and test-retest reliability, and advance clinical decision-making. The Test of Mastication and Swallowing Solids (TOMASS) and the Timed Water Swallow Test (TWST) are functional tests for swallowing that provide quantitative results. AIMS: To explore the relationship between TOMASS and TWST; evaluate test-retest and interrater reliability; explore age and gender effects; and gather normative data. METHODS & PROCEDURES: Healthy community dwelling participants (n = 298, ≥ 20 years old) were recruited. Of those, 126 were included in the reliability study. Participants completed the TWST and TOMASS. OUTCOMES & RESULTS: Associations between TWST and TOMASS measures were found using Pearson's correlation coefficient. Age was positively associated with an increase in the number of bites (n = 292, r = 0.15, p = 0.009), masticatory cycles (n = 291, r = 0.33, p < 0.0001) and duration (n = 292, r = 0.32, p < 0.0001) for the TOMASS. For the TWST, age was positively associated with an increase in duration (n = 296, r = 0.23, p < 0.0001), and negatively associated with volume (n = 296, r = -0.205, p < 0.0001), and swallowing capacity (n = 296, r = -0.24, p < 0.0001). Females required more bites, masticatory cycles, swallows and longer time than males in TOMASS. In TWST, females required more swallows, longer time, and had lower volume per swallow and reduced swallowing capacity than males. Intraclass correlation coefficient (ICC) revealed good test-retest reliability and moderate to excellent interrater reliability. CONCLUSIONS & IMPLICATIONS: This study provides support for the validity of the TOMASS and TWST. Reduced efficiency in one of the tests might indicate a need to evaluate performance in the other. Extended chewing time and increased number of masticatory cycles might be compensatory behaviours for reduced oral processing abilities that are motor, sensory and/or mechanical. WHAT THIS PAPER ADDS: The TOMASS and TWST are functional tests of swallowing that provide quantitative results. They are easy to incorporate as part of the clinical evaluation of swallowing due to low cost and quick administration. Age and gender effects were found for the TWST and TOMASS, but they were only tested on relative measures rather than absolute measures. Different types of crackers used for TOMASS led to differences in performance and in normative values. What is already known on the subject Associations between performance during TWST and TOMASS were found: time, number of swallows and time per swallow were correlated, meaning that need for more time and more swallows is reflected in both drinking and chewing. The study provides further support for age and gender effects in TWST and TOMASS, on both relative and also on absolute measures, which were not investigated previously. Longer durations in TOMASS and TWST with an increase in age, are likely to be the result of compensatory behaviours to allow safe swallowing. Normative data for a country-specific cracker are presented (Israel). What are the potential or actual clinical implications of this work? Reduced efficiency in one of the tests might indicate a need to evaluate performance in the other. Establishing country specific norms for commonly available crackers is necessary, since crackers size and ingredients, such as fat content and moisture, influence chewing and swallowing. There is a balancing act between safety and efficiency in older adults' swallowing behaviour. Reducing pace in eating and drinking probably supports safer swallowing.

What could go wrong? Non-standardized versus standardized food texture classification.

BACKGROUND: Texture-modified foods (TMF) is a common intervention for improving swallowing safety and efficiency for people with dysphagia. Non-standardized texture classification (NSTC) of foods is used worldwide. However, as this study documents, it can introduce a lack of clarity and confusion over definitions that can potentially harm patients' safety. The International Dysphagia Diet Standardisation Initiative (IDDSI) framework offers international terminology and standardized methods for texture testing that can address this issue AIMS: To document differences between NSTC and standardized texture classification (STC) of the IDDSI, to document changes in the STC in the 30 min following meal delivery, and to explore the relationship between food intake and texture level. METHODS & PROCEDURES: In this observational study, data were collected from 24 long-term care departments during five meals served to 624 residents, including at least one breakfast, lunch and dinner. To document differences between NSTC and STC, all NSTC food textures used in the LTC facilities were reclassified to match the IDDSI texture level at the time food left the kitchen (n = 1276). To document time-related changes in texture, the STC texture as food left the kitchen was compared with texture 30 min later (n = 1276). Finally, to explore the relationship between texture and consumption, estimates were made of single-item food consumption (n = 3820) using a subjective evaluation of consumption percentage OUTCOMES & RESULTS: A total of 1276 food items were classified over the course of five meal services (with at least one each from breakfast, lunch and dinner). Statistically significant differences in NSTC and STC texture levels were found that revealed that residents were consuming food that was more difficult to eat than intended by the TMF prescription. In addition, significant changes in food texture were found over time, with texture levels significantly increasing 30 min after food left the kitchen. Finally, greater consumption was found for softer textures in comparison with regular foods; moreover, food consumption was greatest during breakfast and lowest during lunch. CONCLUSIONS & IMPLICATIONS: Residents requiring TMF received harder textures than intended which required complex swallowing ability, thus introducing a choking risk. Using the STC as proposed by the IDDSI could improve patient safety, oral intake and nutritional status. Time-related changes should also be considered in circumstances where patients do not consume food soon after service. Lastly, reduced food consumption during lunch might negatively impact overall nutrient intake, particularly in cultures where lunch is the main meal of the day. WHAT THIS PAPER ADDS: What is already known on the subject Despite widespread agreement on the importance of STC, institutional care providers widely use NSTC. The IDDSI framework offers international terminology and standardized methods for texture testing. The clinical importance of using STC is not well understood. What this paper adds to existing knowledge This study found that residents who required texture-modified foods were eating food textures that were more challenging to swallow than intended. Differences were found in food texture between when it left the kitchen compared with texture 30 min later. Pureed texture had greater consumption than regular textured food. Food consumption was found to be the highest during breakfast, and reduced during lunch, which might negatively impact overall nutrient intake. What are the potential or actual clinical implications of this work? Accurate food texture prescription is the first step towards increasing patients' safety. However, food preparation and handling are also very important steps, not to be disregarded. Time-related changes in food texture are remarkable and should be considered in circumstances where patients do not consume food soon after service, as these can compromise patients' safety.

Association between swallowing function, malnutrition and frailty in community dwelling older people.

BACKGROUND & AIMS: Swallowing function decreases with age and impacts nutritional state and frailty. The aim of the study was to test the relationship between swallowing function, dysphagia, frailty, malnutrition and depression in community dwelling older participants. METHODS: Community dwelling older participants (n = 180), were enrolled (74 men aged 75.9 ± 7.8, 65-91 years, and 107 women aged 75.9 ± 8.0, 65-95 years). Swallowing function was assessed by the Test of Mastication and Swallowing Solids (TOMASS) and the Timed Water Swallow Test (TWST). Dysphagia was identified using Hebrew 10-Item Eating Assessment Tool (H-EAT-10). Frailty was assessed by grip strength and the FRAIL Questionnaire. The Mini Nutritional Assessment - Short Form (MNA-SF) was used to identify nutritional status. Depression was screened with the Geriatric Depression Scale - Short Form (GDS-SF). RESULTS: 18.3% of the participants had a score of 3 or above in H-EAT-10, indicating suspected dysphagia. 17.8% of the participants were malnourished or at risk of malnutrition, and 48.3% were defined as frail or pre-frail. The odds of being malnourished/at risk of malnutrition were 3 times greater in those with suspected dysphagia. The odds of being frail/pre-frail were also 3 times greater in those with suspected dysphagia. Moreover, suspected dysphagia and frail/pre-frail health status coincided in 69.7% of participants. Participants that were malnourished/at risk of malnutrition required more masticatory cycles (p < .05) and more time (p < .05) to eat a cracker and drink 150 mL of water (p < .05), and had reduced swallowing capacity (volume/sec) in the TWST (p < .05) than those who were at normal nutritional statues. Similar results were found for frail/pre-frail participants versus robust health status. A decrease in grip strength was associated with increased (worse) frailty score, decreased nutritional score, decreased chewing function in TOMASS and decreased water drinking function in TWST (p < .05). MNA-SF score, age, GDS-SF score and EAT-10 were the best predictors of FRAIL score. CONCLUSION: A simple multi-dimensional screen should be employed by trained allied health professionals, nurses and their assistants to improve early identification and early referral to relevant health providers in order to provide preventive intervention for dysphagia, nutrition, frailty and depression.

Speech and language therapists' management of ventilated patients and patients with tracheostomy in Israel.

BACKGROUND: There is increased involvement of speech and language therapists (SLTs) in critical care and long-term units supporting patients with ventilatory needs and complex dysphagia. SLTs have a range of specialist knowledge in the function of the pharynx and larynx to enable them to support therapeutic interventions and contribute to the management of those patients. In Israel, there are currently no designated courses or training programmes for SLTs to establish advanced clinical skills in tracheostomy and ventilator management. There are currently standards of care for SLT working in designated wards for ventilated patients, however not in acute wards, critical care, and internal medicine wards where ventilated patients can be hospitalized. AIMS: To identify the skills and expertise of the Israeli SLT workforce working with tracheostomy patients. Specifically, to identify their level of training, access to training, client population, work settings, and level of work confidence. METHODS: The study involved electronic distribution of a 55-item online survey to SLTs in Israel. The questions included demographic information, training, confidence, and clinical support. RESULTS: Responses were received from 47 SLTs. The majority (40.4%) spent between 1% and 9% of their clinical time with ventilated patients. Almost 80% work with seniors (≥65 years) and almost 70% work with adults (18-65 years) half the time or more. In inpatient rehabilitation, 46.8% reported that they manage patients with tracheostomy half the time or more. In outpatient rehabilitation settings, 21.3% reported that they manage patients with tracheostomy half the time or more. Prior to managing complex airway patients independently, 55.3% received less than 5 h formal tracheostomy training whilst 68.1% received less than 5 h training on ventilated patients. Multidisciplinary teams (MDTs) existed for tracheostomy patients (85.1%) and ventilated patients (70.2%) and high levels of confidence were reported for managing patients with tracheostomies (mode of 4 in a scale of 0-5, where 5 means fully confident) and ventilated patients (mode of 3 in a scale of 0-5). A significant relationship was found between level of confidence and presence of an MDT. CONCLUSIONS: Limited training access was found for SLTs working with this complex population. A competency framework needs to be established with access to training and supervision. MDT existence contributes to confidence. Most respondents worked in rehabilitation settings, and very few worked in acute care, critical care, and internal medicine wards. It seems reasonable that in order to change this, minimal standards of care should be established on these wards. WHAT THIS PAPER ADDS: What is already known on the subject Speech and language therapists (SLTs) have an important role in critical care and long-term units supporting patients with complex dysphagia and undergo formal training and supervision in UK and Australia. What this paper adds to existing knowledge In Israel, most SLTs work with tracheostomy and ventilated adult patients in rehabilitation settings, whilst few work in acute, critical care, and internal medicine wards. There are limited opportunities for formal training and supervision, although MDT support enhances clinical confidence. What are the potential or actual clinical implications of this work? SLTs in Israel would benefit from establishing a competency framework for tracheostomy and ventilator patient management to support training, standards of care, and increase clinical involvement in acute settings. This will enhance clinical outcomes for their large population of complex airway patients.

The Test of Masticating and Swallowing Solids (TOMASS): reliability, validity and international normative data.

BACKGROUND: Clinical swallowing assessment is largely limited to qualitative assessment of behavioural observations. There are limited quantitative data that can be compared with a healthy population for identification of impairment. The Test of Masticating and Swallowing Solids (TOMASS) was developed as a quantitative assessment of solid bolus ingestion. AIMS: This research programme investigated test development indices and established normative data for the TOMASS to support translation to clinical dysphagia assessment. METHODS & PROCEDURES: A total of 228 healthy adults (ages 20-80+ years) stratified by age and sex participated in one or more of four consecutive studies evaluating test-retest and interrater reliability and validity to instrumental assessment. For each study the test required participants to ingest a commercially available cracker with instructions to 'eat this as quickly as is comfortably possible'. Further averaged measures were derived including the number of masticatory cycles and swallows per bite, and time per bite, masticatory cycle and swallow. Initial analyses identified significant differences on salient measures between two commercially available crackers that are nearly identical in shape, size and ingredients, suggesting the need for separate normative samples for specific regional products. Additional analyses on a single cracker identified that the TOMASS was sensitive at detecting changes in performance based on age and sex. Test-retest reliability across days and interrater reliability between clinicians was high, as was validation of observational measures to instrumental correlates of the same behaviours. Therefore, normative data are provided for the TOMASS from a minimum of 80 healthy controls, stratified by age and sex, for each of seven commercially available crackers from broad regions worldwide. OUTCOMES & RESULTS: Analyses on a single cracker identified Arnott's Salada, and that TOMASS measures were sensitive for detecting changes in performance based on age and sex. Interrater and test-retest reliability across days were high, as was validation of observational measures to instrumental correlates of the same behaviours. Significant differences were identified between two commercially available crackers, nearly identical in shape, size and ingredients, thus normative samples for specific regional products were required. Normative data were then acquired for the TOMASS from a minimum of 80 healthy controls, stratified by age and sex, for each of seven commercially available crackers from broad regions worldwide. CONCLUSIONS & IMPLICATIONS: The TOMASS is presented as a valid, reliable and broadly normed clinical assessment of solid bolus ingestion. Clinical application may help identify dysphagic patients at bedside and provide a non-invasive, but sensitive, measure of functional change in swallowing.