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OROPHARYNGEAL DYSPHAGIA:
REPORTED ASSESSMENT PRACTICE PATTERNS OF
SPEECH-LANGUAGE PATHOLOGISTS
A thesis submitted in conformity with the requirements for the degree of Master of Science in Clinical Epidemiology Graduate Department of Community Health
University of Toronto
O Copyright by n~rermry Martino 1999
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Oropharyngeal Dysphagia: Reporteci Practice Patterns of Speech-Language Pathologists
Rosemary Martino MSc Clinical Epidemiology
Department of Community Health University of Toronto
1999
ABSTRACT
This research compnsed the first phase of a two-phase project to describe reported
dysphagia assessrnent practices of speech-language pathologists across Canada and the
United States. Specific objectives were to: a) develop a self-administered mail
questionnaire; b) conduct a pilot survey using the questionnaire with Canadian speech-
language pathologists to obtain preliminary descriptive practice information and evaluate
questionnaire reliability.
Questionnaire development included: literature review, expert consensus and pre-
testing. Pilot testing of the questionnaire was conducted with a group of Canadian
speech-language pathologists, both experts and non-experts with dysphagia involvement,
registered with their national association.
Survey success was achieved with high survey and item response rates.
Clhicians were reliable reporters of their practice behaviours. Utilization was
unanimously reported to be high for most physiological parameters. General practice
was relatively more varied and appeared iduenced by at least geography. A pattern of
progressively decreasing utilization was noted, potentiaiiy related to stages of diagnostic
work-up.
ACKNOWLEDGEMENTS
I acknowledge the support of an outstanding thesis committee: Gaylene Pron, PhD. who
supervised the thesis, along with Nicholas E. Diamant, M.D.C.M., F.R-C.P.(C), and
Susan J. Bondy, Ph-D., who together represented a compkentary mix of clinical and
methodological expertise.
I would also like to thank the clinicians that participated in this project, both those who
helped with the development of the questionnaire and those who then responded to it.
This kind of professional vo1unteerism reflects a genuine conmitment toward improving
clinical service and thereby rnaxirnizing patient care. 1 was also fortunate to have had the
endorsement for this research by the Graduate Department of Speech-Language
Pathology at the University of Toronto and the Canadian Association of Speech-
Langage Patho logists and Audiologists.
And finally, 1 would like to thank my immediate farnily and close fiends who each in
their own unique way have provided me with gifis of unrelenting support and love.
TABLE OF CONTENTS
ABSTRAa .................................................................................................................................... u ACKNOWLEDGEMENTS .....m............o................................*...r.....................r......r.... III TABLE OF CONTENTS ......................................................................................................... ïV LIST OF TABLES ........................................................................................................................ LIST OF FIGURES ....... ....... ...... ..................................... WI
........................................................................................................... LIST OF APPENDICES VI11
SECTION A: BACKGROUND ............................................................................ 1
A.1 OVERVIEW OF DYSPRAGIA AND IT'S NATURU EIISTORY ................................................... 1 A.2 RATIONALE FOR THE TEESIS ................................................................................................ 2 A.2.A VARIAT~ONS [N MEDICAL, PRAC~ICE AND -CAL DECISION-~~AKING ...... .., .... .. ......... 2 A . ~ . B SPEECH-LANGUAGE PATHOLOGY CLWICAL DECISION-MAKING IN DYSPHAGIA ................. 5
...................................................................................................... A 3 PURPOSE OF TILE TEESIS 8
SECTION B: OUESTIONNAIRE DEVELOPMENT ............................................................. 10
B.1 INTRODUCTION & GOALS ...................,................................ ......................O....................... 10 B.2 CONTENT DEVELOPMENT ..................................................................................................... 11 B.2.A GENERATION OF DYSPHAGM PARAMETERS ................................... ... 12 B.2.s GENERATION OF MOD~FYING FACTORS ............................................................................... 13 B.2.c RESULTS OF CONTENT DEVELOPMENT ...................... .. ..................................................... 13 B 3 INSTRUMENT LAYOUT AND TESTLNG ................ ........... ......................................... 15
.............................................................................................. B.3 . A QUES~ONNAIRE FORMATION 15 ............................................................................................ B.3.B QUESTIONNAIRE PRE-TESTING 17
............................................................... B.3.c RESULTS OF INSTRUMENT LAYOUT AND -TING 18 B.4 DISCUSSION .....................................................,......... 2 0
SECTION C: PILOT PHASE SURVEY ................................................................................ 23
C.1 ~NTRODUCTION & GOALS ................... ........................................... .............O...................... 23 C.2 SUBJECTS ......O.............. ... ................................................................................................... 23 C.2.A SAMPLING ....................... .... ........................................................................................... 23 C.2.B SAMPLE SISE ............................................................................................................... 2 4 C.3 METHODS .......O........... .... ............... ...................o..o.o..... 24 C.3.A MAIL SURVEY DESIGN ..................................................................................................... 2 5 c . 3 . ~ DATA PREPARATION ....................... ..., .............................................................................. 28 C.3.c DATA INTERPRETATION AND ANALYSIS .............................................................................. 28 C.3.o Emrcs APPROVAL ............................................................................................................... 29 C.4 RESULTS .......................... .... ...... 30 C.4.A SURVEY SUCCESS ................................................................................................................. 30
......................................................................................... c.4.~ RESPONDENT CHARACTER~STICS 31 C.4.c REPORTED PRACTICE BEHAV~OURS ..................................................................................... 32 CS Drscussro~ ................... .... .......... ..................................................................................... 36
SECTION D: RELIABILITY S m . . .................................................................................... 43
SECTION E: DISCUSSION AND CONCLUSIONS ............................................................... 48
E.1 OVERALL DISCUSSION ......... ........ ............................................... 48 E.2 REVIEW OF LIMITATIONS ..................................................................................................... 51 E 3 OVERALL CONCLUS~ONS ....... ........................................................................................... 52 E.4 FUTURE DIRECTIONS ................... .......... ....................................................................... 55
SECTION F: REFERENCES ................................................................................................... 56
SECTION G: APPENDICES ................................................................................................... 124
LIST OF TABLES
Table 1 . Table 2 . Table 3 . Table 4 . Table 5 . Table 6 . Table 7 . Table 8 . TabIe 9.a Table 9.b. Table 9.c. Table 9.d. Table 10 . Table 1 1 .
Primary Assessrnent Content Parameters ...................................................... 71 Modifjrhg Factors ......................................................................................... 72 Questionnaire Matrix ........................................ ... ......................................... 73 Respondent Comment Summaries ............................................................. 74 Eligib le CASLP A Membership and Survey Respondents ................. .. ... .... 78 Respondent Profiles (N=34) .......................................................................... 79 Practice Setting Profiles of Respondents (N=34) .......................................... 80 Patients Profiles of Respondents (N=34) ................................................ 81
......................................................... Patient Waiting Times: Overall (N=18) 82 Patient Waiting Times: Location of Practice ................................................ 82 Patient Waiting Times: Caseload Concentration ...... ..................................... 83 Patient Waiting Times: Type of Facility ........................................................ 83 Method of Dysphagia Assessrnent ........... .. ............ ....,. 84 Availability of Personnel ............................................................................... 85
Table 1 1 .a. Availability of Personnel: Summaries ........................................................... 86 Table 12 . Instrumentation Availability and Utilization ................................................ 87 Table 12.a. instrumentation Availability and Utilization: Summaries ............................. 88 Table 1 3 . Video fluoroscopy kotocol Utilization (N=27) ............................................. 89 Table 1 3 .a. Videofluoroscopy Protocol Utilkation: Summaries ...................................... 90 Table 14.a. Utilization of Clinical Parameters ...................... ... .................................... 91 Table 14.b. Utilization of Instrumental Parameters .......................................................... 93 Table lS.a. Utilization Summaries: Overall ..................................................................... 95 Table 15.b. Utilkation Summaries: Unanimously Perforrned .......................................... 96 Table 15.c. Utilization Sumaries: Unanimously 'Not' Perforrned .............................. 97 Table 15.d. Utilization Summaries: 'Likely' or 'Not Likely' Performed ......................... 98 Table 15.e. Utilization Sumaries: 'Uncertainly' Performed .......................................... 99 Table I6.a. Opinion of Importance of Clinical Parameters .................................. .......... 100 Table 16.b. Opinion of Importance of Instrumental Parameters ........ .. .......................... 103 Table 17.a. Opinion of Importance Surnmaries: Overall ................................................ 105 Table 17.b. Opinion of Importance Summaries: 'Unanimously' Important ................... 106 Table 17.c. Opinion of Importance Summaries: 'Likely' Important ................. .... ......... 107 Table 17.d. Opinion of Importance Summaries: Uncertainly Important ........... .. ........ ... 108
....................... Table 1 7.e. Opinion of Importance Summaries: 'Likely Not' Important 109 ............ Table 17.f Opinion of Importance Summaries: 'Unanimously Not' Important 110
Table 18.a. Stages of Dysphagia Work-up for Clinical Parameters ............................... I l l ....................... Table 18.b. Stages of Dysphagia Work-up for Instnunental Parameters 112
Table 19 . Estimate of Required Sample Size for Test-Retest Reliabili ty ................. 1 13 Table 20 . Practice Behaviour Test-Retest Reliability ............................................... 114
LIST OF FIGURES
................................................ Figure L . Reported Utilization and Mod@ing Factors 115 Figure 1 .a Dysphagia Caseload .................................................................................... 115 Figure 1 . b. Years of Active Practice ............................................................................... 116 Figure 1.c. Country of Training .................................................................................... 117 Figure 1 . d. Level of Employment ............. .+. ................................................................... 118 Figure 1 . e. Patient Age .................................................................................................... 119
............................................................. Figure 1 . f Teaching affiliation ................... ,,., 120 Figure l . g. Location of Practice ...................................................................................... 121
............................................ Figure 1 . h. Type of Facility ................................................ 122 Figure 2 . Practice Utiiization and Opinion of Importance ........................................... 123
vii
LIST OF APPENDICES
...................................................... APPENDIX I Instructions for Survey Reviewers 125 ..... APPENDIX II Drafi Version of the New Self-Administered Mail Questionnaire 126 ..... APPENDIX III Final Version of the New Self-Adrninistered Mail Questionnaire 142
......... APPENDIX N Covering Letter For Canadian Speech-Language Pathologists 162 ............................................................................................. APPENDIX V Envelope 164
.................................................................................. APPEMXX VI Reîum Postcard 165 ....................................................................... APPENDIX W Ethics Approval Letter 166
...................................... .............. APPENDIX VIE Test Retest Covering Letter .... 168
SECTION A: BACKGROUND
A.1 Overview of Dysphagia and it's Naturd History
Dysphagia in itself is not a disease but rather a symptom or sign of one or more
underlying pathologies. In Canada there are no published prevaience data for dysphagia,
however, in the United States it was estimated that there were 6 to 1 O million people with
swallowing disorders in 1989 (Arnerican Speech-Language-Hearing Association, 1999).
Oropharyngeal dysphagia, in particular, is any abnormaiity in swallowing physiology of
the upper aerodigestive tract. A thorough assessrnent of oropbqmgeai dysphagia is
typically conducted by a speech-language pathologist in collaboration with appropnate
other professionals depending on the nature of the underlying pathology. Although other
groups such as occupational therapy and dietitians aiso perform physiological
oropharyngeal assessments, they do so on a less fkequent basis. This type of dysphagir?
has been reported to approximate 10 percent of al1 acute hospital inpatients (Groher et al.,
l986), 30 percent of patients in rehabilitation centers, and half of patients in nursing
home facilities (Logemann, 1995). Oropharyngeal dysphagia affects people of al1 ages
fiom pediatrics (Rogers, 1996) to geriatrics (Nilsson et al., 1996). In new acute stroke
patients alone, the incidence approximates 30 to 65 percent (Barer, 1989; Daniels et al.,
1998). Of those initially affected, approximately 50 percent spontaneously recover to a
normal swallow within 7 days after the onset of the stroke event (Barer, 1989; Kidd et al.,
1995). However, those who rernain affected d e r the first week show much slower
oropharyngeal dysphagia recovery rates. The prevalence of clinically diagnosed
dysphagia in patients at one month post stroke has been reported to be f?om 2 to 21
percent and remains as high as 7 percent at 3 months post stroke (Barer, 1989; Teasell et
al., 1994; Kidd et al., 1995). Aithough the literature to date focuses on dysphagia due to
stroke, it is evident that dysphagia is also common with patients who suffer head and
neck cancer (Kronenberger et al., 1994; Logemann, 1985) and progressive neurological
diseases (Bushrnan et al., 1989; Edwards et al., 1994; Fuh et al., 1997; Horner et al.,
1994; Kagel et al., 1992; Mayberry et al., 1986; Wintzen et al., 1994). Dysphagia cm
also be a potential complication of surgery to the head and neck area, such as anterior
cervical spine surgery (Martin et al., 1997), or medical treatments, such as the
administration of neuroleptic medications (Sokolo ff et al., 1997).
Patients diagnosed to have dysphagia have poorer health outcomes than similar patients
without dysphagia. Acute stroke patients, in particular, diagnosed with dysphagia fiom
videofluoroscopic testing were reportedly 7 times more likely to experience pulmonary
complications such as pneumonia (Holas et al., 1994). Furthemore dysphagic patients, if
untreated or untreatable, may need percutaneous feeding tubes that require special
nursing care. The specialized nursing care required for patients with tube feedings is
often not available in Ontario nursing homes, thereby, preventing their transfer fiom
costly acute beds to the relatively less expensive chronic care beds. The presence of
oropharyngeal dysphagia, therefore likely, not only increases poorer health outcome but
also increases the strain on health care resources.
A.2 Rationale for the Thesis
The rationale for proceeding with the thesis work is based primarily on two factors: a) the
hown fact that when large variation of practice is present the overall quality of care is
sub-optimal; and b), the rapidly expanduig demands on speech-laquage pathologists for
dysphagia services in the absence of forma1 training or practice guidelines have provided
the likelihood of large variation in practice.
A.2.a Variations in Medical Practice and Clinical Decision-Making
The Canada Health Act, first passed by Parliament in 1984, advocates universal access to
health care for every Canadian citizen (Ministry of Health, 1997). Under this Act,
Canadian consumers of health care will receive uniform health services for any disorder
regardless of where or by whom the senice is provided. The premise behind the Act
M e r supposes that given the wide choice of diagnostic or treatrnent services, only those
most suitable will be selected for the patient. However, research on the utilization
patterns of medicd care for patients with similar diseases has not found this to be the
case. Wide differences in surgical procedures have been identified between (Mindel1 et
al., 1982) and within (Anderson et al., 1989; Mindeil et al., 1982; Vayda et al., 1984;
Roos et al ., 1 99 1) Canadian provinces for several common surgical procedures including
coronary artery bypass surgery. Variations have also been identified across countries
(McPherson, 1990; Vayda, 1973), and between regions in other countries such as the
United States (Chassin et al., 1986; Leape et al., 1989; Wemberg, 1988; Ashton et al.,
1999), England (Newton et al., 1994) and Australia (Wennberg, 1999). Not only were
practice variations identified in d l countries studied, but those procedures that showed
hi& (or low) variation in one country showed similar variations in other countries
(Health Services Group, 1992). It appears, then, that geographical practice variations are
a worldwide phenomenon that exist irrespective of any particular health care delivery
system (Wennberg, 1988).
Although recent research has verified the existence of geographical differences, a
phenomenon also known as 'Small Area Variation' (SAV), their causes are poorly
understood and remain areas of research (Health Services Group, 1992). Studies that
adjusted for confounding variables such as incidence and prevalence of disease and age
and sex of patients continue to find staîistically significant different geographical
utilization rates Wemberg, 1988; Health Services Group, 1992; Roos et al., 1991).
Likewise, studies that assessed the influence of available health care resources (Leape et
al., 1989), socioeconomic patient status (McLaughlin et al., 1989), and appropriateness of
care (Chassin et al., 1987) report inconclusive findings regarding their effect on SAVs.
Without detemiining dennitive reasons for SAVs, clinicians and policy makers cannot
conclude whether these practice differences suggest problems with overuse, undenise or
misuse of health care resources (Bodenheimer, 1999; Health Services Group, t 992).
In light of inconclusive empirical data, several theones have been postulated to explain
the widespread phenomenon of SAVs. Wemberg, in particular, claims that differences
in utilization rates may be explained by the subjective attitude of the physician in
combination with existing scientific knowledge, collectively known as the 'practice style
factor' (Wennberg, 1988). He argues that the best available evidence depicting the
influence of physician attitude on utilization rates cornes fkom changes in surgical rates.
Specifically, physicians in Canada, the United States and Norway have been identified to
have changed theu rates for hysterectomy, tonsillectomy and lem extraction after having
reviewed material depicting their current rates (Wennberg, 1988). Wennberg, dong with
others, claims that the influence of subjective attitude is greatest when there is a lack of
scientific knowledge regarding the best health service to provide (Wennberg, 1988; Eddy,
1984; Roos et ai., 199 1). Limited scientific knowledge resutts with a lack of consensus,
thereby creathg physician 'uncertainty'. Uncertainty then ailows room for subjective
interpretation about medical procedure utilization and therefore contributes to a wide
variation in practice. Unfortunately, examples of high uncertainty and there fore high
variability abound and include many common medical and surgical procedures such as
hypertension, tonsillectomy and knee operations (Wennberg, 1988). In contrast, there are
relatively fewer examples of low variability practices and they include hemia and hip
repair (Wennberg, 1988). It appears then that practice style, or more particularly
scientific uncertainty, causes practice variation.
M i ~ s and Chang argue that al1 medicai procedures have an inherent level of uncertainty
that can never be completely eliminated (Mirvis et al., 1997). Uncertainty, they argue,
will inevitably exist because the same condition d l unlikely affect any two individuals
the sarne due to their bioIogical variability. Furthemore, our lmowledge of basic
pathophysiology is not complete and out diagnostic tests are imperfect yielding only
probabilities and not certainties. There exists little empirical evidence to indicate what
practice style produces the most favourable outcornes, therefore, dlowing physicians to
choose within a broad range of acceptable practice that is largely based on uncertainty-
They claim that areas of high uncertaintty will inevitably lead to over-utilization due to
the clinician's natural tendency toward errors of commission rather than omission. la
order to ensure resource conservation, it is argued, practice patterns must be maintained
w i t b a range of acceptable uncertahty while encouraging a trend toward using only
necessary tests. To best guide the physician toward this objective, the authors suggest that
practice guidelines be developed to recommend a range rather than a single-point of
appropriate practice behaviour (Mirvis et al., 1997).
Ideally, every health care chician should attempt to maximize the quality of care while . . . .
at the same time eliminate utilization of unnecessary practices or resources. Minunizing
practice variations across regions can help achieve this ultimate clinical goal (Mïrvis et
al., 1997; Roos et al., 199 1). I d e n m g areas of wide practice variation is the necessary
first step. Since uncertainty is thought to cause wide variation, identification of different
practice utilization or SAVs can be accomplished either directly by surveying actual
practice behaviour, or indirectly by surveying dinician certainty levels. The procedures
with the highest SAV or highest uncertainty can then be prioritized for practice guideline
development, which in turn will help minimize practice variability (Roos et al., 1992)
(Shekelle et al., 1999).
A.2.b Speech-Language Pathology Clinical Decision-Making in Dysphagia
Reports from the American Speech-Language-Hearing Association (ASHA) indicate that
over 50 percent of clhicai time for al1 speech-language pathologists is devoted to the
assessrnent or treatment of dysphagia (American S p e e c h - L a - H e Association,
1997). This marks a 2 1 percent increase over the past 10 years (American Speech-
Language-Hearing Association, 1997). More particularly in 1997, as high as 97 percent
of those clinicians working in health care facilities reported that they regularly served
patients with dysphagia (Americao Speech-Language-Hearing Association, 1 997a).
Similar evidence has not been published for Canadians, however, these figures are in line
to those reported in workload measurement summaries across tertiary care hospital
facilities in Ontario where approximately 55 percent of clinical caseloads was devoted to
dysphagia services (Health Care Professional Xnterest Group, 1999).
In 1997, the Agency for Health Care Policy and Research (AHCPR) in the United States
initiated a systematic review of the dysphagia Merature pertaining to the diagnosis and
treatment of dysphagia in the elderly. One of their goals was to collect information on
practice variation. Following an extensive review of the iiterature by both
methodological and content experts it became apparent that there was no published or
unpublished literature that compares actual practice patterns and nothing that relates
different practice patterns to various patient outcomes (Lerner et al., 1997). The current
lack of evidence on practice behaviour exists regardless of the increasingly high demand
for speech-language pathologists to provide dysphagia services în health care facilities.
In recognition that many of their members are becorning more involved in dysphagia
dong with the current lack of literature describing actual practice behaviour, both the
American (ASHA) and Canadian (CASLPA) national associations have recently initiated
recommendations toward the standardization of dysphagia practice. ASHA has been at
the forefiont in providing policy statements regarding the role of speech-Ianguage
pathologists in the area of dysphagia (Amencan Speech-Language-Hearing Association,
1983). They provide guidelines for the knowledge and skills required by speech-
language pathologists providing dysphagia services (American S peec h-Language-
Hearing Association, 1 99O), and have determined that instrumental diagnostic procedures
for swailowing are within the scope of practice for speech-laquage pathologists if
appropriate education and training was first success M y completed (American Speech-
Language-Hearing Association, 1992). ASHA recognized that graduate-training
programs needed to respond to the increasing employment dysphagia demands by
providing the basis for this education and training. A 1994 survey fiom the Educationai
Standards Board reveaied that of 1 12 accredited graduate programs in the United States
only 18 offered courses in dysphagia and many of them were presented as sections or
series of lectures within another course (Amencan Speech-Language-Hearing
Association, 1995). In 1995, ASHA then drafted a recoxmnended curricuiwn for
graduat e training in swailowing disorders for speech-Ianguage pathologists that inc luded
such areas as the normal aerodigestive tract, abnomal swallowing, both clinical and
instrumental assessment, management, documentation and ethicai issues (American
Speech-Language-Hearing Association, 1 995). In 1 997, ASHA m e r pub lished
preferred practice pattern (PPPs) for practicing speech-language pathologists (American
Speech-Language-Hearing Association, 199%). These PPPs outline the expected
purpose of each procedure, clinical indications for performing each procedure, clinical
processes, setting and equiprnent speci fications, safety and heaith precautions, and
documentation aspects. These PPPs address the approprïateness of administering a
clinical assessment but not the instrumental assessment. Clinical indications for
appropriate use of instrumental assessments have been recently drafted and disseminated
for peer review (Amencan Speech-Language-Hearing Association, 1998). Given the
numerous initiations to standardize dysphagia services, ASHA has made only few
attempts to assess dysphagia outcomes following such services (Amencan Speech-
Language-Hearing Association, 1996; Baum et al., 1998) and no attempts to monitor the
clinicians' actual adherence to these suggested guidelines.
Although ASHA'S attempts at standardizing dysphagia practice have shortcomings, they
outnumber initiatives by its respective Canadian associations. The Canadian Association
for Speech-Language Pathologists and Audiologists (CASLPA) has only recently
instituted directives for dysphagia services. Specifically, in 1995 an ad hoc cornmittee
proposed a position paper on the assessment and management of dysphagia (Canadian
Association of Speech-Laquage Pathologists and Audiologists, 1996). In 1998,
CASLPA for the k t t h e included the area of dysphagia in its scopes of practice
document for speech-language pathology (Canadian Association of Speech-Language
Pathologists and Audiologists, 1998). More recently, the College of Audiologists and
Speech-Language Pathologists of Ontario (CASLPO) has funded ten experts to draft
preferred practice guidelines (PPGs) for speech-language pathologists providing
dysphagia services in Ontario. The resulting PPGs will be the first practice guidelines
prepared for Canadian clinicians. Currentl y, of the nine Canadian universities O f f e ~ g
training programs in speech-language pathology, only the University of Toronto offers a
separate swdlowing disorders course as part of its required curriculum. It appears then,
that in Canada, there is a lack of standardization regarding dysphagia services at the
levels of initial training and actual practice.
The initiatives to introduce dysphagia training at the graduate level and recommend
practice guidelines have been recent in both Canada and the United States, although the
initiatives of the latter have been more numerous. The result for both countries is that
these initiatives may not have yet benefited chicians who have been practicing in
dysphagia for several years. Dysphagia training for these more seasoned clulicians
would have been fkom any combination of sources including workplace mentoring or
focused workshops. The result is a large contingent of senior speech-language
pathologists who have received no uniform teaching curriculum while at the same time
practicing without standardized pmctice guidelines. Having been forced to resort to their
own resources, we hypothesize that these clinicians have likely developed a unique set of
practice behaviours dependent on their specinc leaming experiences and their particular
clinical demands. The ciinical demands, themselves, can vary due to a different set of
factors such as the setting in which service is being provided, the age and etiology of
patients being senriced, and the availability of other professionals to provide consultation
and collaboration. These variables dl combine differently and will likely affect
individual speech-language pathologists in a variety of ways, thereby, promoting
variations in actual dysphagia practice behaviours.
As previously stated, and although highly suspect, the actual practice behaviour
variations of speech-Ianguage pathologists in the provision of dysp hagia services has no t
yet been examined. From Literature on physician practice pattern variations, SAVs have
been shown using weil-established administrative databases. Furthemore, S AVs are
highest in areas of greatest physician unçertainty. Unfortunately, unlike physicians,
speech-language pathologists have no equivaht administrative databases by which to
monitor actual practice behaviour. Therefore, if practice behaviour is to be studied in this
professional group it m u t be either directly via a survey of reported behaviours, or
indirectly, by surveying clinician uncertahty. It is assumed that the result of these
surveys will likely depict widespread clinician uncertainty and practice variation
regarding the provision of dysphagia service and what outcome measures reflect
successfûl assessment and subsequent treatment. This research will not only be the k t
attempt at assessing whether variabiiity does indeed exist in speech-language
pathologists' opinion and self-report of their practice behaviour for dysphagia, but it will
also be the first to employ survey methodology to obtain information on practice
behaviour for this professional group.
A.3 Purpose Of the Thesis
This research comprised the k t phase of a two phase project to describe reported
dysp hagia assessment practice patterns of speech-language pathologists across Canada
and the United States. The overall project will target practice behaviour in al1 settings in
which dysphagia is practiced, regardless of the age or etiology of patients serviced.
Information on practice behaviour will be collected utilizing a new self-administered mail
questionnaire. The overd goals for each of the 2 research phases will include:
Phase 1:
1. To develop the self-administered mail questionnaire (Section B).
2. To conduct a pilot phase survey of Canadian speech-language pathologists on their
reported dysphagia assessrnent practice patterns for the purpose of obtaining
descriptive information that could be used in the later larger-scale survey (Section C).
3. To evaluate the reliability of the new survey instrument by assessing its test-retest
reliability (Section D).
Phase lT:
1. To also conduct a pilot phase survey of Amencan speech-language pathologists on
their reported dysphagia assessment practice patterns for the purpose of obtaining any
idiosyncratic descriptive information that could be used in the later larger-scale.
2. To plan and administer the large-scale survey to both Canadian and American speech-
language pathologists utilizing descriptive infoxmaîion obtained in pilot testing.
This thesis research entaiIed Phase 1 objectives 1 to 3. Phase fI is beyond the scope of
this project and will be completed in the future dependent on extemal funding.
Application for such fiinding will require and benefit fkom results of this pilot research.
SECTION B: QUESTIONNAIRE DEVELOPMENT
B.1 Introduction & Goals
The new self-administered questionnaire is intended for a large-scale survey of speech-
language pathologists. Its primary purpose will be to describe the clinicians ' self-reports
of their dysphagia assessrnent practice patterns and their opinion of the importance for
each assessrnent parameter. In the absence of an administrative database for procedures
administered by speech-ianguage pathulogists, surveying the clinicians' self-reported
behaviour is an indirect method by which to denve information on actual practice. The
secondary purpose of the survey will be to deiineate potential influencing factors on
reported practice patterns and to compare reported practice behaviours between
practitioners in Canada and the United States.
The rationale for selecting the self-administered mail questionnaire mode was multi-
factorial and included the logistics of the sampling population and the sensitivity of the
topic. Specifically, the practice of dysphagia assessrnent is extensive and involves a
variety of both clinical and instrumental maneuvers. In order to collect utilization
information on al1 these maneuvers for clinicians over a large geographical area, the self-
acirninistered mail survey is more cost efficient than either the personal or telephone
interview (Aday, 1996; Mangione, 1995). Furthemore, this method offers the advantage
of relative anonymity for potentially sensitive questions about health care practices
(Aday, 1 996; Mangione, 1 995).
The mail questionnaire does, however, have disadvautages over other survey data
collection modes. Ln particular, sample coverage is limited by the accuracy of the
database selected and the response rates are typicaiiy lower than either the telephone or
personal interview (Aday, 1996). Also, the influence of context fiom either preceding or
subsequent questions is less predictable with mail questiomaires than telephone
interviews where the order of question presentation is controlled by the ù i t e ~ e w e r
(Schwarz et al., 1 995). For the purpose of this research, these known disadvantages did
not outweigh the known advantages of the self-administered mail survey which allowed
for a larger geographicai sampüng with controiled cost and more reliable reporting with
provision of anonymity. To m e r augment the benefits of mail surveying, this research
implemented formatting and survey design techniques to maximize both item and survey
response rates, which are respectively described in Sections B.3 and C.3 of this
manuscnp t.
En summary the specific goals for questionnaire devdapment were:
To ensure content validity of the instnrment by generating a comprehensive Iist of
dysphagia assessment parameters used b y speech-language pathologists, and factors
that may influence them (Section B.2).
To maximize s e e y item response rates by fonnatting and designing the self-
administered questionnaire using the generated parameters (Section B.3).
To m e r maximize s w e y item response rates by pre-testing the draft questionnaire
for content and format to ensure face validity (Section B.3)-
B.2 Content DeveIopment
Content validity is an important element of a questionnaire in that it requires the
instrument to include al1 and only those elements that are relevant to its purpose (Portney
et al., 1993). The determination of content validity is essentially a subjective process that
evolves out of the systematic planning and construction of the instrument. In this
research, content validity refers to the adequacy with which the assessment domain of
oropharyngeal dysphagia was represented by the parameters in the new instrument. The
assessment parameters were generated in a two-step process; first, by a panel of
dysphagia experts over a series of telephone interchanges, and second, by dysphagia
experts during the pre-testing stage of the instrument. The following section will focus
on the fïrst step of the item generation process.
B.2.a Generation of Dysphagia Parameters
Experts: The initiai ciraft of content items was generated in collaboration with 6
established dysphagia experts via telephone conferencing. Ln addition to this author, the
other experts were 4 speech-language pathologists* and 1 otolaryngologist'. Ail experts,
except for this author, practice in the United States and are intemationaily recognized for
their expert clinical and research contributions in dysphagia Although experts
volunteered their participation, together they represented academic leaders in dysphagia
practicing in North American with many years of experience in both research and clinical
practice. The group of six was formed at a meeting in Ann Arbor in September of 1996.
The meeting included 30 invited international dysphagia experts and focused on the
discussion of dysphagia outcome scales. The specific purpose of the six experts was to
develop a physiological outcome scale. In order to continue working toward this purpose
following the initial 1996 meeting, the 6 participants conferenced via telephone and
generated an exhaustive List of p hysiological parameters utiiized by speech-language
pathologists in the assessment of dysphagia There were approxirnately five telephone
conference calls behveen the penod of February to Iuly 1997. Not al1 participants
attended al1 conference calls and some contributed idormation for missed meetings via
the group chair, Cathy Lazarus. Funding for this group's initial meeting in Ann Arbor
and subsequent telephone conferencing came ti-om the Special Interest Division of
Swallowing, a subgroup of the American Speech and Hearing Association, and the
Department of Veterans' Affairs in the USA.
The physiological assessment parameters generated by the 6 experts encompassed both
community and research settings and reflected items assessed in al1 patients, regardless of
age and etiology, who undergo either clinical or instrumental examination. A two step
Cathy Lazanis, PhJ)., Speech-Language Pathologisî, Northwestern University, Evanston, IL. Jeri A- Logemaan, Ph-D., Speech-language Pathologis& Northwestern University, Evanston, EL. JoAnne Robbins, PhD., Speech-Language Pathologist, University of Wisconsin, Madison, WS. Barbara C. Sonies, PLD., Speech-Language Pathologist, National Institute of Health and Clinical Centre ' Jonathan Aviv, MD., Otolaryngologist, Columbia-Presbyterian Medical Centre, New York, NY.
systematic approach to denving parameters was conducted. First generated were the
overall content areas foliowed by the specific assessment parameters for each of the
generated areas.
Literature Review: In order to ensure a comprehensive list of ail relevant dysphagia
assessment techniques, a literature review was conducted of materials denved through
computer searches, persona1 files, and conferences. The Medhe database was searched
fiom 1992 to February 1998 with the MeSH headings of 'deglutition disorders',
combined with 'fluoroscopy' or the text word 'clioical' and M t e d to English speaking
articles.
B .2. b Generation of M o d i m g Factors
A secondary purpose of the questionnaire was to delineate factors that may influence
variations in practice patterns. Previous research on pbysician practice variation
identified the influence of geography and uncertainty in clinical decision making
(Wemberg, 1988; Eddy, 1984; Health Services Group, 1992; Roos et ai., 1991). Other
variables tested but not consistently found significant in changing practice behaviours
were access to other health care personnel and the age and sex of patients (Health
SeMces Group, 1992; Roos et al., 1991). The purpose of this research was to deiineate
factors that would detennine the influence of clinician, patient and setting variables on
practice behaviour. Relevant demographic factors were identified fkom a review of the
Ii terature and personal experience with dysphagia practice.
B.2.c Results of Content Development
Parameters of Dysphagia Assessment: Consensus fkom the dysphagia expert panel
delineated five overall content areas for the two main categones of clinical and
instrumental assessments. Each of these two main categones had up to six sub-
categories. Al1 the phases of swallowing were captured f?om the oral musculature to the
level of the upper esophagus for a total of 17 assessment areas (Table 1).
The fiterature review did not reveal any new clinical (Gottlieb et ai., 1996; DePippo et al.,
1994; Barer, 1989; Horner et al., 1993; Horner et al., 1988; Horner et al., 199 1 ; DePippo
et al., 1992; Kidd et al., 1993; Nilsson et al., 1993; Veis et al., 1985; Splaingard et al.,
1988; Linden et al., 1993; Nathadwarawala et al., 1994; Nathadwarawda et ai,, 1992;
Kim et al., 1994; Selley et al., 1990; Gresham, 1990; Kim et al., 1993; Daniels et al.,
1998; Rhodus et ai., 1995; Halama, 1994; Lorenz et al., 1993; Perlrnan et al., 199 1 ;
Logemann, 1996; Davies et al., 1995; Skuse et al., 1995; Reilly et al., 1995; Leopold et
al., 1 996; Hughes et al., 1996) or instrumentai (Horner et al., 1988; Homer et al., 199 1 ;
Horner et al., 1990; Nilsson et al., 1993; Logemann et al., 1993; Chen et al., 1990; Linden
et al., 1993; Khoo et al., 1996; Ott et al., 1996; Chen et al., 1992; ertekin et al., 1996;
Rosenbek et al., 1996; Lof et al., 1990; Ekberg et al., 1988; Scott et ai., 1998; Logemann,
1995; Rademaker et al., 1994; Mendelsohn, 1 994; Johnson et al., 1993; Ohmae et al.,
1995; Kahriias, 1993; Crary et al., 1994; Freson et al., 1994; Wintzen et al., 1994;
Pauloski et al., 1995) assessment parameters than those already generated by the expert
panel. However, it did generate three additional instrumentation techniques, namely
cervical auscultation, the Repetitive Oral Suction Swdow (ROSS) test, and
Computerized Laryngeal Analysis (CLA). Although cervical auscultation can be
described as a subjective reading of pharyngeal swallowing sounds, it was included in
this survey as instrumentation in Light of the additional cluiician training requked for its
proper administration and interpretation (Anonymous, 1995). The ROSS test is a
relatively new technique trialed with healthy adults (Nilsson et al., 1996b), and
neurogenic (Nilsson et al., 1995) and Parkinson's Disease (Nilsson et al., 1996a) patients.
It requires the patient to drink 200 ml of water through a straw. The patient is asked to
'suck' and 'swallow' twice and on the third attempt, the patient must first breath in
through the nose and then 'suck' and 'swallow' the rest of the water as rapidly as possible
using repetitive ingestion cycles. Swallow readings include bolus volumes, laryngeal
movement, inspiration and expiration breathing phases, bolus passage via pharynx and
overall swallow time. In contrast there exists no research testing of the accuracy of the
CLA technique, however, it is fiequently advertised in popular dysphagia joumals and its
clinical value discussed on a current dysphagia list serve (http://www..dysphagiacom).
Other instrumentation techniques akeady generated by experts were also derived fiom
the Iiterature, namely videofluoroscopy (Iforner et ai., 1988; Horner et al., 1991; Homer
et al., 1990; Nilsson et al., 1993; Logemann et al., 1993; Chen et ai., 1990; Khoo et al,,
1996; Ott et al., 1996; Chen et al., 1992; ertekin et al., 1996; Lof et al., 1990; Ekberg et
al., 1988; Scott et al., 1998; Logemann, 1995; Rademaker et al., 1994; Mendelsohn,
1994; Johnson et ai., 1993; Ohmae et al., 1995; Kahrilas, 1993; Crary et al., 1994; Freson
et al., 1994; Wintzen et al., 1994; Pauloski et al., 1995; Logernann et al., 19931,
Fiberoptic Endoscopic Examination of Swdow (FEES) (Murray et al., 1996; Langmore
et al., 1988) Fiberoptic Endoscopic Examination of Swallow and Sensory Testing
(FEESST) (Aviv et al., 1996; Aviv et al., 1994), sonography (Sonies, 1991), oxygen
saturation monitoring (Sellars et al., 1998), and manometry (Olsson et al., 1996).
Mudifihg Factors: This research targeted investigation of clinician, patient or practice
setting influences on dysphagia assesment practice behaviour. In order to develop
questions that addressed these variables, specific indicators for each were outlined
thereby generating a total of twelve different factors from which to frame survey
demographic questions (Table 2).
B.3 Instrument Layout and Testing
B.3 .a Questionnaire Formation
Published research has shown that certain questionnaire formatting will reduce the
likelihood of respondents to inappropriately miss individual questions or decide not to
cornplete the entire questionnaire itself (Aday, 1996; Mangione, 1995). This formatting
includes unambiguous navigational guides and uncluttered visual and information
organization (Jenkins et al., 1997). In contrast, questionnaire length by itself has not been
shown to consistently inauence response emrs or response rates (DiIlman et al., 1993).
This research included the following formatting strategies in the design of this new self-
administered mail questionnaire:
Information Organization: The individual physiologicai parameters generated were
worded into questions suitable for a mail survey self-adrninistered questionnaire. The
new questionnaire was structured to delineate practice utilization for each assessment
pararneter. The same question with 3 stated response choices was used for each
parameter. In order to maintain a similar format, opinion of importance was delineated
for each of these assessment parameters using a comparable closed response format. The
responses to both practice behaviour and opinion question types were measured dong a
3 -point continuum including 'never', 'occasionally ' and 'always' ; or along a 5-point
continuum including 'definitely not', 'probably not', 'not sure', 'probably' and
'definitely' respectively. The closed set format was preferred because it simplified
coding for data analysis (Aday, 1996; Mangione, 1995).
The placement of open-ended questions immediately foiiowing closed-end questions
served to generate more content items. Since this is a pilot stage of the new questionnaire
this was considered to derive pertinent information which may be used for future versions
of the questionnaire (Streiner et al., 1995; Aday, 1996).
The influence of question order on response rates with the self-administered survey has
not been conclusive (Dillman et al., 1993). However, others have suggested that placing
demographic infoxmation after the more important content questions is preferred. The
reason given has been the possibility of more accurate content responses (Aday, 1996).
Furthemore, it is reported that response accuracy of the more difficult questions is
increased if they are completed when the respondent is still fkesh and motivated versus at
that end of the questionnaire when there may be fatigue (Mangione, 1995). For these
reasons, the demographic questions for the new questiomaire were placed at the end.
The wordhg of demographic questions varied according to the content targeted.
Attempts were made to repeat the same format for similar content groups. Specifically,
al1 the innuencing questions pertaining to patient volume utilized the bonded recall
method. Use of memory cues minimizes cognitive processing thereby facilitating shorter
response t h e and increasing response accuracy (Aday, 1996)-
Visual Organization: The visual presentation of the questionnaire was maximized
according to the laws of 'Tragnanz and Proximity" (Jenkins et al., 1997). The former
indicates that questionnaire layouts that are simple, regular and symmetrical wiI1 be more
easily perceived and processed than those that are irregular. Likewise, the law of
proximity advocates that spacing helps distinguish between question groups whereby
questions close in space will be seen to belong together and distinct from those more
distant. This questionnaire implemented greater spacing between practice areas and
smaller spacing between subsections in each of the primary practice areas. Also,
responses for each of the practice behaviours were kept regular throughout.
The benefit of green versus white paper has been tested the most and found to have an
increase in response rate (Mangione, 1995). It is felt that a questio~aire that is green
will stand out more than if it were white on the respondent's desk. This questionnaire
was designed to be in booklet form, using 8"x1lW size white paper, with a green cover
and a green blank last page.
Navigational Guides: The response Iayou t was maintained uni form in a vertical direction
to act as a useful navigational device directing respondents systematically through the
questionnaire with minimally missed items (Jenkins et al., 1997). Furthemore, regular
numbering of all questions, bolding for each new section and contrasting fonts were aiso
implemented. The main title and instructions for respondents were placed on a separate
page at the fiont of the questionnaire to encourage every respondent to read this section
before proceeding with competing the questionnaire. Ensuring that instmctions are read
at the start facilitate completion of the questionnaire in the same systematic rnanner for
al1 respondents (Aday, 1996; Mangione, 1 995).
B .3 .b Questionnaire Pre-Testing
The draft version of the questionnaire was pre-tested to further generate content items
and ensure face vaiidity. Face validity cannot be statistically tested. It is a post hoc
subjective measure that essentially indicates if the questionnaire 'appears' to test what it
is supposed to test and that it does so in a plausible method (Portney et al., 1993). The
presence of face validity is important to ensure that the questionnaire instrument will be
completed by respondents and that its results will be considered an accurate reflection of
practice behaviour by the speech-language pathology community in general.
Subjectc Since the overall purpose of the large-scale survey will be to compare practice
patterns of both Canadian and Amencan speech-language pathologists, subjects fkom
both these groups were selected as subjects. Furthemore, a criterion was set that at least
one subject must have mainly pediatric experience and one mainly adult expenence. This
was to ensure that the appropnateness of the new questionnaire would be assessed for
practices servicing patients of ail ages. The k a 1 selection included 8 Speech-Language
Pathologists, 3 Canadian and 5 American. Al1 are considered experts and most have
published in the area One works with oniy pediatric patients and the others with mainly
adults. One uses mainly fiberoptic endoscopy and the others mainly videofluoroscopy.
Four of the 8 were also involved in the item generation stage.
Procedure: Each subject was asked to review the ciraft questionnaire independently using
a feedback response form (Appendix 0. The use of the form was to ensure that the
subjects considered targeted areas in their review. Specifically, feedback was solicited
for the total tirne required to complete the survey, impressions of the format and content,
identification of ambiguous wording and the ease in providing responses. Subjects
completed the review and submitted theu responses to the author by either mail or e-mail.
The final version ofthe questio~aire was completed according to the feedback received.
B.3.c Results of Instrument Layout and Testing
Instrument Layout.. A draft version of the questionnaire was completed and made ready
for pre-testing. It consisted of a total of 124 questions on 16 pages. It contained each of
the previously declared content areas in three main sections. Section A of the survey
consisted of clinical assessment, Section B of instrumental assessment, and Section C of
demopphic questions (Appendix II).
Testi~g: Seven of the eight subjects submitted feedback. The one who did not was
reminded on three occasions and was willing but couid not follow though due to other
commitments. Timing of the feedback varied fiom under 2 weeks fiom 5 subjects and
longer than 2 rnonths fiom 2 subjects. The late respondents each required one reminder-
Feedback fiom respondents concentrated on content, with a totai of 46 question additions,
35 question revisions and 1 question eiimination. Many of the suggested additions were
the same across reviewers and focused on adding response choices for demographic
questions pertaining to patient etiology, collaborating team members and practice setting.
Question revisions for select assessment parameters were suggested to clariQ ambiguous
wording or increase closed-set response choices. Al1 ambiguous questions were re-
worded but response choices were maintaineci the same throughout Sections A and B to
abide by the formatting rules of mail survey design (see Section B.3.a). One question
was elirninated according to the reviewers' suggestions that it was a repeat of another
question.
Feedback on format was unanimously positive for visual layout, ease in questionnaire
cornpletion and clarity of navigational guides. Three reviewers reported that the
questionnaire required fkom 20 to 35 minutes to complete. The other reviewers did not
report time fkames. Feedback fiom the two late respondents was similar to that fkom
earlier respondents thereby not introducing any new information. This redundancy
suggested that the questionnaire had achieved maximum face validity and was therefore
ready for h a i printing.
The fina1 version of the questionnaire consisted of 18 pages with 161 questions.
(Appendix III) Apart fiom the increase in questions, elhination of the redundant
question, and rewording to eliminate ambiguous questions, no other changes were made.
A questionnaire matrix was constnicted to summarize the content of the instrument
including the purpose served by each question and the characteristics of the resulting data
elernents (Table 3).
B.4 Discussion
There is currently no tool in the Iiterature by which actuai dysphagia assessrnent practice
behaviours of speech-language pathologists could be descnbed. This phase of the
research targeted the systematic development of such a tool. The advantages of using the
self-admuùstered mail survey mode, for practitioners across a large geography and with
the extensiveness of dysphagia practice, outweighed its disadvantages. As the specific
purpose of the new tool was to survey speech-language pathologists in both Canada and
the United States, expert clinicians representing both these groups generated the survey
content items. The use of experts was intended to maximize content validity, and
therefore promote item generation that was cornprehensive yet restricted to relevancy.
Experts were dso utilized to perform the pre-testing of the initial s w e y ciraft and,
therefore, maximize its feasibility and acceptance by practicing clinicians.
Ideally both general and expert practitioners would have been utilized in the construction
of the questionnaire. However, only experts were accessed for this phase of the research.
Dysp hagia experts are a finite group and most practitioners who provide this service
develop expertise due to their professional responsibility to lirnit the risk of pulrnonary
h m to their patients. Although professionai bodies do not yet mandate specialization, it
is highly encouraged (American Speech-Language-Hearing Association, 1997b;
Arnerican Speech-Language-Hearing Association, 1992; Amencan Speech-Language-
Hearing Association, 1990; American Speech-Language-Hearing Association, 1998;
Canadian Association of Speech-Language Pathologists and Audiologists, 1996). As a
result, the inclusion of the dysphagia general practitioners in tool development was
considered more useful as part of the pilot swey . They then would be providing
anonymous feedback and possibly be more truthfbl without the intimidating presence of
experts.
The use of intemationally well known experts proved usefiil in systematically generating
content items in a relatively expedient and comprehensive manner. Results fkom the pre-
testing phase offered few changes to the survey content with mainly question omissions
and wording ambiguities highlighted. This fiding may suggest hornogeneity between the
expert groups generating the items and those pre-testing the survey because 4 of the 8
pre-testers also participated in item generation. The same 4 experts were used to ensure
that the items originaiiy proposed by the experts had been correctly adapted into a self-
administered mail survey form. To counter a potential membership bias between item
generation and survey pre-testing groups, 4 other experts were intentionaily seiected to
compliment and overcome some of the practice elements not represented by the original
4. Specifically, none of the experts generating items represented the paediatric service or
expertise in fiberoptic endoscopy and 2 were fkom the same practice settuig. Therefore,
the complete pre-testing expert group represented main practice features, including both
adult and paediatric patient services and instrumental expertise in fiburoptic endoscopy,
videofluoroscopy and sonography. Furthemore, this group consisted of speech-language
pathologists f?om various cities and practice settings in Canada and the United States.
Evidence that the overall pre-testing group did in fact differ from the previous group is
that, of the few comments provided, not only did they recommend additional question
items but they also spotted redundant content.
The relatively few recommended changes to the survey following completion of pre-
testing would indicate that the literature review and expert input have been complete.
Furthemore, the survey was meticulously formatted in information, visual and
navigational organization according to what had been previousiy published to be
successfiil in maximizing item response rates. The success of the survey's first draft
may, therefore, have been a result of this diligent methodological effort.
The h a 1 product is an 18-page self-administered mail survey containing 3 main sections
including clinical and instrumental assessment parameters dong with potential modifiers
of practice behaviour. According to pre-test results this seemingly lengthy survey is
cornpleted within 3 0 minutes and appears comprehensive yet no t overwhelming to the
respondent. In short, at this stage of the research it cm be s u m m k e d that both content
and face validity of the new survey have been achieved.
SECTION C: PILOT PHASE SURVEY
C.1 Introduction & Goals
The second main objective for this thesis research was to obtain preliminary descriptive
information regarding the reported dysphagia assessment practice behaviours of
Canadian speech-language pathologists, dong with information on po tentiail y influentid
factors. This pilot phase met this goal by administering the new survey to a sub-set of
eligible Canadian speech-Ianguage pathologists. Collectively, the descriptive practice
and methodological results will form the groundwork for fûture revision and large-scale
administration of the new self-administered mail m e y to speech-language pathologists
across Canada and the United States.
Zn summary, the specific goals for the pilot phase survey were:
To select a small representative sample of Canadian speech-language pathologists
who practice in the area of dysphagia, regardless of age or etiology of patients served
and setting in which the service is provided.
To determine item and s w e y response rates in order to assess the benefit of rigorous
questionnaire development and mail survey design.
To obtain a preliminary o v e ~ e w of speech-language pathologists' self-reported
dysp hagia assessment practice behaviours, and factors that may in£ luence them.
C.2 Subjects
C.2.a Sampling
Sampling aimed to obtain a random representative collection of speech-language
pathologists engaged in dysphagia assessrnent in Canada. The sampling M e was the
1997-membersbip database of the Canadian Association of Speech-Language
Pathologists (CASLPA). Practitioners in most provinces are higtily encouraged, and in
some even mandated, to be members of this association, For Canadians, this source
served as the only single database available to capture a national sampling W e . A total
of 229 certified speech-language pathologists were listed to have an interest or specialty
in dysphagia (S. Fraser, personal communication, July 2 1, 1998). The database did not
differentiate which members are pha r i l y involved in research versus clinical practice or
those that work with adult versus pediatric patients, therefore, stratification according to
these variables was not possible.
The names of the 3 Canadian speech-language pathologists who participated in the pre-
testing of the instrument were eliminated. The remàining 226 speech-language
pathologists were randomly selected for inclusion. Al1 speech-language pathologists
were first assigned a 3-digit number fÎom 123 to 351 and then selected for inclusion
using a random numbers list generated with Windows 1995 Excel software.
C.2.b Sample Size
This phase of the research includes administration of a preliminary survey to yield a
description of reported practice behaviours. The calculations of sample size were made
with reference to the analytical objective of test re-test reliability described in the next
research phase (Section D). In order to find statistical significance for the reliability
analysis a muiimal sample sue was required. On the other hand, descriptive information
can be obtained fiom any convenience sample. For this reason, the targeted sample sue
used for reliability testing was also used to conduct the pilot survey. Descriptive
information was delineated fiom the entire sample.
C.3 Methods
C.3.a Mail Survey Design
A high survey nonresponse error rate is the largest disadvantage of self-administered
questionnaires (Aday, 1996; Mangione, 1995). Although this error was adjusted for in
the calculation of sample size (see Section D), several survey design strategies in addition
to those required for reliability testing were implemented to reduce the nonresponse error
and faciiitate an increase in response rate. The strategies incorporated into this research
were selected because previous studies have showri them to be effective in this regard
The specific strategies implemented in the initial covering letter (Appendix IV) sent to
participants wiîh the h t mailing are detailed below:
Appeals: Egoistic appealing which suggests a benefit to the respondent fkom the survey
results have been shown to increase response rates (Yammarino et al., 199 1; Mangione,
1995). This research used an egoistic appeal in the cover letter. It suggested that the
information fiom the hture large-scale survey may lead to improvements in the
education of speech-language pathologist students, advise govermnent and institutional
policy makers on services which best meet patient needs, and initiate fûture chical
studies investigating the effectiveness of speech-language pathologist assessrnent in
identifjhg swallowing conditions-
Sponsorship: Research has shown that respondents are more likely to respond to surveys
endorsed by government agencies or universities meberlein et al., 1997; Yammarino et
al., 1 99 1 ; Mangione, 1995). The importance of this research was estab lished by
indicating in the covering letter that it stemmed fiom work initiated by this author in
collaboration with 5 other international dysphagia experts and fiinded by the national
American Speech-Language Pathologists' Association (ASHA). Furthemore, the
covering letter contained an endorsement by the Canadian Association of Speech-
Language Pathology and Audiology (CASLPA) and a statement indicating that the
research was being presented at the 1998 annual convention of the American Speech-
Language-Hearing Association in San Antonio, Texas.
Incentive: Previous research indicates several incentives to effectively increase response
rate. One method that has been cited to be consistently effective for professionals has
been the offer of survey findings with the fkst mailing (Aday, 1996; Mangione, 1995).
The reason for this benefit has been theonzed to be the saliency of the information in
combination with the feeling of professional obligation to cooperate on the part of the
respondent(Heber1ein et al., 1997). In keeping with this knowledge and in an attempt to
maximize survey response rates, this research included the promise of survey fbdings in
the covering letter with the h t mailing.
The following are the mailing strategies initially implemented with the covering letter
and then maintained throughout the mail survey pilot:
Return Envehpe: SeLf-addressed retum envelopes have consistentIy been proven
effective in reducing nonresponse error and were therefore included with the aii rnailings
(Heberlein et al., 1997; Yammarino et al., 199 1; Aday, 1996; Mangione, 1995).
(Appendix V-a)
Reiurn Postage: Stamps, especially those that are attractive such as cornmernorative
stamps, are consistently effective in increasing the response rate (Heberlein et al., 1997;
Yarnmarino et al., 1991; Aday, 1996). Respondents tend to not want to waste the starnp
by not responding (Mangione, 1995). Al1 return postage in tbis research included
cornmernorative stamps.
Lost Mail Labek On every envelope sent to participants, a label was placed dong the
lower left corner requesting recipients of misdirected parcels to open the envelope, check
the appropriate box on the enclosed self-addressed stamped postcard, and mail it back to
the researchers. This initiative originated from the thesis cornmittee in order to reduce
nonresponse errors due to incorrect address information fiom the database source
(Appendix Wb).
Additional strategies, that were not restricted to mailing but were also initiaily
implemented with the covering letter and then maintained throughout the mail survey
pilot, are detailed below:
ConfldentiaIi@c S peec h-language pathologists may consider providing information on
their practice patterns a sensitive topic because it may reflect the quality of their
professionai service. Surveys that deal with sensitive topics are more susceptible to both
nonresponse and respondent errors (Groves, 1989). The promise of confidentiality has
been shown to effectively reduce both these emors especially if clearly stated with the
initial survey instnictions (Groves, 1989; Heberlein et al., 1997; Yammarino et al., f 99 f ;
Aday, 1996; Mangione, 1995). This research included the promise of confidentiality
with the 6rst mailing and eliminated the need for identimng uiformation on the survey
forms. Iden t iwg information was instead placed on accompanying postcards, which
the respondents retumed separately fkom the survey to indicate their participation
(Mangione, 1 995) (Appendix VI). Using the postcard, the author was able to identiQ
non-respondents for reminder telephone calls. Only confidentiaiity and not anonymity
could be offered. This is because the respondents with a completed survey had to be
identified for participation in the test retest reliability phase of this research. Following
the request for participation by telephone contact, respondents' identimg information
was kept separate and three digit codes, only interpretable by the thesis author, were used
on the survey forms in place of personal names.
Personufization: Research has shown that response rates increase when contact with the
respondent has been personalized (Heberlein et al., 1997; Fowler, 1993; Yamrnarino et
al., 1 99 1 ; Mangione, 1995). This research personalized wrïtten correspondence by
including the participants' name in both the covering Ietter and post cards retums.
Furthexmore, telephone reminders were implernented because they have been shown to
be more effective than maiIed written reminders (Fowler, 1993). Phone contact may not
have been as feasible if this was a large-scale survey.
Follow-Ups and Repeated Contacts: Participants whose completed survey or return
postcard was not received 6 weeks after the initial mailing were contacted by telephone.
The purpose of the cd1 was to deliver a gentle and fiiendly reminder to return the
completed suvey. This process was repeated at week 15 and week 18 or until the
participant indicated refusal to partake in this research. Repeated contact with the
participants have been consistently found to positively influence response rate (Fieberlein
et al., 1997; Yammarino et al., 1991 ; Aday, 1996; Mangione, 1995).
C.3 .b Data Preparation
All responses were numerically coded, except for those that were open-ended. Responses
to open-ended questions were reviewed for consistencies among respondents and answers
fkequently provided will be considered for inclusion in future versions of the
questionnaire. The raw data was entered ushg the Data Build Editor software of the
SPSS statistical package (version 8.0). This software facilitated a reduction of on-line
data entry errors by placulg limits on numerical response options and not accepting data
that was outside the predetermined range. Further data cleaning was conducted after
entry of al1 data by reviewing responses in table format, thereby, detecting inappropriate
missing items. Questions with more than 10 percent rnissing responses were reviewed
for potentid arnbiguities or irrelevauce and targeted for revision in füture versions of the
survey.
C.3.c Data Interpretation and Analysis
The primary objectives of this phase of the research were to describe the success of the
survey formatting and mail design strategies on response rates, and to obtain a
preliminary o v e ~ e w of the reported practice behaviours and their potential influencing
factors. Univariate statistics, such as, kequencies, percentages, range, median and mean,
were used to describe the data. Ninety-five percent confidence intervaIs were also
calculated. Associations between reported practice behaviours and rnodimg factors
were explored to formulate hypotheses regarding infiuencing factors. Associations were
tested using nonparametric statistics. Tests included the Kniskal-Wallis, Mann-Whitney
and the Wilcoxon Signed Ranks. Statistical significance for tests was set at 0-05 alpha
level- Al1 forms of data analysis were perfonned with the SPSS statistical package
(version 8.0).
To simpli& interpretation of practice behaviours, response options were grouped into 2
categones. The 'never' and 'occasionally' responses for each parameter were combined
into one 'never' response, thereby, creating a dichotomous scale of 'never' and 'always'.
Response fkequencies were then grouped into one of five summary categories for both
availability and utilization reports. The category Limits were arbitrarily chosen aprion in
reference to the respondents' reported availability or utilization fiequencies; 80% or
greater = 'manimously yes', 1960% = 'likely yes', 5940% = 'uncertain', 39-20% =
'likely not', and less than 20% = 'unanimously not'. Furthemore, reported opinion of
importance was also summarized into two groups. Group 1 inchded 'dennitely
important' and group 2 included 'probably important' which was the sum of 'dennitely
not', 'probably not', 'not sure' and 'probably' responses. The same five fiequency
categories were appiied. Frequency summaries for opinion, availability and utilization
data were reviewed to ensure no significant changes in interpretations if the arbitrary
category lirnits were varied by 5% in either direction.
To permit utilization and opinion cornparisons for assessment parameters among the
three primary structural phases of swallowing, response summaries were M e r sub-
divided according to oral, pharyngeal and esophageal swallowing phases. The response
frequencies for assessment parameters were used to generate patterns of practice
behaviour responses.
C.3 .d Ethics Approval
The final version of the survey and the covering letter sent to participants in the first
mailing was reviewed and approved by the University of Toronto Ethics committee
(Appendix W).
C.4 Results
C.4.a Survey Success
Survey Response Rates: Thirty-four (68%) of the 50 Canadian speech-language
pathologists who were sent the self-adrninistered mail survey returned the completed
survey. Most surveys, 22 (or 44% of al1 those mailed) were returned within 6 weeks of
m a i h g and without rexninders- Relatively fewer surveys were retumed after this initial
time penod regardless of the number of telephone reminders. Specifically, an additional
9 (1 8%) were received following one telephone reminder, 1 (2%) was received after two
telephone reminders, and 2 (4%) were received after three telephone reminders. Five of
the 34 retumed surveys were received after mail re-routing due to an initial wrong
address. The post card r e m rate (54%) was lower than the survey r e m rate (68%).
Of the 50 participants who were sent a survey, 16 (32%) were non-respondents. Reasons
for nonresponse included 5 (10%) who rehsed to participate: 2 because they no longer
worked with dysphagic patients; 1 because of family matters; 1 because the questionnaire
was "too onerous" to complete; and, 1 did not give a reason. Three others (9%) could not
be located; 2 because they were on rnaternity leave and could not be reached; and 1
because she left her practice without a forwarding address. The remaining 8 non-
respondents either did not return telephone reminder messages or did not follow through
with their promise to r e t m the s w e y .
Item Response Rates: Most survey questions, with the exception of 3, had item response
rates above 90%, and many of the questions (95%) had rates above 95%. Seventy
percent of the questions had a perfect response rate with no missing items. The 3
questions with less than 90% response rates were in the third, and last, section of the
survey and had response rates between 76 and 88%. Two questions focused on practice
behaviour and one on modifLing factors (Table 4.a). Unsolicited comments for these
questions, al1 written dong the page margins, were reviewed and two common themes
evolved pertaining to either word ambiguity or task difficulty. Specificdly, respondents
were not sure whether 'available' professional was distinct fiom 'participahng'
professional and whether 'patients seen in the pst year' meant patients with ail etiologies
or only those with dysphagia. Furthemore, respondents expressed difficulties in
obtaining exact information regarding caseload volumes and a few suggested no existing
departmental databases with this information.
Suwey Content and Forniarti- Open-ended questions requesting comments kom
respondents were included at the end of assessment sub-sections and the survey itself. ln
each of these 8 assessment sub-sections, comrnents were received fiom 6 to 23% of al1
respondents, with an average of 5 respondents commenting for each section (Table 4.b).
Most comments suggested the addition of assessment parameters and none suggested
elimination of questions or clarification of ambiguities. One comment focussed on the
nature of practice policy regarding esophageai assessment at her practice. As the final
survey question, the open-ended question in the third section of the survey requested
overall survey feedback (Table 4.c). A totai of 26, from possible 34 (76%) respondents,
submitted comments that focused on suggestions for content inclusion or comments on
general and setting-specific practice. Explicit supportive feedback regarding the
initiative behind the survey was received fiom 3 respondents.
In the third section of the survey there were also 6 questions with 'other' as a response
option. The average number of comments received per question was 4, with a range fiom
O to 10. Most comrnents recommended additional patient etiologies (Le. trauma, cerebral
palsy, etc.) and a variety of paediatric settings (Table 4.d).
C.4.b Respondent Characteristics
Cornparisons between characteristics of survey respondents and members of the
Canadian Association of Speech-language Pathologists and Audiologists (CASPLA)
found survey respondents to be generally representative of CASLPA members (Table 5).
Specifically, most practitioners in both groups graduated within the past 10 years and are
full members of CASLPA. Most were practicing in Ontario with fewer practicing in the
Canadian mid-western provinces. One CASLPA member, however, was practicing in the
United States but no survey respondent practiced outside of Canada
The specific profiles of survey respondents showed that most had a dysphagia caseload
between 5 1 % and 75% with an overwhelmùig rnajority currently in MI-time practice
(Table 6). Approximately two-thirds received graduate training fiom a Canadian
institution and the other third attended an American university. Most respondents were
trained at the Master's level, thereby, reflective of the current national requirements for
entry into the profession of speech-hguage pathology. The respondents, as a whole,
equally represented teaching and non-teaching institutions and a large rnajority practiced
in an acute inpatient facility (Table 7). Aithough respondents served patients of al1 ages,
they mainly worked with adults rather than paediatrics. The predominant etiology
serviced was neurological, with acute and progressive diseases being the most cornmon
type. Respiratory disease and head and neck cancer were also common (Table 8).
C.4.c Reported Practice Behaviours
Getteral Practice: Reported patient waiting times, in days, for dysphagia assessments
were denved for overall respondents and several potential modifiers (Tables 9.a to 9.d).
Overall mean waiting days were 4 tirnes less for inpatients than outpatients, with
inpatients waiting twice as long for instrumental versus clinical testing e . 0 0 2 , t-
3.166). For outpatients, clinical waiting times were longer than instrumental waiting
times (Table 9.a). Regional differences in waiting times were noted but the relation was
not straightforward. Specifically, Ontario respondents reported the shortest inpatient
clinical waiting times but the longest overall outpatient times. Eastern respondents
reported the longest inpatient clinical waiting times (Table 9.b). The relation between
dysphagia caseload concentration and waiting times was also not Linear but the tendency
was for respondents with larger concentrations to report shorter waiting times (Table 9.c).
Type of facility was not associated with different inpatient clinical waiting times, but
acute centers did report a shorter inpatient instrumental wait (Table 9.d).
Respondents were asked to report the Erequency by which they administered different
types of dysphagia assessments (Table 10). Clinical testing was administered to
approximately two-thirds of ail patients seen, whereas instrumental testing was
administered to only one-third @=~000 1, z 4.440) . Most speech-Ianguage pathologists
included food with clinical testing. They reported that instrumental testing did not
necessarily follow clinical testing, with less than half of the patients who received chical
testing fo llowed with instrumental testing. Rarely, however, was instrumental testing
administered without prior clinical testing.
Respondents reported on the availability of various health care workers for coliaboration
in dysphagia assessment (Tables 1 1 .a and 1 1 .b). Respondents reported that instrumental
specialists, such as radiologists, were 'uncertainly' available for clinical assessment but
' unanimo us 1 y' available for insirumental testing . Dietitians, nurses and occupational
therapist were 'likely' to be involved in cIinical testing but 'not likely' involved in
instrumentai testing. Physicians, such as pulmonologists and neurologists were reported
' unanimously not' involved in either testing .
Respondents reported on the availability of various instrumentation techniques at their
facility, and then, indicated whether they utilized the instrument (Tables t 2.a and 12.b.
Respondents reported neither availability nor utilization of CLA, FEES, FEESST,
manometry and ultrasound. Videofluoroscopy was reported to be the most 'likely'
available and utilized procedure. Limited availability and utilization were noted with
auscultation and oxygen saturation monitoring.
Al1 27 respondents who reported using videofluoroscopy indicated which protocols they
used during this procedure (Tables 13.a and 13.b). Overail, the most utilized protocols
were self-interpretation and administration of various food textures. However, texture
preparation protocols or commercially available textures were not common. Frame-by-
frame videotape review and introduction of treatment strategies were 'uncertainly'
utilized. A timer was 'unanimously not' utilized for result interpretations.
Utifization of Assessrnent Parameters: Respondents reported on utilizattion for specific
clinical and instrumentai assessment parameters (Tables 14.a to 14.d). Ovedi, most
parameters were fiequently utilized with fewer reportedly 'occasionally' or 'never'
utilized. The following ciinical parameters (n=4) were consistently utilized by aU
respondents: drooling of saliva, drooling of food, involuntary coughing, and dysphonia
such as wet or gurgly vocal quality (Table 14.a). An even larger number of instrumentai
parameters (n=8) were consistently utiiized by al1 respondents: bolus manipulation and
propulsion, delayed oropharyngeal initiation, laryngeal motion, delayed pharyngeal
swallow, laryngeal penetration, response to penetration, response to aspiration, and
effectiveness of response (Table 14.b). Frequencies for utilization were mapped
according to the 'always' response. A ciifference of category iimits of 5% in either
direction did not greatly alter results for either clinical or instrumental parameters.
Respondents reported 'unanimously' utilizing a majority (40%) of al1 assessment
pararneters (Tables 15.a to 1S.e). Wtilization of the remaining pararneters divided equally
into each of the 4 other kequency summary categones, with each category containing
less than haif of the parameters in the 'unanimously' utilized category alone (Table 15.a).
The clinical parameters most utilized referred to clinical food oral and pharyngeal testing.
The instrumental parameters most utiiized referred to p h v g e a l testing (Table 15.b). In
contrast, of the 20 parameters reported to be 'unanimously not' utilized 16 (80%)
pertained to clinical oral sensory testing without food (Table 15.c). Oniy 17 (15%) of all
1 17 assessment parameters were reported 'uncertainly' utilized- Approxirnately half of
these parameters pertained to cfinical aonfood oral testing and the other haif to
instrumental pharyngeal or esophageal testing (Table 15.e).
The survey content was stnictured to derive information on rnodifj4ng factors that could
potentially influence clinical and instrumental assessment parameter utilization. Since
overail reported practice was fairly uniform this cornparison was limited to the 17
assessment pararneters with greatest uncertahty (Figures 1 .a to 1 .h). Nonparametnc
testing found statisticd significance for relatively few associations. There were no
assessment parameters consistently more or less variable. Descriptively, utilization was
most variable across dysphagia caseload concentrations but the direction of the influence
was inconsistent (Figure 1 .a). Of the other 3 clinician related modifying factors, 1
appeared to influence clinical and instrumental parameters diEerently. For example,
respondents 6 t h more years of active practice utilized clinicd parameters more than
those less experienced but were not different in utilization of instnunental parameters
(Figure 1.b). Clinicians trained in Canada and those who worked less than 25 hours per
week, however, utilized both clïnical and instrumental parameters slightly more than non-
Canadian trained and full-time practitioners (Figure 1 .c and 1 .d). Likewise, adult patients
tended to influence greater utilization of both clinical and assessment parameters (Figure
1 .e). Each of the three practice setting factors ùifluenced utilization. Specifkally,
parameters were reported most utilized by respondents workïng in settings: with teaching
affiliation, located in eastem Canada including Quebec, or, predominately acute, chronic
or rehabilitative (Figure 1. f to 1. h).
Opinion of Importance of Assessrnent Parameters: Respondents reported on their
opinion of importance for assessment parameters in survey sections A and B (Tables 16.a
to 16.d). Thirteen clinical and only 1 instrumental parameter had definitely 'no'
diagnostic value. No clinical parameter reached unanimous 'definite' importance but 2
were reported with 97% fiequency : involuntary cough and dysphonia (Table 16.a). In
contrast, four instrumental parameters reached unanimous 'definite' importance: presence
of pharyngeal bolus residue, delayed pharyngeal swallow, response to aspiration, and
effectiveness of response (Table 16.b). Most of the remaining 99 (85%) clinical and
instrumental parameters were rated between 'uncertain' and 'definite' importance.
Opinion fkequencies were mapped according to 'definite' importance. A difference of
category limits of 5% in either direction did not greatly alter fkequency summaries for
either clinical or instrumental parameters.
The majority of pararneters were rated as 'unanhnously' or 'likely' important (Tables
17.a.). Of the important parameters, most pertained to ciinical and instnimental
pharyngeal testing (Table 17.b). Of the 'Iikely' important parameters, most pertained to
clinical oral and instrumenta1 pharyngeal testing (Table 1 7.c). The 20 (1 7%) pararneters
with 'uncertain' importance were equally dispersed between cLinical and instrumental
testing and included oral, pharyngeal and esophageai areas (Table 17.d). Relatively
fewer parameters rated as 'not likely' or 'unanimously not' important (Table 17.e and
17.f). Of the not important parameters, most pertained to clinical nonfood sensory
testing.
Uîüization and Importance: Mean fiequency scores for reported utilization and opinions
of importance were compared (Figure 2). ûverall, these two dimensions had a positive
and equal relation where highly utilized parameters also demonstrated high opinion and
rarely utilized parameters dernonstrated low opinion. The slight tendency, however, for
respondents to rank instrumental parameters with higher importance than clinical
pararneters was evident.
Patterns of Pructice Beltaviour Responses: Utilization fkequencies were divided by
swallow neurophysiology (Tables 18.a and b). Each neurophysioIogica1 area was tested
by several parameters. Some parameters in each neurophysiologicai area differed across
fiequencies and others clustered in the same fiequency category. The overall result was a
progression of decreasing utilization of assessment parameters with 5 hieratchical stages
starting with Stage 1 and ending with Stage V. All clinical neurophysiological areas were
tested with at least 1 parameter in Stage 1, and 4 (Le. facial expression, oropharynx,
laryngeal area and bolus presence) were tested with several parameters. Sensation
nonfood clinical testing was implemented primarily in Stage V (Table 1 8 .a). Testing of 4
of the 8 instrumental neurophysiological areas was mainly targeted in Stage 1;
orop harynx, laryngeal area, sensation, and swallow duration. Instrumental testing for
tongue ability and bolus presence was primarily in Stage ïI, and esophageai testing
between Stages III and IV (Table 18.b). Respondents ranked most assessment pararneters
in the same Stage for both u t i b t i o n and opinion of importance.
CS Discussion
Survey Success: The self-administratecl mail questionnaire on dy sphagia assessment,
developed in phase one of this research (Section B), was piloted with Canadian speech-
language pathologists. This preliminary research was the first to develop a stnictured
survey instrument and the first to survey practice patterns with speech-language
pathology professionals. Overall, speech-language pathologists responded favourably.
Response rates both for surveys and s w e y items were high and consistent with
successful rates for other professional groups (Aday, 1996; Mangione, 1995). The
ngorous s w e y fonnatting (Section B) and mail survey design (Section C) strategies
IikeIy contributed to response success. Specifically, the 'lost mail label' alone was
responsible for the return of 5 (10%) surveys following the successfÛi re-routing to the
designated respondent.
This pilot research phase not o d y served to assess survey response rate with speech-
language pathologists but also to assess the comprehensiveness and feasibility of the
survey itself. Interestingly and despite original concems that the 18-page survey may be
too lengthy, qualitative analysis of respondent's comments unanhously suggested
addition of more assessment parameters. Comments also indicated that paediatrïc
practice settings and specific swallowing difficulties, such as with oral reflexes, were not
well represented. It appears that dysphagia assessments by speech-language pathologists
are currently not only extensive but are tailored to the patients' age.
Respondent comments were reveaiing in another dimension. Specifically, the survey
requested information on patient caseload volumes, such as the total number of patients
seen in the period of one year. At the f3st level of data analysis it was obvious that these
questions were troublesome due to their relahvely high non-response rate. However,
upon qualitative analysis it became apparent that although wording arnbiguities may have
contributed to the nonresponse rate there was another more prirnary reason. Specifically,
respondents indicated those facilities in which they practiced often did not provide
workload statistics. In light of the inherent lack of administrative databases for speech-
language pathology in the current health care system, the concurrent lack of departmental
databases poses a senous information gap. Accurate patient volume infurmation is a
required minimum not only for the assessment of practice behaviour but also for the
advocacy of proper seMces with policy makers. The implications for departments not
having this information readily available can be serious, especiaily in iight of limited
health care resources and decreasing budgets.
One of the Limitations of the self-administered mail survey is that research questions are
Iimited to the accuracy of the database utilized. Certainiy the membership database fiom
the Canadian Association of Speech-Language Pathologists and Audiologists (CASLPA),
represented the single largest source for Canadiau speech-language pathologists
practicing in dysphagia, however, it did pose research limits. For example, information
on potential practice modifiers, such as type of practice facility, teaching affiliation, or
age of patients typically served would have permitted stratification according to these
variables to ensure equal representation. Overall, however, our randorn sarnple selection
appeared to include a Spica1 CASLPA membership with respondents working in a
variety of settings and with a variety of patient age and etiology groups. Most of the
respondents were trained at the Master's level and therefore were likely more reflective
of clinical practice versus research settings.
Reporîed Pracîice Behrrviours: In addition to assessing survey success, another objective
for this research phase was to provide a preliminary description of reported speech-
language pathology practice behaviours for dysphagia assessment. Overall, results
showed minimal practice variation for physiological assessment and relatively more
variation for general prac tice behaviours. Specüically, inpatients waited fewer days than
outpatients for dysphagia assessment, which is clinically significant considering that
inpatients are typically more impaired. Likewise, inpatients waited less for clinical than
instrumental testing with more patients receiving the former. This result supports the
published preferred practice pattern recommending that clinical assessment should be the
first stage of dysphagia testing, the results which provide not only diagnostic information
but de termine the appropriateness for instrumental testing (American Speech-Language-
Hearing Association, 1997b).
The instrumental technique reportedly used most fiequently was videofluoroscopy.
Other techniques were rarely or never utilized and included Computerized Laryngeal
Analysis (CLA) and the two endoscopy procedures, Fiberoptic Endoscopic Evaluation of
Swallowing (FEES) and Fiberoptic Endoscopic Evaluation of Swallowing with Sensory
Testing (FEESST). Their inhquent use existed regardless that CLA is advertised in
almost every issue of the major dysphagia journal and the validity of endoscopy is well
supported in the literaîure. Although the utiiization of these procedures may be limited
because of cost, their disuse is more likely due to either no scientific evidence of benefit,
such as with CLA, or that procedures require extensive training, such as with endoscopy
or sonography. In keeping with this rationale, the simpler techniques of auscultation and
oxygen saturation monitoring are more commody utilized likely because they are
relatively inexpensive, and easier to administer. There is also recent Li terature suggesting
their clinical benefit (Anonymous, 1995; Sellars et al., 1 998).
Aithough videofluoroscopy is a common instrumental procedure, respondents were not
consistent with the protocol utilized. SpeciGcally, use of either guidelines to prepare
food textures or those that are commercially prepared varied, thereby suggesting poor
standardization, Poor standardization of food test materials is clinicaliy significant since
many practitioners reported the fiequent use of liquid to solid textures with
videofluoroscopy. Furthemore, the use of We-by-fiame analysis was also highiy
variable. The inabiiity to review results using slow motion videotape may directly
compromise the accuracy of swallow physiology interpretations (Logemaun, 1993). In
contrast, practice variation was minimal for two videofluoroscopy protocols, that is, most
respondents always interpreted their own results but rarely used a timer to rneasure
swallow duration. The Radiologist was the health care worker with whom respondents
reported the greatest collaboration during assessments, which is consistent with the
reported common use of video fluoroscopy .
Respondents u n i f o d y reported high utilization for most assessrnent parameters testing
swallow physiology. The parameters always utilized by al1 respondents included clinical
food and instrumental testing for airway protection, oral bolus control and swallow
duration. Since few respondents reported using a timer to interpret swallow duration, it is
likely that these times are crude clinical estimations at best. The parameters reportedly
never used by respondents related to oral nonfood sensation testing. Interestingly and
Iikely related, is the fact that recent Literature fouad no iong-term therapeutic benefit on
swallow physiology with regular thermal stimulation to the oral cavity (Rosenbek et al.,
1991).
Respondents' high utilkation of assessment parameters may have resulted because the
survey was not restricted to assessment behaviours for select patient age groups or
etiologies, and dinicians may have responded comprehensively even if in practice they
select appropriate parameters according to the patient characteristics. Furthemore, it is
also likely that there may be some memory error in the recall of reported behaviours.
Another explanation for uniformly high utilization is that these are rote behaviours that
conform to professional protocols published in leading textbooks and taught at various
workshops (Groher, 1997; Logemam, 1993; Perlman et ai., 1997)- Only with fiinire
research can any of these potential causes of hi& utilization be tested. Future research
shou1d also assess the individual parameters' evaluative and predictive value which
would help streamline currentl y extensive diagnostic work-ups to include only c linically
relevant parameters. Such an irnprovement in dysphagia assessment would not only cut
costs but also be less invasive to the patient.
Mudipers of &adce Beliaviours: Ontario respondents reported the shortest inpatient
waiting times suggesting that Ontario may have a better pool of resources fiom which to
serve inpatients. However these respondents also reported the longest outpatient times,
suggesting instead, that in Ontario speech-language pathology resources are düected
mainly to inpatient services. If this is true, the next step would be to determine whether
there exists unmet outpatient needs, and then, if meeting these needs would reduce the
relatively more expensive inpatient health care load.
The influence of modifiers on physiological parameters used in assessrnent could only be
tested on the few that showed variability. Dysphagia caseload concentrations generated
the most variation, but respondents serving adult patients tended to systematicaIly
adrninister more overall parameters. Other modifiers such as, practice setting and
clinician experience also appeared iduential, with higher parameter ut ilizat ion b y more
experienced respondents and those working in teaching afEliated facilities. Although the
value of statistical significance testing was limited because of small sample size, these
preliminary findings support fllture research to stratifL respondents by at l e s t patient age
groups.
This survey was the first to provide information on how respondents rate importance for
dysphagia assessrnent parameters. In keeping with the high utilization behaviours,
respondents also reported uniformly high importance with a positive and equal relation
found between the two. The parameters most valued, and also most highly utilized, were
those that tested laryngeal ainvay protection and swallow duration. Also highly valued
was the instrumental test for pharyngeal residue. In the absence of airway protection, the
presence of pharyngeai residue poses a larger aspiration risk Few parameters were rated
with no value. This suggests that either survey development was successfûl in generatinz
oniy relevant content (Section B), or that respondents placed a high value on available
assessment protocols (Groher, 1997; Logemann, 1993; Perlman et ai., 1997). Of the
parameters with least importance, most referred to oral nonfood sensation clinical testing.
Oral sensation testing, with both low importance and utilization results, was the oniy
dimension of dysphagia testing that respondents were confident to reject regardless of
published protocols.
Stages of Dysphtzgia Work-ffp: Respondents reported a consistent progression of
decreasing parameter utilization summarized in five stages (see Tables 18.a and b). This
pattern may simply be demonstrating a steady decrease in utilization frequencies thereby
differentiating which parameters were highly used, moderately used and rarely used.
Another explanation may be that this utilization pattern represents the sequence of
diagnostic work-up for clinical and instrumental dysphagia assessments. Specifically, it
is possible that respondents' typically start their dysphagia work-up by always
administering those parameters in Stage I and then sometirnes administering parameters
in subsequent stages. Results fiom Stage 1 testing may conceivably determine the
appropriateness and need for administering related parameters in Stages II to V. For
example, if Stage 1 iaryngeal clinical testing indicated abnormal functioning, then the
need for Stage III laryngeal testing would be appropriate.
The overall results from this pilot phase survey appear to highlight two overlapping
hierarchies. The first hierarchy refers to the possibility that assessment parameters are
utilized in a decreasing progression for both clinical and instrumental testing, with the
largest number administered in Stage 1 thereby assesshg the most relevant
neurophysiological areas. The second hierarchy r e k to the respondents' report that
clinical assessrnent was administered nrst to detennine the need for M e r testing with
instrumentation. It appears, then, that the two hierarchies overlap to suggest that ciinical
testing is conducted before instrumental testing, and, that diagnostic work-up for each test
occurs in stages. Together these hierarchies reveal that respondents assessed dysphagia
by h t administering Stage I clinical parameters, foilowed next by clinicai parameters in
subsequent stages, followed next by Stage 1 instrumental parameters, and finishing with
instrumental parameters in subsequent stages. Advancement to the next stage was not
consistently reported and, therefore, likely determined by the results of the previous
stage.
According to this combined hierarchy, respondents always started the dysphagia work-up
with ClinicaI Stage 1, testing the integrity of lips, oropharyngeal swallow trigger, airway
protection and oral residue. For approxirnately half the patients assessed clinicaily,
dysphagia work-up was foilowed with instrumental Stage 1, testing the integrity of the
oropharynx, airway protection, and swailow duration. This hierarchy of clinical to
instrumental dysphagia work-up ensures that appropriate diagnostic infornation is
obtained in a comprehensive and efficient manner, an outcome beneficial for both policy
makers who have to prioritize limited resources and patients who would receive only
necessary tesîhg.
SECTION D: RELIABILITY STUDY
D.l Introduction & Goais
The goal for this new self-administered maii questionnaire is to describe practice
behaviows and systematic ciifferences in practice across subgroups of speech-language
pathoiogy practitioners. One important step in instrument development toward this goal,
of course, is to ensure that the practice behaviours reported are stable within one
practitioner and cm be measured reproducibly. Test-retest reiiabiiity reff ects the stability
of a survey tool measured on two occasions with the same person.
The specific goal for tbis research phase was to assess the test-retest reliability of the
questionnaire developed in Section B. Key measures included utilization of assessrnent
parameters and general practice behaviows reported by the speech-language
pathologists' .
D.2 Subjects
The subject sample for test-retest reliability was identical to that included in the pilot
phase survey (Section C). In summary, eligible subjects were Canadian speech-language
pathoIogists who were rnembers of CASLPA and registered to have an interest in
dysphagia in the 1997 membership database.
D.2.b Sample Size
The purpose of the sample size calculation was to ensure adequate power to assess
reproducibility of key measures. Sample size calculations were made using a one-sided
test with 5% level of significance, beta at 20% and power at 80%. The key measures
were estimated to include a range of reliability fiom almost perfect (htraclass coefficient
(ICC) 2 0.80) to poor reliability (ICC 1 0.40). For assessrnent parameters which are
reported to be 'unanimously utilized' or 'unanimously not utilized' we hypothesized an
almost perfect reliability. ln contrast, for 'uncertainly utilized' parameters we
hypothesized a poor reliability. For questions pertaining to videofluoroscopic protocols
we hypothesized a fair reliability (ICC 1 0.60) since these would likely be common and
familiar procedures to respondents. However, for questions pertaining to either
frequency of assessments over the past year or patient waiting times, we hypothesized a
poor reliability. The Iower reliabiiity was assumed because mauy speech-language
pathology departments did not maintain these workload statistics and, therefore, required
respondents to estimate fiom memory.
The contour graphs by Donner and colleagues (Donner et ai., 1987)were used in the
caiculation. A sample size of 30 individual survey respondents was sufficient to estimate
test-retest reliability for the anticipated reliability range (Table 19). Sarnple size
calculations were adjusted for non-response rates using response estimates of 50%, 60%
and 70%. The typical baseline response rate for professional groups approximates 50%
(Aday, 2 996; Mangione, 1995). Reports kom the Canadian association (CASLPA)
comply with this fïnding (K. Christopher, personal communication, August 1 1, 1998).
The strategies implemented by the Canadian association to obtain the 50% responçe rate
include the provision of self-addressed response envelopes, short survey length, a
combination of closed and open response formats and the occasional incentive offer of
one year Eiee membership to early respondents. These strategies are considered standard
requirements by mail s w e y experts (Aday, 1996; Mangione, 1995). In addition to these
standard survey design methods, this research included other strategies shown to be
effective in increasing response rates. Namely, three telephone reminders, offer of
survey findings to participants, and commemorative stamps. Reminders in the form of
persona1 contact are reported to be more effective in increasing response rate than no
reminders (Fowler, 1993). The offer of survey findings is thought to increase the
relevance of the survey for a professional respondent and thereby improves overall
response rate to approximately 70% (Mangione, 1995). The use of cornmernorative type
starnps has been shown to have an advantage over regular stamps by reducing the
nonresponse rate (Mangione, 1995). Although together these three non-standard
strategies were expected to produce at least a 70% response rate, a more conservative
60% response rate estimate was utilized to calculate target sample size for this research.
These calculations derived a targeted subject sample of 50 S-LPs in order to obtain the
required minimal sample of 30 speech-language pathologists.
D.3 Methods
D.3 .a Test-Retest Survey Design
The randomly recruited speech-language pathologists were asked to complete a
conlidential self-adminïstered mail survey on practice patterns. On the first mailing of
the questionnaire, they received a cover letter infonning them that they were part of a
methodological pilot study in preparation for a large-scale survey (Appendix IV). They
were not informed that upon receipt of their responses they would then be asked to repeat
the survey for the purpose of test-retest reliability. The participants were telephoned
following the arriva1 of their completed original survey response form and asked whether
they would agree to repeat completion of the survey. At this tirne, the purpose of the
repeat administration of the survey for test-retest reliabilïty was disclosed. Each
participant was asked specifically not to refer to any persona1 notes or copies taken of
their previously completed survey. tfthe respondents agreed to complete the survey for a
second time, another copy of the survey was sent to them dong with a covering Ietter
thanlàng them for their efforts (Appendix Vm) and another self-addressed stamped
envelope was inchded.
Expert opinions Vary regarding appropriate interval times behveen first and second
survey completion, however, a retest interval of 2 to 14 days is usual and dependent on
the level of complexity of the material (Streiner et al., 1995). In this research,
approximately 2 weeks was considered enough time to forget original responses yet not
enough time to change reported practice behaviour. The minimum two-week waiting
period, assumuig one week for retum mail, was judged to be one week foiiowing receipt
of the original survey response by the research office. Refùsais to participate in repeat
testing were noted and replaced with the respondent who retumed the next completed
survey. This was continued until the minimum sample size requirement of 30 speech-
language pathologists was satisfied or until aii respondents were contacted, whichever
came h t .
D.3.b Data Analysis
The majority of measures or variables in this research took the form of either continuous
adjectival ordinal response scales or continuous interval open-ended responses.
Therefore, the intraclass correlation coefficient (ICC) statistic was used to assess test-
retest reliabiiity using data fiom a repeated measures ANOVA (Streiner et al., 1995)
(Portney et al., 1993). Overall, an intraclass correlation coefficient (ICC) was the
preferred method over the product-moment correlation, r, because it not only determines
the strength of the correlation but also if there exists a systematic difference. It does so
by considering whether the slope and intercept Vary fiom those expected with repeated
measures (Deyo et al., 1991).
D.4 Results
Successfiil telephone contact requesting the respondents' participation with test-retest
assessrnent ranged fiom 2 to 6 weeks following receipt of their initial completed swey.
The actually longer contact times were related to holidays or respondents' extended
vacation schedules. A total of 23 respondents participated in the test-retest of the
questionnaire. Two people declined to participate: I because of a busy clinical schedule
and 1 because she no longer was practicing in dysphagia. The rest did not return
telephone messages and, therefore, were never asked to participate.
Eleven of the 16 key measures evduated had aimost perfect reliability (ICC > 0.80) and 3
measures showed no variance. Two other measures scored with fair reliability (ICC >
0.60) which were relatively lower than other measures but stiU higher than apriori
expectations (Table 20).
D.5 Discussion
These results suggest that the new self-administered questionnaire, developed in Section
B to describe dysphagia practice behaviours of speech-language pathologists, is a stable
tool that can measure reported practice reproducibly with at least Canadian practitioners.
Reproducibility likely also exists for American speech-laquage pathologists since many
of the Canadian practitioners sarnpled were trained in Amencan institutions and severai
Amencan content experts were involved in questionnaire development and pre-testing.
However, fbture reliability testing with specifically Arnerican clinicians should be
conducted to confim tool stability with this clinician population.
Interestingly, al1 measures scored with at least fair reliability including those that were
anticipated to have poor reliability, such as uncertainiy used assessment parameters and
general practice behaviours. Although respondent comments suggested that severai
speech-language pathology departments did not have current workload statistics, they
were able to reliably estimate caseload volumes and waiting tirnes. It is possible that
respondents either have a good perception of these statistics or that they referred to their
own objective data in personai calendars. Future research should differentiate if these
reported figures are indeed reliable perceptions of what is thought to be the tmth or
reliable figures fiom an objective database, be it personal or one which is maintained by
practice admînistrators.
SECTION E: DISCUSSION AND CONCLUSIONS
E.1 Overall Discussion
This research comprised the fkst phase of a two phase project to describe reported
dysphagia assessment practice patterns of speech-language pathologists across Canada
and the United States. It included the development of a s e l f - M s t e r e d mail
questionnaire for the purpose of collecting reported practice behaviours and factors that
may influence them, regardIess of age or etiology of patients served and settings in which
the service was provided. Furthemore, it conducted a pilot survey of the new
questiomaire with Canadian speech-language pathologists to obtain a preliminary
overview of their reported practice behaviours, information that could be used in the
design and administration of the later large-scale survey. Findiy, this research also
evaluated the reproducibility of the new survey instrument with test-retest reliability.
Questionnaire development focused specifically on comprehensive content item
generation and survey formatting design. Telephone conferencing of international
dysphagia experts was the primary method used to generate content items for
physiological assessment parameters. Survey formatting was designed according to
Somation and visual organization strategies proven successfid in increasing survey
item response rates- The nrst draft of the survey was subjected to pilot testing with
dysphagia experts, haif of which were not included in generating original content items.
The h a 1 product was an 1 &page self-administered mail s w e y containing three main
sections Uicluding clinical and instrumental assessment parameters dong with potential
modifiers of practice behaviour. Pre-testing concluded that the seemingly lengthy survey
was comprehensive yet not overly time consuming to complete, thereby, suggesting the
achievement of both content and face validity.
The development of the questionnaire pemiitted the k t opportunity to describe practice
behaviours of speech-language pathologists and to assess the success of the survey
method with this professional group. Piloting the questionnaire with Canadian speech-
language pathologists proved the survey method successfûl. Survey succws was marked
with both high item and survey response rates that were consistent with rates fkom other
professional groups (Mangione, 1995). High response rates were Likely the result of
diligent methodological efforts for not only questionnaire development but also for pilot
survey mail design. Specifically, proven strategies were implemented such as egoistic
appeals, the incentive offer of survey hdings, misdirected mail re-routing labels on
envelopes, respondent confidentiality and telephone reminders. The combination of
rigorous survey methodologies was presumably also the basis for the questionnaire's hi@
test-retest reliability. In summary, the results of the survey phase pilot proved the new
questionnaire to be a stable tool that is exhaustive in content and well accepted by at least
Canadian speech-language patho logists.
Piloting the questionnaire also provided a preLiminary description of practice behaviours.
The researchers did not expect the practice uiformation gleaned from the questionnaire.
In light of the existing lack of dysphagia standardization in both the United States and
Canada combined with the diversity of patients who present with dysphagia, it was
anticipated that speech-language pathologists would report large differences in practice
behaviours for dysphagia assessment. The piIot survey results demonstrated the opposite
to be the case. Although there was minimal practice variation in reported utilization of
physiological assessment parameters for cihical and insanimental testing and relatively
more variation in general practice behaviows, overall, these differences were the
exception and not the rule.
Overall, respondents reported u n a ~ o u s l y high utilization of physiological assessment
parameters. Parameters especially utilized were those related to airway protection, oral
bolus control and swallow duration. In particular, airway protection was assessed with
clinical signs of involuutary coughing or dysphonia such as wet or gurg1y vocal quality.
This is in keeping with recent literaîure that demonstrates these clinical signs to be highly
predictive of aspiration on videofluoroscopic testing, which in turn, is associated with a
higher likelihood for the development of pulmonary compromise (Holas et al., 1994;
Martino et al., 1999). In contrast, assessment parameters that have Little scientific support
were reported not utilized. These included nonfood clinical sensation testing of
temperature, touch and smell. Only 17 (15%) of al1 1 16 assessment parameters were
reported with varied utilization among respondents. Factors relating to patient age,
practice setting and clinician expenence al1 appeared to iduence utilization trends for
these most varied parameters, however, the small sample size iimited the vaiue of
statistical testing to confïnn these associations.
Relative to assessment parameters, general practice behaviours were reportedly more
varied. S peci ficall y, waiting times for inpatients were shorter for clinical versus
instrumentai testing, and overall inpatient waiting times were consistently shorter than
overall outpatient waitïng times. These digerences were found to be statistically
significant. Regional differences in waiting times were noted with Ontario respondents
reporting the shortest inpatient and the longest outpatient waiting t he s . Uther general
practice behaviours identified videofluoroscopy as the primary instrument utilized with
the Radiologist being the heaIth professional with whom most respondents collaborated.
In spite of its popularity, however, videofluoroscopic procedures were not uniform with
respondents reporting inconsistent use of standardized food textures and We-by-fiame
videotape analysis.
The reported utilkation of practice behaviours were cornpared to the respondents'
opinion of importance for physiological assessment parameters and established to be a
positive and equal relation. That is, parameters highiy valued were aiso highly utilized,
and those not valued were also not used. Furthermore, patterns of utiiization fiequencies
were reviewed for consistencies and found to present in a progression of decreasing
utilization speculated to be a reflection of respondents' diagnostic work-up for dysphagia-
Specifically, a two level hierarchy was proposed with assessment assumed to start with
Clinical Stage 1 testing and progress through to Instnimental Stage 1 only if deemed
appropriate from clinical test results. The second and overlapping hierarchy proposed
progressed f?om Stage 1 to Stage V in each of the clinicai and instrumental stages of
testing. The utilization of parameters f?om Stages II to V was not consistent and
therefore assurned prescribed fiorn results of previous testing. This diagnostic work-up
mode1 evolved fiom the pilot phase survey results and was concordant with overall
reported utilization and opinion of importance for physiological parameters. Although
promising, fiiture testing will be needed to validate the model.
E.2 Review of Limitations
This research has several limitations, some of which have already been discussed in
previous chapters. Additionai Limitations will be detailed below according to the research
phase most affecteci-
Questionnaire Deyelopment: The primary limitation with questionnaire development
concemed content omissions. Specifically, respondents were requested to List al1
appropriate patient etiologies but were never asked to focus their report of practice
according to one select etiology. What may have resulted was a comprehensive
description of practice for ail etiologies serviced, therefore, leading to an artificial
impression that most assessment parameters were consistently utilized rather than, what
rnay be more likely the case, selectively utilized according to etiology. Furthemore,
questions regarding total assessment time and specific dysphagia training would have
been usefiil. This information would have helped determine if the efficiency in
adrninistering the same assessrnent parameters was dependent on not only the amount of
training but also the specific type of specialized training. Finally, the questionnaire did
not address the utilization of instrumental testing for oropharyngeal food spillage.
Cornparison of reported utilization for this parameter with that rneasuring delay in
oropharyngeai swallow trigger would have been clinically relevant in Iight of recent
controversy regarding their distinction, or lack thereof (Chi-Fisherman et ai., 1998).
These missed content aspects will be introduced in future versions of the questionnaire.
Pilot Phase Suryey: The limitations in the pilot survey phase are either due to study
design or external sources. The latter refers to the limitations of the database which
formed the sampling h e . Specifically, the 1997 CASLPA database used for this
research listed only 229 eligible speech-language pathologists but in 1998 this nurnber
grew by ten fold, thereby, suggesting an incomplete membership directory in 1997.
Furthemore, the database lacks information regarding potentially inauencing factors,
such as the age and etiology of patients typicaiIy serviced by each mernber, Not having
this information prevented apriori stratification dong these variables. Unlike p hysicians,
speech-language pathology services are not remunerated according to procedures
administered and there exists no equivalent administrative database to veriw actual
practice behaviours. Practice behaviours for speech-language pathologists cari be
collected as either prospective reports of what is typically utilized, as was done in this
research, or recordeci simuItaneously with the execution of assessments which may
detract fiom service delivery. Regardless, both data coilection methods can result with
an inaccurate recording of utilization patterns.
Other limitations of the pilot survey related to the possibility that cluiically irrelevant
b i t s were chosen for anaiysis of dysphagia caseload concentrations, which rnay explain
the haphazard influence of increasing concentrations on both patient waiting times and
parameter utilization. As a pilot survey, this research had a small sample size which
limited comparisons between respondents versus nonrespondents and early versus late
respondents. These comparisons would have assessed the contamination of motivational
biases on survey responses. Finally, although provided as a response option, no
respondent reported working in a cornmunity hospital which is Iikely where most non-
expert dinicians practiced. Udortunately, the CASLPA database did not have
information on facility type to detennine whether this was indeed a reporting error.
Reliabiliry Study: The targeted sample of thirty speech-language pathologists was not
obtained because several respondents could not be reached by telephone to participate in
the survey's test re-test methodological research. Telephone contact was most
unsuccessfuI during the Christmas holidays when many respondents were away ftom
their practice for an extended period of t h e .
E.3 Overall Conclusions
The new self-~drninistered mail quesîiinnaire wasproven !O have 60th content and
face vaiidity, and !O be stable for Candian speech-language paihologisrs. The use of
telephone conferencing with experts proved usefil in generating a comprehensive list of
dysphagia assessment content areas. Pre-testing the first dr& of the questionnaire with
experts was beneficid in ke-tuning originally generated items by eiixninating redundant
content, clarifj6ng word ambiguities and adding missed content. Including non-experts
in the pilot phase pennitted additional item generation and highlighted other word
ambiguities. The inclusion of non-experts M e r benefited by revealing that responses
to questions of caseload volumes might not be accurate since many respondents' have
lirnited access to objective workload information. Regardless, test re-test reliabilities for
key measures including workload responses were found, at a minimum, to be fairly stable
(ICC 1 0.75).
The mail survey m h o d was successfuC with Canadian speech- fangrrage path oiogisîs.
The known disadvantages of the se&-administered mail survey were successfùlly
overcome with both high item and survey response rates achieved. Survey success was
likely a result of rigorous fonnatting and mail design strategies. This research showed
that speech-language pathologists responded to survey incentives similar to other
professional groups. Specifically, the combination of commemorative stamps and the
incentive offer of survey fïndings increased standard swvey response rates to
approximate 70%.
A prefiminary description of speech-Ianguage pathoiogisis ' reported practice
beïzaviours reveafed minimal pradice variation with unanirnously high utiiizafion of
most physiological assessment parameters. Parameters reported most utilized were
those assessing airway protection, bolus control and swaliow duration. As wouïd be
expected, parameters proven to have a high correlation with aspiration on
videofluoroscopy (Le. dysphonia and involuntary coughing) were most utilized and
parameters with no scientific evidence of predictive value (i.e. nonfood oral sensation)
were least utiiized. However, other parameters, such as those measuring swallow
duration, whicb have no proven predictive value and known to have poor inter-rater
reliability (Lof et al., 1990), were also highly utilized. Interestingly, the Aspiration-
Penetration Scale (Rosenbek et al., 1996) wbich has proven high inter-rater reliability
was not utilized but subjective observations of penetration and aspiration were. It
appears, then, that fiiture research should not oniy focus on assessing the clinicai
relevance of those parameters that have no scientific support and are highly utilized, but
future research should also focus on developing methods for better dissemination of
research results to przctitioners.
Speech-language pathofogisis' reported opinion of importance for each physioiogicai
assessrnent parameter correlated in a linear fashion with utilization report of the same
parameters. OveraLl, respondents valued most parameters highly and rated no parameter
with no importance. Those parameters highly valued were aIso those highly utilized, and
visa versa
General practice behaviours appeared somewhat more varied and were possibly
influenced by modifiing factors; however, a smaff sampfe sire limited statistical testing
of these associations. As SAVs were found to influence physician practice behaviours,
regional Canadian differences also appeared to influence inpatient waiting times for
clinical and instrumental testing. Specifically, Ontario respondents reported shorter
inpatient waiting times but longer outpatient waiting times.
A pattern of progressive& decreasing parameîer utiiization was noted und specu fated to
represent a typicaï diagnostic dysphagia work-up. A model was proposed to explain the
pattern of decreasing parameter utilization. Specifically, it was speculated that this
pattern depic ts the sequence of prioritized phy siological swallow testing fiom clinical to
instrumental parameters. If this model were correct, it then would refiite the possibility
that high parameter utilization was rote behaviour conforming only to available protocols.
Furthemore, this model would suggest an efficient and yet comprehensive approach to
assessrnent whereby only relevant parameters are utilized. The prioritization of clinicai
testing at the start of the diagnostic swallow work-up, stresses the importance of having
clinical rneasures that accurately predict swailow pathophysiology.
E.4 Future Directions
This research compnsed the first phase of a two-phase project to describe reported
dysphagia assessment practices of speech-language pathologist across Canada and the
United States. Certainly, it is recognized that reiiability and validity are essential
components that must be established for a new questionnaire. This thesis deveIoped the
questionnaire and piloted it with a limited sample of the target population, however,
M e r psychometric testhg will be required. Test-retest reliability was assessed with the
Canadian speech-language pathologists and found to range fiom fair to no variance.
Criterion validity testing was beyond the scope o f this research, however, face and
content validity were established through pre-testing with both Canadian md Amencan
practitioners. This validity testing is not sufncient to ensure that reported practice
behavioun accurately depict tnie practice behaviours. Therefore, the goal for the next
phase of research will be to m e r establish the overall validity of the quest io~aire and
test-retest reliability with specifically Amencan speech-language pathologists. Pnor to
M e r research, the questionnaire should be revised to înclude content items identified
rnissing in the pilot survey phase. The demographic response options also need to be
expanded to better represent paediatric settings and etiologies.
On a conceptual level, the thesis detected a pattern of decreasing utilization in practice
that potentially is related to stages of diagnostic dysphagia work-up. This fincihg
provokes many possibilities, one of which is to suggest that current dysphagia practice is
prioritized to highiy utilize cluiically relevant parameters fiorn which al1 other assessment
is prescribed. If future research c o b s the presence of such an underlying logic, then,
the diagnostic value of clinical parameters that reliably predict sw aiiow pathophysiology
and eventual health outcornes is heightened and should be prioritized as fiiture research.
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Table 1. Primary Assessment Content Parameters
A) Clinical SwaIlowin~ Assessmen t
1. Pre-Swallow (Assessrnent of swallow physiology wilhout the use of food stimulus) i) Oral Motor ii) Oral Sensory
O Touch O Temperature O Taste a Smell
iii) Xerostomia iv) Other
2. SwaîJowing with Food or Liquid (Assessrnent of swallowphysioiogy with the use of food stimuli) i) Oral Phase
O Movements O Bolus control O Bolus sensation
ii) Pharyageal Phase O Movements O Bolus sensation O Temporal measures O Dysphoaia
iii) Esophageal Phase iv) Other
BI Instrumental Swallowin~ Assessment
1. Oral Phase (Assessment of oral motion and sensation) a Movements a Sensation
2. Pharyageal Phase (Assessment of phoryngeal motions* timing. sensory and bolus direction)
0 Movements Tempod measures Sensation
a Bolus residue 0 Bolus misdirection 0 Oropharyngeal swallow efficiency
3. Esophageal Phase (Assessment of bolus misdirection and structurai problerns) 4. Other
Table 2. Modifying Factors
A) Cfinician Variables
0 Years of clinical experience II) Opinions of clinical importance for each physiological parameter m) Concentration of dysphagia caseload IV) Worked hours
B) Patient Variables
0 Age Etiology
Cl Practice Settine Variables
1) Country 11) Province or State m) Teactiing affiliation IV) Institution type V) Instrumentation available VI) Personnel avaiiable
Table 3. Questionnaire Matrix
Question # Content Area
Skip Oral
Question motor speech and non-speech motions.
bb
Oral sensory such as touch, m e & etc. bb
Skip Question Oral motions and bolus control,
Lb
Pharyngeaï motions, sensation and timing. bb
Esophageai food entry or reflux. bb
Skip Question
1 - 14 Oral motion and sensation. 15 bb
Level of Roie of Variable in Measmement Final Analysis
nominal Descriptors of practice ordinal patterns (dependent
qualitative variables) ordinal
qualitative nominal ordinal
qualitative ordinal
qualitative ordinal
qualitative nominal
ordioal qualitative
16-47 Pharyngeal motions, timing, bolus sensation ordinal 48 bb qualitative
49 - 57 Esophageal structurai abnormalities, etc. ordinal 58 44 qualitative
Section C: Generui Prodice Behviour and Demographk 1 Patient Demographics 2 LL
3 Cihician Demographics 26,28 - 30 U
ordinal Potential modifiers of nominal practice patterns ordinal (stratification and control
nominal variables)
4, 5,27 Setting Demographics 6-8 bb
nominal ordinal
11 - 19 General Practice Behaviours 9- IO LI
interval ordinal
22 66 nominal ----------.-.-_-___-----------------*-+-*-------------*---------*---------*-*-*---*-----*-*---*-*-*-*-------*-------------
23 - 25 Research Generating nominal Exploratory analysis for 35 ad aualitative future research
Table 4. Respondent Comment Summaries
Table 4.a Questions with less than 90% item response rates
Question Type Unsolicited Written Comments
Potentid Practt'ce Modier
C.8 In your practice, is each of the following -AvaiJable but not used professionais available for collaboration in -Do not use instrumentai assessments. (3) dysphagia instrument assessrneut? -Available versus participates?
-Not 'always' but 90% of t h e
Prartrëe Behaviour Dcsct@tor
C.9 Which of the foliowing instrumentation -NIA techniques do you use to assess dysphagia? -Endoscopy performed by ENT by
consult/referriù, MBS if appropriate iÏom testing. 1 use the information obtained fiom other's assessment of above to assist in diagnosis. I perform only 2 above.
C.34 During the past year, how many patients did -Approximately (7) you see? (Round to nearest whole) -Don? know' or '?' (4)
-Dysphagic patients or total patients? (4) -New versus active patients? -Maybe more -NIA (2)
Table 4.b. Open-ended assessment parameter questions in suvey sections A and B
-- -
Questions N (%) Type Examples (Some respondents provided more than one comment)
Clhicai (Iv=34) A17 Oral Motor 6 (1 8) Inclusion Structural assessrnent
-Hyolaryngeal elevations for dry swallows. -VF functioa -Lingual appearance. -Respiratory support for speech. -Ability to sit up. -Diadochokine tics and motor speech quality
A38 Oral Sensory 2 (6) Inclusion -Dentition
-~uco&mernbrane guality. A53 Oral Food 8 (23) Inclusion -Tangue pumping and praxis.
-Consistency of food -Assistance. -Bolus cohesion -Length of mastication- -Tangue ROM. -Delayed initiation of oraI phase. -Retrïeval of food/flui& fiom utensil. -Nasal regurgitation. -Judgement of positioning. -Suck and swallow. -Duration of meal
A.65 Pharyngeal Food 6 (18) Inclusion -1ncreased respiration post swallow- -Sound of swaiiow. -Vocal assessment pnor to food -Pooling and residue in pharynx- -Anterior movement of larynx -Auscultation. -Coughing, choking either before, during or after the swallow.
A.68 Esophageal Food 7 (2 1) Inclusion -Obstruction of burping. -Behaviod manifestations of reflux. -Backfiow or regurgitation p s t meal. -Halitosis. -Retrostemal pain on swaliowing (odynophagia), problerns with solids.
Insfrumenrd W 7 ) B.15 OraJ 2 (7) inclusion -Location and amount of oral residue- - -
-Premature spillapre to pharynx. B.48 Pharyngeal 3 (1 1) inclusion -Compensatory îreamient strategies and their effects.
-Endoscopically: Degree of hydration, saliva secretions, residue, how secretions dealt, sensation of pharyngeal wall, and base of tongue and constrictor motion.
B.58 Esophageal 3 (1 1) Inclusion -Radiologists feel SLP not appropriate to assess esophagus. & -If concerns noted, UGI series ordered.
Practice -Previous esophageal surgery. -Flow of bolus through both upper and lower esophageal sphincters.
Table 4.c. Open-ended question in survey section C
Type Examples Content -Consider elderly dementia .... or with sever physical handicap for whom standard assessments Inclusion are impossible. (8) -An essential part of assessrnent is thorough case history. Or deterrnining associated conditions-
-Detail roles of SLP vs others (Le. OT, RDN), -What about SLP role in tube feeding decisions? -Specific therapy protocols such as educational standards. suctioning (Le, who does it), tracheostomy patients 8 testing (Le- blue dye). -This survey was difficult because my role has changed in the past year. 1 now work in a school and am on team with OT. PT. I do feeding Ax during meals and refer children for more forrnal assessments as needed in another part of the facility- I observe assessments and collaborate on behalf of the team. -Do you want hours of education in dysphagia +/- dinical hrs of clinicai mentoring? -Not mentioned suctioning which is on the increase.
Content -This survey took 50 minutes to compiete. It was impossible to give accurate data regarding Exclusion workioad without extensive more time-Sorry.
-
(1) Ambiguity -Use cervical auscultation as of my 'clinical' evaluation. Confused when you put it in the (1) instrumental section. Format -Dysphagia assessment may Vary with each individual patient- 1 completed survey referencing a Revision comprehensive assessment that 1 generally use- Modifications are part of clinical decision (1) making.
-Sony so late but knew that it would take longer than 30 minutes (actually 1 hour at least). Supportive -Your survey was very interesting. (3) -Look forward to findings.
-Than ks for the initiative. Practice -We need for outcome scales not of physiological measures but of patient satisfaction scales. comments -Conflict with disciplines (i-e. OT) whose training and philosophy are different, I feel strongly that (12) who introduces food to an at flsk patient should be a controlled act under RHP-
-Presently working in a regional program in rural Manitoba. Alttiough I serve adults, rny caseload is primanly preschool. Instrumental procedures are not available but 1 can refer to an outpatient clinic in a nearby major city (pending that the patient has travel access). -In our facility there is only 1 SLP- OT carries out screening and bedside evaluations- l consult OT on complex cases and provide training for OT regarding dysphagia. 1 coordinate instrumental exams. -In my setting, assessments done by paediatric physicians who have training & specialization in respirology 8 dysphagia* SLP has role of clinical judgement & referral with CO-assessrnent. -0nly in current position for 4 months, -1 believe SLP educational institutes should place a great deal of emphasis on dysphagia coursework. At my program this was considerably lacking. As clinicians we are being faced with large dysphagia caseloads. 1 was lucky to have experienced SLPs mentor me. -I've included a copy of ouf dysphagia bedside evaluation fom for your information. -We are a general hospital with a regional base in a rural setting. One difficulty with dysphagia is changing staff 8 the OT who 1 work closely with are chronically short staffed 8 not farniliar with dysphagia. Generally. 1 have good working relationship with Radiology. -1 see patients where there is a higher concentration of dysphagia on a rotational basis. Typically, 1 would see in-patients for 4 monthsfyear. 1 have woked with dysphagia for 2 years, meaning 2 rotations of 4 months. -1 am operating out of a smaller city and significanuy understaffed. My FT position is a bit of everything (.5 CHC, .5 Hospital out patient, LTC (auxiliary + NRSG home)). Other disciplines (i.e. O f & RD) are more involved in dysphagia than in other facilities that I t e worked. -Much of what we don7 do is due to patient status (Le. apraxia, late stage of disease) or caseload time pressures.
Table 4.d 'Other' responses for questions in survey section C
Questions Type Comment Examples
C.2 Etiologies of patients. (10) Inclusion -Trauma (2) -Cerebral Palsy (3) -Delayed Development (2) -Rend Failure -NYD -Spina Bifida
C.4 Setting of practice. (6) Inclusion -Public health -Rehabilitation out patient -Homecare -In & ont patient chic -School with c hildren's rehabilitation center -Rivate school with disabled children
C.6 Instnimentation available. (0) None -NIA
C.7 Professionals avaiiable for Inclusion -Physiatrist clinicai assessments, (2) -Family doctor
C.8 Professionals available for Inclusion -Physiatrist ins tnimental assessments. (4) -Speech-Language Pathologist in acute centre
-Physician -Radiology Technician
C.9 Instrumentation utilized. ( 1) General -Scintigraphy occasionally Comment
Table 5. Eligible CASLPA Membership and S w e y Respondents ' + '
Factor CASLPA Respoadents N=229, (O& N=34, (%)
Years since final graduation ' 0-5 6-10 11-15 16-20 2 1+
Membership Fees Paid Fuil Reduced
Location of Practice Atlantic Provinces
New Bninswick (12; 1) Newfoundland ( 10;2) Nova Scotia (10;3) Prince Edward Island (0;O)
Alberta British Columbia Manitoba Ontario
Saskatchewan Other
"CASLPA, Canadian Association of Speech-Language Pathologists and Audiologist + Expressed as percentage of column total and rounded to nearest whole number.
Reduced fees are granted to clhicians working l e s than 800 hrs. / yr. (15 hrs. /wk.) %=l70 for CASLPA members because data not always available.
Table 6. Respondent Profiles (N=34)
Profiles No (%) of Respondents
Years of Active Pracüce 0-5 6-10 11-15 1 6-20 214-
-- - -
Percent Caseload with Dysphagia 1-25 26-50 5 1-75 76- 1 O 0
Currently Seeing Patients with Dysphagia Yes
Hours Worked Per Week < 25 1 25
Training Institution Canadian University
Nova Scotia Dalhousie University (3)
Quebec University of McGU (3) University of Montreal (3)
Ontario University of Ottawa (1) University of Toronto (2) University of Western Ontario (3)
Alberta University of Alberta (5)
British Columbia University of British Columbia (1)
Amencan University British University
- - -
Level of Final Training Bachelors Masters Doctorate
Table 7. Practice Setting Profiles of Respondents (N=34)
Profdes No (%) of Respondents
Teaching AfZiiiatiou Yes
Practice Facility Acute Inpatient Hospital Chronic Care Inpatient Faciiity Rehabilitation Inpatient Hospital Hospital Clinic Outpatient Community inpatient Hospital Other
Table 8. Patients h o files of Respondents (N=34)
Profüe No (Y.) of Respondents
Acute Neurological 28 (82) Progressive Neuroiogical 30 (88)
Head & Neck Cancer 10 (30) Psyc hogenic Systematic Diseases Esop hageai Disorders 6 (18) Iatrogenic Respiratory Disorders Surgeries (6)
Transplant Surgeries (1) 1 (3) Thoracic Surgeries (2) 2 (6) Cardiac Surgeries (3) 3 (9)
Other 15 (44)
Table 9.a. Patient Waiting Times: Overail (N=18)
Patient Settings Average T h e (Days) 95%CI Range
In-Patients
ClinicaI
fns tnunental
Out-Patients
Clinicai
Instrumental
Table 9.b. Patient Waiting Times: Location of Practice
Location of Practice
East Que bec Ontario West Avg. &YS (95%CI) Avg, &ys (95%CI) Avg. days (95%CI) Avg. days (95%CI)
In-Patients
Clinical 7 (O - 25) - 1 (1 -2) 5(1-9)
Instrumental 9 (O - 22) 1 O (O - 55) 8.20 (O - 17) 6 (1 - 10) Out-Patient
C i i n i d 20 (2 - 37) 37 (O - 329) 91 (0-282) 14 (6 - 21) ins tnunental 12 (0-31) 22 (O - 124) 89 (O - 281) 13 (O -27)
Table 9.c. Patient Waiting Times: Caseload Concentration
Dysphagia Caseload Concentration '
26 - 50% 51 - 75% 76 - 100% Avg. &ys (95%CI) Avg, days (95%CI) Avg. days (9S%CK)
In-Patients
C l i n i d 4(0- I I ) 4(0-11) 4 (O -9)
Insirumental S (O - 12) 6(3-9) i l (1 -20)
Out-Patient
Clinical 11 (0-24) 67 (O - 169) 22 (12 - 32)
Table 9.d. Patient Waiting Times: Type of Facility
Type of Facility
Acute UP Chronic or Rehab UP Avg. &YS (95%CI) Avg. &ys (9S%CI)
In-Patients
Clinical 3 (O -7) 3 (O - 8)
Instrumental 7 (3 - IO) i l (0-36)
' No reportcd cases existed for caseloads of 1 to 25%.
83
Table 10. Method of Dysphagia Assessrnent
Average Percent 95%CI
Of a11 patients seen (n=32), those who bad:
Clinical testing
Instrumentai testing
Of ail patients receiving ciinical assessments, those who had:
Food tesMg (n=32)
Instrumental testing (n=28) - p-p p-
Of al1 patients receiving instrumentai assessments (n=29), those who had: No clinical testing
Table 1 1 .a. Availability of Personnel: Summaries
Availability
Assessrnent Unanimously Yes Likely Yes Unceriain Likely Not Unanimously Not
Clinical Nursing Radiology Gastroenterology Pulmonology Dietitian Physiotherapy Otolaryngology Neurology Occupational Social Work Psyc holog y Therapy Respiratory Therapy
Instrumental Radiology Dietitian Gastroenterology Nursing Neurology Occupational Otolaryngology Therapy Pulmonology
Physiotherapy Psyc holagy Respiratory Therapy Social Work
Table 12. Instrumentation Availability and Utilization '
Availa blc
Never Occasionally Always Instrumentation Type N (%) N (%) A' tw Mobile
Auscultation
CLA
FEES
FEEST
Oxygen Saturation Monitor
Space Dependent
Manometry
ROSS
Ultrasound
Videofluoroscopy
Ncver Occasionally Always N tw A' 1%) N (W
' N varies according to missed rcsponscs, tlicrcforc oiily valid pcrccntagcs providcd.
8 7
Table 1 3. Videofluoroscopy Rotocol Utiiization (N=27)
Procedures
-- - - --
Never Occasionaiiy Always N (W N (%) N (W
Equïpment Used
Frarne-by fiame advance
Timer
Commercial textures
Assessment Protocols Used
hterpret own results
Administration of Food
Texture Preparation
Liquidç to Solids Admhhtered
TX strategies Introduced
Expressed as percentage of total videofluoroscopy users.
Table 13.a. Videofluoroscopy Protocol Utilization: Summaries
Utilization
Procedures Unanimously Yes Likcly Ycs Uncertain Likely Not Unanimously Not
Equipment Used
Frame-by frame advance Commercial textures Timer
Assessrnent Proiocols Used
lnterpret own results Administration of Food Texture Preparation Liquids to Solids Administered Treabnent sbatcgies introduced
Table 14.a Utilization of Clinical Parameters
Utiiizatibn Frequency Never Occasiondly Always
Assessment Parameters N a/, N % N YO Wdhorrt FOUR. Oral M i
I
I A ~ P Lip resistance 1 4 16.7 ( 9 37.5 1 I I 45.8 j 1A7P Drooling 1 - - 1 2 8.3 i 22 91.7 i 1A8P Tongue range of motion 1 - - I - - 1 24 100.0 !
A2P Facial weakness 1 - - 1 1 4.2 1 23 95.8 1
-
A9P Tongue rate of motion - - I 10 41.7 1 14 58.3 1 A 1 OP Tongue target for /t, ch, W 1 3 12.5 1 14 58.3 7 29-2 1 A 1 1P Tongue resistance 1 3 12.5 [ 12 50.0 1 9 3 7 3 1
I A 12P Velo~harvnereal closure 1 1 4.2 1 5 20.8 1 18 75.0 1
A3P Lip range of motion I - - I A ~ P Lip rate of motion 1 2 8.3 ASP Lip target for fp, b/ 1 3 12.5
1 A I 3P ~an&bu.arian~e of motion J
1 4.2 j I1 45.8 12 50.0 f
1 4.2 1 23 95.8 i 12 50.0 I 10 41.7 1 12 50.0 1 9 37-5 1
1A 14P Mandibular rate of motion 1 9 37.5 1 11 45.8 1 4 16.7 1 1 A 1 SP Mandiidar resistance 1 10 41.7 ( 10 41.7 j 4 16.7 1 1 A 16P Overall motor svmmetrv 1 4.2 1 7 29.2 1 16 66-7 1 W h o m E o d Oral Sensery I A18P Light touch of face
f A2 1P Light touch anterior 113 tongue 1 6 25.0 1 I3 54.2 1 5 20.8 j A22P Light touch posterior 113 tongue 1 7 29.2 A23P Light touch of posterior pharynx 1 9 37.5 A24P Temuerature remouse on face 17 70.8 A25P Temperature response on lips 1 15 62.5 1 8 33.3 1 1 4.2 1
--
( ~ 3 2 ~ Saltv taste 1 13 54.2 I 10 41.7 1 1 4 . 2 I
5 20.8
14 58.3 1 3 12-5 ( 12 50.0 1 3 12.5 1 7 29.2 1 - - i
A26P Temperature response on tongue A27P Temperature response inside cheeks
A29P Temperature response on tonsils I 19 79.2 1 5 20.8 1 - - i I
12 50.0 1 7 29.2 1 A19P Light touch of lips 1 4 16.7
A30P Sour taste 1 12 50.0 A3 IP Sweet taste I 11 45.8
- --
A36P Overall oral reflex 1 s 20.8 1 7 29.2 I 12 50.0 A37P Overall sensory symmetry 6 25.0 1 IS 62.5 1 3 12.5
11 45.8 1 9 37-5 1
13 54.2 16 66.7
11 45.8 1 1 4.2 1 11 45.8 1 2 8.3 1
1 13 54.2 1 10 41.7 ( 1 A33P Bitter taste 4 -2 A34P Smell 1 14 58.3 1 8 33.3 1 2 8.3 ,
Table continued
A20P Light touch of inner cheeks 1 6 25.0 11 45.8 1 7 29.2 I
9 37.5 1 2 8.3 1 7 29.2 1 1 4.2 i
A35P Xerostomia
6 25.0 1 - - I A28P Temperature response on palate
4 16.7 1 7 29.2 1 13 54.2 1
18 75.0
Table 14.a Utilization of Clinical Parameters (cont)
1 ~ 4 6 ~ ~ m o ~ n t of bolus residue i 1 3.m 7 3.0 j 9 3 . 9 - j
Assessrnent Parameters N % N ?'O N W~ Food: Oral A40P Lip closure - - 1 1 2.9 1 33 97.1 A4 1 P Vertical tongue range - - 11 32.4 1 23 67.6 1 A42P Lateral tongue range 1 - - ' 5 14.7 1 29 85.3 A43P Tongue seal with alveolar ridge 7 20.6 A44P Presence of bolus residue 1 - -
14 41.2 1 13 38.2 ! 1 2-9 1 33 97.1 1
A47P Oral bolus spillage 1 1 2.9 j 2 5.9 1 31 91.2 A48P Awareness of bolus or saliva 1 2.9 1 4 11.8 1 29 85.3 1
1 ~ 5 5 ~ Delayed Iaryngeai elevation 1 2 5.9 1 2 5.9 1 30 88.2 j A56P Nasal regurgitation 1 - - 1 4 11.8 1 30 88.2 A57P Throat clearîng 1 - - 1 3 8.8 1 31 912 !
A58P Voluntarv coueh - - 1 3 8.8 1 31 91.2 1
lA45P Location of bolus residue 1 - - 1 2 5.9 1 32 94.1 f
A49P Drooliag ASOP Presence of secretions 'AS 1 P Origin secretions 1 4 11.8 1 15 44.1 15 44.1 1
- - 1 - - 1 34 100.0 1 1 2.9 1 6 17.6 1 27 79.4 1
4 11.8 / 30 88.2 1 A52P Mandiiular mastication movements
A60P Dysphonia (wet/gurgly voice quality) 1 - - 1 - - t 34 100.0 i A6 1 P Noisy breathing 1 2 5.9 3 8.8 1 29 85.3 1
Wdh Food: Pkqngeaî 1 IA54P Extent of lamneal elevation 1 2 5.9 1 3 8.8 1 29 85.3 i
- -
A62P Repeated swallows with one bolus 1 - -
A64P Respiration and swallow cycle 1 9 26.5 1 7 20.6 ] 18 52.9 1 Wi2h Food: Esophagd
3 8.8 1 31 91.2 j
A66P Reflux symptom A67P Nocturnal coughinn
A63P Delayed ~h-geal swallow 2 5.9 1 3 8.8 1 29 85.3
30 88.2 14 41.2 1
- - 9 26.5
4 11.8 11 32.4
Table 14.b. Utilization of instrumental Parameters
Table continued
Urilttrdion Frequency Never Occasiondiy Always
Assessrnent Parameters N % N % N O L
Oral Phase B 1 P Lip ciosure 1 3.7 5 18-5 1 21 77.8 [
3 11.1 1 24 88.9 1 2 7.4 1 25 92.6 1
B2P Delayed oral initiation 1 - - B3P Tongue control - -
IO 37-0 17 63.0
B4P Lateral tongue seal to alveolar ridge f 6 22.2 1 11 40.7 BSP Vertical tongue range B6f Tongue mget for /t, ch, k/ B7P Antenor-postenor tongue range
2 7.4 8 29.6 19 70.4 4 14.8 1 4 14.8
1
3 11.1 1 5 18.5 1 19 70.4 lB8P Laterai tongue range on chewing 1 7 25.9 f 9 33.3 1 11 40.7 f B9P Bolus manipulation and propulsion 1 - - 1 - - 1 27 100.0 1 B 1 OP Tongue pumping 2 7.4 1 2 7.4 f 23 852 1
2 7.4 1 19 70.4 1 3 11.1 1 4 14.8
B37P Amount of aspiration, in categories B38P Aspiration / Penetration Scale B39P Orophaxyngeal Swaliow Efficiency 1 10 38.5 j 6 23.1 1 1 O 38.5
6 22.2 20 74.1
B 1 1 P Tongue t h . t 1 1 3.7 1 7 25-9 1 19 70.4 1 B 12P Dry swailows to clear residue ! - - 1 4 14.8 1 23 852 B 13P Delayed oropharyngeal initiation - - 1 27 100.0 1 B 14P Oral transit t h e 1 3 11.1 1 2 7.4 1 22 81.5 Phmngeril Phase B 16P Velopharyngeal closure - - 2 7.4 1 25 92.6 B 17P Base of tongue range of motion B 18P Posterior pharyngeal wail motion
3 11.5 1 4 15.4 1 19 73.1 1 1 3.8 9 34.6 16 61.5 1
14 53.8 ! 9 34.6 1 4 15.4 21 80.8 5 19.2 1 21 80.8 4 15.4 1 19 73.1 1 - - 1 26 100.0 1
B 19P Symmetty of pharyngeal wall motion 1 3 11.5 B20P Laryngeal vestibule closure B2 1 P Laryngeal vocal fold closure B22P Hyoid motion
1 3.8 - - 3 11.5
B24P Epiglomc deflection 2 7.7 1 - - 1 24 92.3 [ B25P Cricopharynged opening 1 2 7.7 1 2 7.7 1 22 84.6 1
B23P Laryngeal motion 1 -
B26P Coordination of structural movement B27P Nasal regurgitation B28P Presence of pharyngeai bolus residue B29P Symmetry of bolus residue
- - 1 2 7.7 1 24 923 1 - - - 3 11.5
B30P Amount of bolus residue 1 1 3.8
1 3.8 1 25 962 1 1 3.8 25 96.2 7 26.9 1 16 61.5 1 5 19.2 1 20 76.9
B3 1 P Delayed pharyngeal swaiiow B32P Pharyngeal transit time
- - 1 - 1 26 100.0 1
4 15.4 1 4 15.4 1 18 69.2 1 B33P Total swaiiow tirne 1 2 7.7 1 9 34.6 1 15 57.7 1
- - 1 27 100.0 1 2 7.4 1 21 77.8 [ 13 48.1 1 5 18.5 1
B34P Laryngeal penetration B35P Timing of laryngeal aspiration
- - 4 14.8
~ 3 6 P Amount of aspiration, in % 1 9 33.3
Table I4.b. Utilization of Instrumental Parameters (cont.)
Urilitoa'o'on Frequemcy Never Occasionnlly Always l
I Assessrnent Parameters N % N 34 N YO Phryyngcel Phase (Corcdnue@ B40P Sensation to touch or air pulse 1 22 81.5 [ 4 14.8 1 1 3.7 1 B4 1 P Response to nasal reflux 1 6 223 1 7 25.9 14 51-9 B42P Response to pharyngeal residue 1 2 7.7 2 7.7 1 22 84.6 1 B43P Response to penetxation 1 - - - - 1 26 100.0 B44P Response to aspiration i - - 1 - - 1 26 100.0 1 B45P Effectiveness of response f - - 1 - - f 26 100.0 / B46P Structurai abnormalitîcs 1 - - 1 1 3.7 1 26 96.3 1 B47P Respiration and swdow cycle 7 25.9 1 6 22.2 1 14 51.9 1 Esopkagcel P k
13 50-0 1 11 42.3
B49P Diverticulum 1 1 3.8 1 12 462 BSOP Cervical osteophytes
7 25.9 1 6 22-2 1 O 37.0 6 22-2 1
5 192 B5 1 P Esophageal web 1 14 51.9
10 38.5
B52P Esophageal stenosis 11 40.7 B53P Cricopharyngeal bar BS4P Back flow B55P Esophageal stasis
13 48.1 [ 6 22.2 1 8 29.6 3 11.1 11 40.7 1 13 48.1 7 25.9 12 44.4 1 8 29.6 '
12 44.4 1 8 29.6 12 44.4 1 11 40.7
B56P Esophageai dismotility 1 7 25.9 B57P Gastroesophageal reflux 4 14.8
Table 15.a. Utilization Summaries: Overall
Total (ab) Utilization Phase Without Food With Food Ununimous YES ( Oral 1 4 9 1 7
(utilimtion 2 80%) l Pharyngeal 16 Esophageal
Total Likeiy YES
(utilization 79 - 60%)
Tord hcetîain
(utilization 39 - 59%)
Oral
Toral Likely NOT
Pharyngeal Esophageal
Oral Pharyngeal Esophageal
(utilization 40 - 21%)
4 20 2 2
Oral Pharyngeal - t Esophageal 5
Totd Ununimous NO T
(utilization s 20%)
- 16 (II)
8 4 5
17 (15) 10 1 5
23 4
2 2 6 1
I 1
Total G ~ u d Tords
8
12 1 3 4
6 3 7 1
Oral Pharyngeal Esophageal
8 2
16 - 35 (30) 26 (22)
7 1 16
- 4
55 (47)
8 1 3
Table 15.b. Utilizatioii Summaries: ~ n a n i m o u s l ~ ~erfomed'
Oral
Pharyngeal
- - -
Esophageal
Without Food ( ~ ~ 2 4 )
Instrumental Paramctcrs (N=27)
With Food (N=34) - - - -- -
VTongue range of motiol .Facial weakness .Lip range of motion 1
.Drooling l
-Drooling -Lip closure -Presence of bolus residue -Location of bolus rcsidue -Amount of bolus residue -Oral bolus spillage -Mandibutar mastication movements -Lateral tongue range -Awareness of bolus or saliva
4nvoluntary cough (Le. Choking) -Dysphonia (weîlgurgl ylvoice quality) -Throot Clearing -Voluntary Cough -Repeated Swallow With One Bolus -Delayed Laryngeal Elevation -Nasal Regurgitatioii -Extent of Laryngeal Elevation -Noisy Breathing -Delayed Pharyngeal Sallow
-Reflux Symptoms
-Bolus manipulation and propulsion -Delayed oropharyngcal initiation -Tongue control -Delayed oral initiation -Tangue pumping -Dry swallows to clear residue -Ors( transit time
-Laryngeal movement -Delayed pharyngcal swallow onset -Laryngeal penetration -Responst to penetration -Response to aspiration -Effectiveness of response -Structural Abnormalilies -Nasal Regurgi tation -Presence of Pharyngeal Bolus Residue -Velopharyngeal Closure -Epiglottic Deflection -Coordination of Structural Movement -Cricopharyngeal Opcning -Response to Pharyngeal Residue -Laryngeal Vestibule Closurc: -Laryngeal Vocal Fald Closure
Utilization 2 80% l
Table 15.c. Utilization Summaries: Unanimously 'Not' ~ e r f o m e d *
Oral
Pharyngeal
Esophageal
Clinical Parametcrs
Without Food
-Temperature responsc on face -Temperature response on palate -Temperature response on tonsils -Tcmperature response on lips -Temperature response inside checks -Sour taste -Salty taste -Bitter taste -Sweet taste -SrneIl -Temperature response on tongue -Light touch of posterior 113" tongue -Light touch of posterior pharynx -0verall sensory syrnmetry -Mandibular rate of motion -Mandibular resistance
With F'ood
Instrunientat Parameters
-Tangue target for / t , ch, W
-Sensation to touch or Air Pulse -Aspiration Penetration Scale -Amount of aspiration, in %
Utilization c 20%
Table 15.d. Utilization Summaries: 'Likely' or 'Noi Likely' Perfomied
LIKELY YES (Le. 60 to 79%)
LIKELY NOT (Le. 20 10 39%)
-- -
Oral
Pharyngeal
Esophageal
Oral
Pharyngeal
Esophageal
Without Food With Food
-VelopharyngenI closure -0verall motor symmetry
-Presence of secrctions -Vertical tongue rnnBe
-Light touch of anterior 2/31d
tongue -Tonguc target for /t, ch, W -Light touch of lnner Checks -Light iouch of Face -Lip target for /p, b/ -Tangue resisfance -Light touch of lips
-Tonsue seal with alveolar ridge
-Lip closure -Anterior-pasterior longue range -'i'onguc ihnrst -Vertical longue range
-Timing of laryngeal aspiration -Estimate amount of bolus residue -Base of tonguc range of motion -Nyoid motion -Amount of aspiration in categories -Pharyngeal transit time -Posterior pharyngeal wall motion -Symnietry of bolus residue
-Symmetry of pharyngeal wall motion -Lateral tonyuc seal to alveolar ridge
-Esophageal web -Esophageal stcnosis -Cricopharyngcal bar -Esophageal stosis -Esopliageal dismotility
Table 15.e. Utilization Summaries: 'Uncertainly' Perfomed'
Oral
Pharyngeal
- - -
Esophageal
Without Food
Clinical
With Food -- -
-Lip rate of' motion -Lip resistance -Tangue rate of motion -Mandibular range of motion -Xerostomia -0verall oral reflex
-0rigin of secretions
-Respiration and swallow cycle
-- -
I -Nochimal coughing
-Lateral tongue range on chewing
-Total swallow duration -Response to nasal reflux -Respiration and swallow cycle -Diverticulum -Cervical osteophytos -Back flow -Gastroesophageal reflux
Table 16.a. Opinion of In~portance of Clinical Parameters
Opinion of Importance Freqiicncy Defiriitely Not Probably Not Not Sure Probnbly Definitely N % N % N % N % N %
W/IAiont Food: Orai Motor A2P Facial weakness 1 1 1 I 1 4.2 1 1 5 1 20.8 1 18 1 75.0 A3P Lip range of motion A4P Lip raie of motion A5P Lip target for Ip, bl A6P Lip resistance
I A ~ IP Tonpue resistance 1 1 1 1 1 4.2 1 5 1 20.8 1 9 1 37.5 1 9 1 375 1
1 3
A7P Drooling A8P Tongue range of motion A9P Tongue rate of motion L l O P Tonmie target for /t. ch. W
1
4.2 12S
1 3
A 12P Velopharyngeal closure A 13P Mandibular range of motion
4.2
A 14P Mandibular rate of motion A 15P Mandibular resistance A 16P Overall motor symmetry
1 4
4,2 12S
1
A 19P Light touch of lips A20P Light touch of inner checks A2 1 P Linht touch anterior 113 tonnuc
4 1
W&horct Fbdr O d Se~~sory A 18P Liaht touch of face 1 1 1 4 1 16.7 1 8 1 3 3 3 1 6 1 25,O 1 6 1 25,O
1 1
A22P Light touch posterior 113 tongue A23P Light touch of posterior pharynx A24P Temperature response on facc
1 ~ 2 9 ~ Temperature response on tonsils 1 1 1 4.2 1 2 1 8.3 1 15 1 62.5 1 6 1 25.0 1 1 1
4.2 16.7
1 1 4 3
4.2
3 2 1
A25P Temperature response on lips A26P Temperature response on tonguc A27P Temperature responsc inside chceks A28P Temaçrature response on palale
Table continued
16.7 4.2
4.3 4,3
2
7 1 O
4.3 4.2 16.7 12.5
1
12,s 8,3 4.2
1 1 1 1
4 5
5 3
8.3
29.2 4 1,7
4 2 7 12
-
4.2
5 6 9
4.2 4.2 4.2 4.2
16.7 20.8
21.7 13.0
1 4 3
15 7
17.4 8,3
29.2 50.0
3
20.8 25,O 37s
3 1 2 1
62.5 29.2
11 7
6 6 5
4.2 16,7 12.5
18 2 1 12 6
12.5
9 1 O 8
12.5 4.2 8.3 4.2
45.8 29,2
78.3 87.5 50,O 25.0
26.1 26,l 20.8
9 7 13
7 7
37.5 41.7 33.3
11 1 O 11 15
5 1 O
7 9 6
37.5 29.2 54.2
20.8 4 1.7
29,2 29.2
7 6 6
458 41.7 45.8 62.5
30.4 39.1 25,O
29.2 25.0 25.0
9 9 6
16 13
7 1 O 8 7
66,7 54,2
4 4 13
37s 37.5 250
17.4 17.4 54.2
29.2 41.7 33.3 29.2
5 4
20,8 16.7
2 2 2
8.3 8.3 8.3
Table I6.a Opinion of Importance of Clinical Parameters (cont.)
Table Continued
Opinion of importance Frequency Definitely Not Probably Not Not Sure Probably Definitely N % N % N % N % N %
Without Food: Oral Sensoty (Continued) A30P Sour taste A3 1P Sweet taste A32P Salty iastc A33P Bitter taste A34P Smell A35P Xerostomia A36P Overall oral reflex A37P Overall sensory symrnetry
1 1 1 1
Wh Food: Onl
4.2 4.2 4.2 4.2
A40P Lip closure A4 1 P Vertical tongue range A42P Lateral tongue range A43P Tongue seal with alveolar ridge A44P Presence of bolus residue A45P Location of bolus residue A46P Amount of bolus residue A47P Oral bolus spillage A48P Awareness of bolus or saliva A49P Drooling ASOP Presence of secretions A5 1 P Origin secretions A52P Mandibular mastication movements
2 2 2 2 4
1
2
1
1
8.3 8,3 8.3 8.3 17.4
4.2
5,9
2.9
2.9
13 13 13 13 15 5 5 6
3 1 24 2 7 14 3 O 30 27 26 2 2 2 5 22 16 2 5
1 1
91.2 72,7 79,4 412 88.2 88.2
1
79.4 76.5 647 73s 64.7 47.1 73.5
542 54.2 54,2 54.2 65,2 20.8 20.8 25.0
2.9 3 .O
7 7 7 7 3 8 9 14
2 8 7
7
1 1
1 3 6 1
5,9 24,2 20,6
11 4 4 5 7 12 8 9
20.6
2,9 2,9
2.9 8.8 17.6 2,9
4.2 4.2 4 2 4.2 4.3 45.8 41.7 12.5
29.2 ' 29.2 29.2 29.2 13.0 33,3 37.5 58,3
32.4 11.8 11.8 14.7 20,6 35,3 23.5 26,s
1 1 1 1 1 11 10 3
12 7
35.3 20,6
Table 16.a. Opinion of Importance of Clinical Parameters (cont.)
Opinion of Importance Frequency Definitely Not Probably Not Not Sure Probably Definitely N % N % N % N % N %
Wbh Food: Phatyngeal A54P Extent of laryngeal elevation A55P Delayed laryngeal elevation AS6P Nasal regurgilation A57P Throat clearing A58P Voluntary cough A59P Involuntary cough A60P Dysphonia (wet/gurgly voice quality) A 6 1 P Noisy breathing A62P Repeated swallows with one bolus A63P Delayed pharyngeal swallow A64P Respiration and swallow cycle
1
Wkh Fod; Esopkagd A66P Reflux symptoms A67P Noctumal coughing
2.9
4 3
1 2
6 2 1 6
11.8 8.8
2 9 5.9
18.2 5.9 3.0 18.2
1
5 2 6 2 4 1 1 3 7 5 9
2.9
14,7 5.9 17.6 5.9 11.8 2.9 2.9 9.1 20.6 15.2 27.3
25 29 2 8 30 2 8 33 33 24 25 27 18
1 8
73,5 85.3 82,4 88.2 82.4 97,l 97.1 72.7 73.5 8 1 8 54.5
82.4 38,2
2.9 23S
5 12
14.7 35.3
28 13
Table 16.b. Opinion of Importance of Instrumental Parameters
Opinion of Importance Frequcncy Dcfinitely Not Probably Not Not Sure Probably Definitely N % N % N % N % N %
O d Phase L
Table Continued
B 16P Velopharyngeal closure B17P Base of tongue range of motion B 18P Posterior pharyngal wall motion B 1 9P S ymmetry of pharyngeal wall motion B20P Laryngeal vestibule closure B2 1 P Laryngeal vocal fold closure B22P Hyoid motion B23P Laryngeal motion B24P Epiglottic deflection B25P Cricopharyngcal opening B26P Coordination of smictural movemcnt
B 1 P Lip closure B2P Delayed oral initiation B3P Tongue control B4P Lateral tongue seal to alveolar ridge BSP Vertical tongue range B6P Tongue target for /t, ch, W B7P Anterior-posterior tongue range BSP Lateral tongue range on chewing B9P Bolus manipulation and propulsion BlOP Tongue pumping BI 1 P Tongue h s t BI 2P Dry swallows to clear residue B 13P Delayed oropharyngeal initiation B14P Oral transit time
1
Pharyngd Phase
I
3.8
3,7
3 2 2 2
2
1 2 1
5
1
1
2
11.5 7.7 7.7 7.7
7,7
3,8 7-7 3.8
18S
3.7
3,7
7.4
4 4 9 12 1 4 3 2 2 4 5
1 1
7 2 14 3 5 1 2 4 2 2 2
14.8 154 34.6 46,2 3.8 15.4 11.5 7.7 7.7 15.4 19.2
3,7 3.7
25,9 7.4 5 1.9 11.1 18.5 3.7 7.4 14.8 7.4 7.4 7.4
5 3 2 I I 9 5 6 8
5 8 5
3
23 19 15 12 23 22 2 1 24 2 2 20 20
18S 11.1 7.4
40,7 33.3 18.5 22.2 296
18.5 29,6 18.5
11.1
85.2 73.1 57.7 46.2 88.5 84.6 80.8 92.3 84.6 76.9 76,9
20 23 25 9 16 3 18 13 26 19 15 20 2 5 20
74.1 85.2 92.6 33,3 59,3 11,l 66.7 48,l 96.3 70,4 55,6 74.1 92.6 74.1
Table 16.b. Opinion of Importance of Instrumental Parameters (cont.)
Opinion of Importance Freqiiency Definitely Not Probably Not Not Sure Probribly Dcfinitely N % N % N % N % N %
Pharyngeal Phase (Conî.) B27P Nasal regurgitation B28P Presence of pharyngeal bolus residue B29P Synuneûy of bolus residue - B30P Amount of bolus residue B3 1 P Delayed pharyngeal swallow B32P Pharyngeal transit time B33P Total swallow time B34P Laryngeal pene tration B3SP Timing of laryngeal aspiration B36P Amount of aspiration, in % 337P Amount of aspiration, in categories 1 1 338P Aspiration I Penetration Scale 339P Oropharynaeal Swallow Eficiency
1 3
1 1
340P Sensation to touch or air pulse 04 1 P Reswnse to nasal reflux
7 1 25.9 1 3 1 11.1 1 17 1 63.0 14 9
342P Response to pharyngeal residue B43P Response to penetration B44P Response to aspiration B45P Effectiveness of response a46P Structural abnonnsli~ies B47P Respiration aiid swallow cycle
3.8 11.5
3.7
5
Esophugeai Phase
( B 5 7 ~ Gastroesophageal reflux 1 1 1 1 I 1 3.7 8 1 29.6 1 18 1 66.7 1
51,9 33.3
- .
B53P Cricopharyngeal bar B54P Back flow B55P Esophageal stasis B56P Esophagcal dismotility
1
4 3
I 1
5 10
18.5
B49P Diverîiculum B5OP Cervical osteophytes B5 1 P Esophageal web B52P Eso~haaeal stcnosis
8 8
2
4
4 1 3 3
3,8
15,4 11.5
3.8 3.8
18.5 37,O
16 8
73.1 61.5 50,O 46.2
1 4 3 2
29.6 296
7.7
- - 14.8
3.8 15,4 1 1,5 7.7
19 16 13 12
6 6 10 12
15.4 3.8 11.5 11.1
59,3 29.6
23,l 23.1 38.5 46.2
1
4 3
6 6 1 2 10
5 10
1
1 -- 9
9 9 8 7
24 25 18 20 26 18 16 26 20 6
3.8
15.4 11.5
23.1 23.1 3.7 7.4 37.0
18.5 37,O
6 7
92.3 100.0 69.2 76.9 100.0 69.2 61,s 96.3 74.1 22,2
3.8
3,7 33,3
34.6 34.6 30.8 25,9
22,2 25,9
23 26 26 26 26
- 7
14
13 16 15 17
12 88,s 100.0 100,O 100.0 96,3
-
5 1,9
50.0 61.5 $7,7 63 .O
44.4
Table 17.a. Opinion of Importance Summaries: Ovcrall
Phase Clinical
Importance Without Pood With Food Unanimous YES ( Oral 1 1 3
(importance 2 80%) I Phary nged Esophageal
Tora1 Likeiy YES
(importance 79 - 60%) l Pharyngenl Esophageal
Oral
- Total
Unceriain (importance 39 - 59%)
J 11 4 8
T9td Likely NOT
Oral Pharyngeal Esophageal
(importance 40 - 2 1 %)
4 I I 4 4 - 1
Oral Pharyngeal Esophageal
Tord Unairimous NOT
4 5 l 1
(importance S 20%)
Instrumental Total (%)
- -
Oral Pharyngeal Esophageal
Total G m d Tolols
11 1 13
- - 13 -
33 (28) 28 (24)
Table 17.b. Opinion of Importance Summanes: 'Unanimously' ~mportanl'
Without Food With Food -Tangue range of motion -Lip closure
-Presencc of bolus residue -Location of bolus residue
-1nvoluntary cough -Dysphonia -Delayed laryngeal elevation -Thront clearing -Nasal regurgitation -Volunt;iry cough -Delayed pharyngeal swallow
Instrumental
bBolus manipulation and propulsion -Tangue control -Dela yed oropharyngeal initiation .Delayed oral initiation -Presence of pharyngeal bolus residue .Delayed pharyngeal swallow -Response to penetration -Response to aspiration -Effcctiveness of response -Laryngeal penetration -Structural abnomlities -Laryngeal mot ion -Nasal regurgitation -Laryngeal vestibule closure -Responsç to pharyngal residue -Velopharyngeal closure -Laryngeal vocal fold closure -Epiglottic deflection -Hyoid motion -Diverticulum -Gastroesophagcal reflux -Esophageal dismotility -Cervical osteophytes -Back flow
E cn c g .- a E 2 -= - 0
0' I
tO s e s p "ps-c.,nQ> - -- x = O = 6 0 2.g d' B -2 _X_ &== Q " o p p = . & - 0 , % y , , - - c o I n ' Z E . E s g p - 8 5 ' ~ ~ g-g &i! p - . , " s f + p q 0 s ~ 8 S ~ 8 ~ = = O U , - MZ g = c e E O * Q P ~ ~ . , ~ = z c w = . S U E p e s u & --- 0 - 0 .= 8 E - E B E 0 - 2 2 2 $ $ ? Y ~ P = ? ~ $ ? Q ~ F V *
Table 18.a. Stages of Dyspliagia Work-up for Cliiiical aram met ers'
Stage 1 Ununimous Utilited
Drooling of food Llp closure .Facial weakness .Lip range of motion -Drooling of secretions
Facial Expression
Mastication
Tongue
Orophrrynx Are8
Laryngeal Arta
Esophagus Sensation
Bolus presence
dral bolus spillage ~Mandibular mastication motion
-
.
-Pnsence of bius rnidue -toc(~t&u of botus m&lue -Amount of bolus residue
Likely Utilized Prcsertce of secretions Overall motor symmctry
Vertical tongue rangc
-Vclopharyngeal closure
Stagc III
-Lip rnte of motion 1 -Lip resistance -Xerostomia -0verall ord r e j a -0rigin of secretions
-Mandibular range of motion - Toiigue rate of motion
-Respiration / swallow cycle
-Noctumnl coughing
Stagc IV Likely Not Utilizcd
-Lip targef for 4, b/
-Tangue target for h, ch, k/ - Tongue resistance -Tangue seal@ aalcolar ridge
-Llght touch anterior 2/3 tongue -&kt touch of lnner checks -Light touch of face -L ight ~ O U C ~ of ( i p ~
Stage V Uaanimous Nol UfIIked
.Mandibular rate of motion
-Tea$mture rcsponse orr tow& - T e ~ u ~ mpwe orr @s - Tempnuww mpoll~e Iusiûe che& -Sour tasîe -S* taste - B h taste Swccrtaste -Terrip'ratuw mpoose on tonglie -Light touch postedot 1 /3 tongue -Light tocrck postcrJor piraty~
Italicized parameters were also ranked in the samc Strige for 'Opinion of Importance' 1 1 1
Table 18.b. Stages of Dysphagia Work-up for Instrumental p ara in et ers'
Facial Expression Tongue
Oropharynx
Lary ngeal l Area
Esophagus
Sensation
Bolus presence
u
Stage I
-Bolus munipnlai&n / propulsion -Tangue control -Tangue pumpin~
Stagc 11 Likel'y Utilized
-Base oftongue range of motion -Anterior-posterior tongue range -Tonguc thrust -Vct-îical tonguc range -Posterior pharyngcal wall motion
-Hyoid motion
-Amount of bolus residue -Amonnt of aspiration, in caregories- -Sjwwerry 01 bolus residue -Timing of laryngeal aspiration - Pharyngeal transit lime
Stage 111 Stage IV Uncetîainly Utilized Likelj Nd Uîilized
I
-Rcsponse to nasal -Syrnmciry of phiiryngcûl wall reflx motion
Stage V Unadmous Nor UtilIzed
,Lateral longue range -Lateral longue seul to rn clrewing alveolar rldge
-~ct-vica~ ost coph yin -Orophaty~~gd~wallow Eflcielcncy
-Tangue targcl for jl, ch, A/
-Divcrticulum -Esophagcal wcb -Back flaw -Esophagcal stenosis -Gastroesophagcal -Cricopharyngcal bar reflux dise& -@sophagcal masis
-Esophagcal disrnot ility
1
-Total swallow timc
S e ~ s d s e #O @MC& sr cr&pw(sc
1
* halicized parameters were also rûnked in the sanie Shgc for 'Opinion of Iniportancc'
-Aspiradoon / Peuchorlon S d t -Amount of aspiration, in %
Table 19. Estirnate of Required Sample Size for Test-Retest Reiiability
(n [rep eated testingl-2)
Scenarios
< 0.40 > 0.60 > 0.80
Sample Size ( with no response rate adjustment) 12
Response rate adjusment @ 50% 24
Resgonse rate adjustutent @ 60% 20
Response rate adjusment @ 70% 17
Table 20. Practice Behaviour Test-Retest Reliability
Survey Question p p
In traclass correiation (95% CI)
Uitaniinous& UdAsscrrnicrrt Pammdcrs (Srcrion A & B) ' A.60 Dysphonia (clinical) B .9 Bolus manipulation and propulsion (instrumentai) B.3 1 Delayed pharyngeai swallow onset (instrumentai) Ununimous& Not U d Assessment Porenrdcts (Sdon A h B) A.24 Temperature on face (clinical) A.28 Temperature response (ciinical) A.29 Temperature response on tonsils (clinical)
A+35 Xerostomia (clinical) A.67 Noctumal coughing (clinical) B -49 Diverticulum (instmenid)
C. 10 Use protocol to adminïster foods in videofluoroscopy C. 1 1 Percent fiequency of clinical assessments C. 12 Percent fiequency of instrumental assessments C. 13 Inpatient clinical waiting tirnes (days) C. 15 Inpatient instnunentai waiting times (days) C. 14 Outpatient clinical waiting rimes (days) &
No variance No variance No variance
Groupings based on respoases fiom origùial sunrey.
114
Figure 1. Reported Utilization and Modifjing Factors
Figure 1 .a. Dysphagia CaseIoad
i. Dysphagia Caseload and Ciinka1 Parameter
ii. Dysphagia Caseioad and Instrumental Parameters
Figure 1. b. Years of Active Practice
I i. Years of Active Practice and Clinieal Parameters
ii. Years of Active Practice and Instrumental Parameters
Figure I -c. Country of Training
i. Country of Training and Clinical Parmeters
* Clinical Paramaten
ii. Country of Training and Instrumental Parameters
* Instrumental Paramaten
Figure l .d- Level of Employment
f li. Emplayment Level and ClinicaI Parameters
ii. Employment Level and Instrumental Parameters
Figure 1 .e. Patient Age
i. Patient Age and Clinical Parameters
ii. Patient Age and Instrumental Parameters
l Over 18 yrs
Figure 1. f. Teaching affiliation
i. Teaching Affilitaion and Cünical Paramtem
ii. Teaching Affiliation and Iastrumeatal Parameters
Figure 1 .g. Location of Practice
i. L o c a t i o n o f Pract ice a n d Cl in i ca l P a r a m e t e r s
Clin idal Param .ter+
ii. Location of Practice and Instrumental Parameters
Instrumontil Panmeten
Fi,we 1. h. Type of Facility
i. Facility Type and Clinical Parameters
Clinical Parameters
ii. Facility Type and Instrumental Parameters
Figure 2. Practice Utilization and Opinion of Importance
Assessrnent type
01 Instrumental
Clinical
1
Frequency of Practice
SECTION G: APPENDICES
APPENDIX 1 Instructions for Survey Reviewers
INSTRUCTIONS FOR SURVEY REVIEWERS
The purpose of this questionnaire will be to survey both Canadian and American S-LPs who practice in the area of dysphagia- Our specifîc focus will be the assessrnent of oropharyngeal and upper esophageal swallowing disorders. The results will allow us to accomplish two tasks:
A) Compare and contrast practice patterns in these two countries and different regions in north Amencan-
B) Develop a dysphagia severity index based on clinical judgement of importance for each parameter-
It is best if you block off two hours to complets this review in one session. Please use the suggested guidelines on this sheet to complete yow review.
Step 2: r Complete the questionnaire fkom beginning to end as if YOU were the S-LP being surveyed. Note the following information either while you are completing the questionnaire or afier having completed it, You may write your comments directly on the questionnaire, on this sheet or on additional sheets-
h y problerns with content areas:
Any problems with format:
Any other changes that you suggest:
Please give any other comments, including any remarks about this review process.
Please do not show Ulis survey to any other S-LP. 1 enily have a relatively small Canadian
contingent fkom which to sample compared to the U.S. sample, so 1 will need as many S-LPs out
there as possible. I will be happy to discuss with you the development of this questionnaire at
any time that is convenient for you, please either e-mail [[email protected]] or
telephone me 1416-97 1-22401. Thank you for offering me your valuable tirne.
126
APPENDM II Draft Version of the New Self-Administered Mail Questionnaire
CLINICAL DECISION MAKING
WHAT FACTORS ARE IMPORTANT?
A SURVEY OF SPEECH-LANGUAGE PATHOLOGISTS' PRACTICES IN THE ASSESSMENT OF OROPHARYNGEAL DYSPHAIGA
Department of Clinïcal Epidemiology University of Toronto
Toronto, Ontario
In clinical decision making Speech-Language Pathologists routinely choose between various techniques for either the
clinical or instrumental assessment.
The questions on the following pages ask about various assessment techniques. The purpose of these questions is to gain an understanding of
factors YOU consider to be important to assess for everyday clinical decision making.
It is critical that you (the Speech-Language Pathologist) complete al1 the questions.
Your responses are important. If you practice in more than one location, please answer this questionnaire
for your primary practice only.
AU responses will be submitted anonyrnously. Only the research team d l see your answers. Procedures have been
implemented to ensure your complete anonymity.
Read First: In Section One you are to indicate if you use the attribute in your clinicai assessment of dysphagia. Then, regardless of whether you use the attribute, give your opinion if the attribute is needed in an assessment of swallowing. Please select one response for each of these two questions by placing a mark in the appropriate box and a circle around the appropriate nurnber.
Section One: The Clinical Assessment
1. Do you administer clinical assessments of dysphagia without the use of food? .... No.. .[7 ,-wlfNo, skip to question #30.
Yes ......O
The following areas are those that may be assessed to measure the physîology of the swallo wing mechaiiism without the administration of food
Oral Motor Assessment: Bis refers to both speech and non-speech movernents.
.............................. Lip rate of motion O
Do vou use this attribute?
Never Occasionaiiy Always
................................. Facial weakness 0
In vour o~inion. is this attribute needed? Definitely Proba bly Not
Not Not Sure Probably Definitely
Lip target for /p,b/ .............................. O Lip resistance ..................................... O Drooling ............................................. U
....... Vertical tongue target for /t,ch,k/
............................... Tongue resistance 0 Tongue rate of motion ........................ 0 Lateral t o n p e rate of motion .............
Velop haqngeal closure ..................... 0
Oiiter motor clinical areas that should be included (Piease specr%i, below):
Oral Sensory Assessnient: This refers to light touch . temperature . taste . and smell . D o vou use this attribute:
Never Occasiondly Aln-aj
13 . Light touch of the face ................... .... O 14 . Light touch of the Lips ........................ 0 15 . Light touch of the tongue .... .. ............. 0 16 . Light touch of the cheeks ................... 0
. 1 7 Light touch of the posterior tangue ....
1 8 . Light touch of the posterior pharynx .
Temperature of the face ..................... 0 Temperature of the lips ............ .. ..... ... 0 Temperature of the tongue ................. 0 Temperature of the cheeks ................. 0
............. ...................... . 23 Sour taste ,,. 0 . 24 Sweet taste ........................,,............... O
. .................................... 26 Bitter taste ,..,.. 0
......................................... 28 . Xerostomia 0
29 . Other oral motor or sensory areas that should be inciuded
In vour oilinion. is this attribute neeâed? Definitely Probably Not
Not
S....... I
........ 1
......S. 1
........ 1
P....... 1
.....a.. 1
..S..... t
....... 1
S...... 1
....... 1
....... 1
....... 1
....... 1
....... 1
....... 1
....... 1
Not
2
2
2
2
7 . 2
2
2
2
2
2
2
2
2
7 . 2
Sure Probably Definitely
'lease specifi below):
30 . Do you administer clinical assessments of dysphagia with the use of food? . ....... No 0 . -lfNo. skip pro question #56
Yes ...... U
The following areas are those thut may be assessed tu measure the physiofogy of the
swallo wing mechanisna with food
Oral Phase: This phase refers to oral movements. bolus control and sensation .
......................................... 3 1 . Lip closure
Do vou use this attribute? In vour o~ in ion . is this attribute needed?
. 32 . Vertical tongue range ......................... 0 0 ... ........ i
Never Occasionaliy Nways
. 33 Laterd tongue range .. ..... .... ............... ........ 1 2 3 4 5
Definitely Probably Not Not Not Sure Probably Definitely
34 . Tongue seal with alveolar ridge ......... [7
3 8 . Unaware of bolus or saliva ................ 0
........... 1
35 . Presence of bolus residue ................... 0 0 0 36 . Arnount of bolus residue .................... 0 0 37 . Oral bolus spillage ............................. [7 0
39 . Drooling ................... ..., ................... 0 0 0 ... ........ 1 2 3 4 5
........... 1 2 3 4 5
............ 1 2 3 4 5
........... i 2 3 4 5
40 . Throat clearing ................................... 2 3 4 5
41 . Voluntary cough ................................. 0 0 0 ... (........ 1 2 3 4 5
43 . Orlier oral clinical areas that should be included (Piease specifjr below):
44. Range of laryngeal elevation .............
Pharyngeal Phase: mis phase refers to pharyngeal movements, bolus contml and sensation, and timing.
45. Rate of laryngeal elevation .-.............. En
Do vou use this aitribute?
Never OccasionlLIy Always
46. Nasal regurgitation .....--.-..-.---......-.-...- 0
In vour odnioa. is this attribute needed? Definitely Probably Not
Not Not Sure Probably Definitely
47. Throat clearing .................................. ........ 0 48. Voluntary cough ....-............. .... -...... .... 0 49. Choking ............-...*..--.--.-..-....-.--....-.-.. 0 50. Repeated swallows on one bolus .......a 5 1. Delayed oropharyngeal swallow .......[III
53. Dysphonia (wet/gurgly voice quality)
53. Orh er plwyngeal clinical areas thai should be included. (Please specifi belo w) : I
54. Reflux signs ...................................... ......... 0 0 m.../ ........ 1 2 3 4 5
Esopliageal Phase: 7%is phase refers to entry of food into pharynxfi-om esophagus. Do vou use this attribute? In vour o~inion. is this attribute needed?
Never Occwionally Always Definitely Probably Not
Not Not Sure Probably Definitely
55. Other esophageal clinical areas that should be included. (Please specify below):
I
56. Do you administer instrumental assessments of dysphagia? ...... No. [7 --b P o , skip to question the top of page 10.
Yes.. ... .n Section Two: The Instrumental Assessment
Read First: In Section Two the focus will now change toward questions about instrumental assessment. You are to indicate if you use the attribute in your instrumental assessment of dysphagia. Then, regardless of whether you use the attribute, give your opinion if the attribute is needed in an assessment of swallowing. Please select one response for each of these two questions by placing a mark in the appropriate box and a circle around the appropriate number.
Oral Phase: This phase refers to oral motion and sensation.
Do vou use this attribute?
I In vour o~inion. is this attribute needed?
Definitely Probably Not .......................................................Ne ver Occasionally Alway Not Not Sure Probably Definitely
57. Lip closure ......................................... 0 58. Delayed oral initiation ......... ,.. ....... 0 59. Tongue control ................................... 0
............. 60. Tongue seal to alveolar ridge
6 1 . Vertical tongue range .... .. ................... 0 62. Anterior-posterior tongue range .........
63. Bolus manipulation and propulsion ...n 64. Tongue pumping ............................. 0 65. Tongue thrust ...................... .. ......... 0 66. Dry swallows to clear residue. ...........
67 . Other oral phase instrumental areas that should be included . (Please specify below):
I
Pliaiyrtgeal Phase: m s phase refers ?O pharyngeal motions, timing. sensory. and bolus direction .
Do vou use this attribute?
t In vour o~inion . is this attribute needed?
.............. ....................................... Defiuitefy Probably Not ....................... .,.. Never Occasionaiiy Aïway Not Not Sure Probably Definiteiy
68 . VelopharyngeaI closure ......... ,. .......... O 69 . Base of tongue range of motion ......... [71 70 . Lqngeal vestibule closure ............... 0 7 1 . Laryngeal vocal fold closure ..............
72 . Posterior pharyngeal wall motion ......a 73 . Symmetry of pharyngeal wail mot ion0
. ........................****......... 74 Hyoid motion 0 75 . Laryngeal motion ............................... O 76 . Cricop haryngeal opening ...................
77 . Coordination of structures .................. O 78 . General delayed pharyngeal swailow I[lj
. ................................. 79 Oral transit time 0 80 . Pharyngeal delay time ........................ O 8 1 . Pharyngeal transit tirne ...................... O 82 . Total swallow duration ...................... O
............. 83 . Sensation to touch or air puE 0 84 . Response to residue ............................ O 85 . Response to nasal reflux .................... O
............................... 86 . Presence of bolus 0 87 . S ymmetry of bolus residue ................ O
(Pharyngeail Phase continue@. . ...
88. Estimate amount of bolus residue ..... ... ........ 1 I 2 3 4 5
Do vou use this attribute? In vour oninion. is this attribute needeà?
Never Occasiooaily Nways
93. 0th er pharyrrgeal phase instrumental areas that shou fd be identr'fied (Please speczfjl beiow):
Defitely Probably Not Not Not Sure Probably Definitely
a .
89. Nasal regurgrtation ...,............--... -- ...... 0 0 [7 90. Laryngeal penetration ...-......... .. ..... .... 0 C] 9 1 . Timing of laryngeal aspiration .......... ....
Esophageail Phase: ï2is phase refers to bolus misdirection shrctural problems.
........... 1 2 3 4 5
........... 1 2 3 4 5
........ 1 - 7 3 4 5
Do vou use this attribute? In vour o~inion. is this attrïbute needed? Definitely Probably Not
Never Occasionaily Always 1 Not Not Sure Probably Defiaitely
94. Diverticulum ...................................... 2 3 4 5
92. Amount of larynged aspiration ........O [a O!-.-.- 1 2 3 4 5
95. Back flow ................... ... ..................... 2 3 4 5
93. Aspiration I Penetration Scale ............ ...
94. Oropharyngeal Swallow ~ f f i c i e n q ...O O ...,
96. Gastroesophageal reflux.. .......... ......... - 7 3 4 5
.......- 1 2 3 4 5
........ 1 2 3 4 5
97. Cervical osteophytes .... ...... .. ........... ... 2 3 4 5
98. Cricopharyngeal bar ..... ............. ..... 0 o...I ........ 1 2 3 4 5
99. Ollrer esophugeal rirstrumentd areas thaf shoufd be ident~ped (;Pieuse spec1B below): 1
Read First: In Section Three the focus will change toward questions about your practice and patients. Please provide & most appropriate answer for each question.
Section Three: Practice and Patient Characteristics
100. What are the ages of your patients? (Check all that are appropriate.) ................................. O - 2 years..
3 - 6 years.. O
................................. 7 - 18 years
0 .................................
19 - 65 years.. .............................. 66 years or more.. ......................... 0
10 1. What are the most common etiologies of your patients? (Check all that are appropria te.)
Acute neurologicai.. ........................ Progressive neurological.
O ..................
Neurosurgical ................................
Psychogenic ....................
B Head and Neck Cancer.. 0
................................ -0 Systemic Diseases.. ......................... Esop hageal Disor den.
0 ......................
Other (Please speciQ: O
)
102. Of al1 the patients that you see, approximately what percentage have dysphagia? 1-25% ..................................... 25 - 50%
0 ....................................
50 - 75%. O
................................... 75 - 100%. O .................................
Read First: For the questions # 103 to #IO9 choose & most appropriate answer fiom the three
I choices provided.
103. 1s each of the following instrumentation techniques avuifubfe for you to use, either independentiy or in collaboration with others, at your setting?
Never Occasionally Aiways
Video fiuoroscopy .......................... Fiberoptic endoscopy
CI ....................
Manometry O
.................................... Ultrasound ...
O ........ ..........................
None O
.............................................. 0 Other (Please speciQ:
104. 1s each of the following professionals availabïe for collaboration of dysphagia assessrnent in your practice?
Never Occasionally Always
Dieti tian ......................................... Nursing
O ..........................................
........................... Gastroenterology Otolaryngology
O .............................
Radiology .. O
........ .......................... Neurology
O ......................................
Occupational Therapy O
................... Physiotherap y..
0 ..............................
Social Work O
................................... Psychology ..
O ............... ...................
None .. O
......... ................................... O Other (Please speciijc 1
105. Which of the foliowing instrumentation techniques do you use to assess dysphagia?
Never Occasionatly
Videofluoroscopy .................................... 0 [7 Fiberoptic endoscop y.. ............................. Manometry
O O ...............................................
Ul trasound 0 O
............................................... None
O O .........................................................
Other (Please speciQ: 0 O
)
Always
O O O O CI
106. If you do not use videofluoroscopy, skip to question #118. Otherwise, if you & use videofluoroscopy, do you:
Never Occasionail y Aiways
a) interpret your own results? ................. b) use frame-by-fkne analysis? ...........
O O c) use a timer? .......................................
O O ..
c) use standard viscosi ty measures? O 0
....... O O
107. Of al1 your patients during the past year, on did you actually administer a clinical assessment?
(Enter %)
108. Of a11 your patients during the past year, on what oercent did you actuaiïy administer an instrumental assessment?
(Enter %)
109. Of al1 your patients during the past year, after how long that you received an initial referral did you administer a complete or partial elinical assessment?
(Enter days)
1 10. Of a11 your patients during the past year, after ) o w g that it was decided that an instrumental assessrnent be conducted did you adminlster it?
(Enter days)
1 1 1. Do you treat or manage dysphagia? No. . . . . . .O Yes.. . . . .O
1 12. Do you use auscultation? No .....-- n Yes ......O
1 13. Do you think policy or guideünes for dysphagia assessrnent are needed? ClNo C ] ~ a ~ b e m y e s
1 14. Would you randomize patients with trace aspiration to treatment versus no treatment?
1 15. Are you currentlv seeing patients with dysphagia? No . . . . . . . cl Yes. .... .O
116. In what province or state do you practice?
1 17. In what setting do you primariiy practice? (Check only one)
............................... Acute Inpatient Teaching Hospital.. Rehabilitation Inpatient Teachuig Hospital..
n ...................... O
....................... Chronic Care Inpatient Teaching Facility.. Community Inpatient Hospital..
0 ....................................
Hospital C h i c Outpatient.. O
......................................... Private Practice Outpatient.
O .........................................
Other (Please specifjc O
...
1 18. Where did you complete p u r final university training? Name of institution:
City of institution::
1 19. In what year did you complete you final university training?
120. List ail of your academic and professional initiais. (e.g. MA, S-LP(C), CCC-SLP, CASLPO-Reg.)
121. How many years have you been actively practicing? (round years to nearest whole)
122. How many hours do you usually work per week? (round hours to nearest whole)
123. Of the past 52 weeks, how many weeks did you work? (round weeks to nearest whole)
1s there anything we may have overlooked? Please use this space for iny additional comments you would iike to make about your dysphagia assessment practice.
Your contribution to this effort is greatly appreciated.
APPENDIX III Final Version of the New Self-Administered Mail Questionnaire
CLINICAL DECISION MAKING
WHAT FACTORS ARE IMPORTANT?
A SUR KEY OF SPEECH-LANGUAGE PATHOLOGISTS' PRACTICES IN THE ASSESSMENT OF OROPWARIWGEAL D Y S P ' G A
Department of Clinical Epidemiology and Health Care Research Faculty of Medicine
University of Toronto Toronto, Ontario
In clinical decision making Speech-Language Pathologists routinely choose between various techniques for either the
clinical or instrumental assessment.
The questions on the following pages ask about various assessment techniques. The purpose of these questions is to gain an understanding of factors YOU consider to be
important to assess for everyday clinical decision making in dysphagia.
It is critical that you (the Speech-Language Pathologist) complete all the questions. It wiil require approximately 30 minutes of your time.
Your responses are important. If you practice in more than one location, please answer this questionnaire for your
primary practice only.
AU responses will be submitted anonymously. Only the research team d l see your answers. Procedures have been implemented
to ensure your anonymity.
Read First.. In Section A you are to indicate if you use the attricbute in your clinical assessrnent of dysphagia. Then, regardless of wbether you use the attriiute, give your opinion if the attribute is needed in an assesment of swailowing. Please select Tesponse for & of these two questions by placing a mark in the appropriate box -4 a circle around the appr0pfliate number.
Section A: The Clinical Assessment
2. Do you administer clinical nssessments of dysphagia without the use of food? ............... NO ............... lfNo, skip to question #39.
Yes .............
The following areas are those that may be assessed to nieasure the physiology of the swallowing mechanism without the administration of food
Oral Motor Assessment: This refers to both speech and non-speech rnovements.
12. Facial wealcness ................................. 0
Do vou use tbis attributel
Never Occasioaally Always
13. Lip range of motion ........................... 0
In vour o~inion. is tbis attribute needed? Definitely Probably Not
Not Not Sure Probably Definitely
14. Lip rate of motion .............................. 0 15. Lip target for /p,b/ .............................. 0 16. Lip resistance ..................................... 0
1 8. Tongue range of motion.. ................... 0 1 9. Tongue rate of motion. ....................... 0 20. Tongue target for /t,ch,W ................... 0 2 1 . Tongue resistance ............................... 0
23. Mandibular range of motion .............. 2 3 4 5
l i (Oral motor wirhout food continued)
24. Mandibular rate of motion ... .... .......... 2 3 4 5
Do vou use this attributel
Never Occasionaliy Always
25. Mandibular resistance ........................ 2 3 4 5
la vour o~inion, is this athibute needed? Definitely Probably Not
Not Not Sure Probably Definitely
26. Overail motor symmetry ................,. .. 2 3 4 5
17. Other motor clinical areas thaî should be included (Pleuse specia below):
Oral Sensory Assessment: TIik refers to Iight touch, temperature, taste, and smell.
29. Light touch of face ....................-S...-.-. u
Do vou use this attribute?
Never Occasiondly Always
30. Light touch of lips ..................,........... 0
In vour odnioa. is this attribute needed? Definitely Probably Not
Not Not Sure Probably Defmitely
3 1. Light touch of inner cheeks .............-. 0 32. Light touch of anterior 2/3d tangue ...O 33. Light touch of posterior 1 / 3 ~ tongueu
34. Light touch of the posterior pharynx[7
35. Temperature response on face ........... 0 36. Temperature response on Lips ............O 3 7. Temperature response on tongue ....... u 3 8. Temperature response inside cheeksn
3 9. Temperature response on palate.. . .. . . . .O 40. Temperature response on tonsils ........
(Oral sensory without food continued) Do vou use this attniute?
Never Occasionally Always
In vour o~inion. is this attribute needed? Definitely Ptobabty Not
Not Not Sure Pro bably Definitely
.. .*........ . ................. 4 1 Sour taste. ,... ,. 0 0 0 42. Sweet taste ......................................... 0 0 0
........... i 2 3 4 5
........... 1 2 3 4 5
44. Bitter taste .......................................... 0 0 0
38. Other oral motor or sensory areus that should be included (Please specaB below):
............ 1 2 3 4 5
45. SrneIl ......................... ... ...................... 0 0 ............... ................... 46. Xerostomia ,. a 0 rn
........................... 47. Overall oral reflexes I71 [71 [71........... ................. 48. Overall sensory symmetry 0 0
39. Do you administer clinical assessments of dysphagia with the use of food?
........... i 2 3 4 5
.*......... 2 3 4 5
i 2 3 4 5
........... 1 2 3 4 5
............... NO ............... WU, skip to question #69. ............. Yes
The following areas are those that may be assessed to mesure the physiology of the swallowing mechanism
with food.
Oral Phase: This phase refers to oral movements, bolus control and sensation.
43. Lip closure ......................................... 2 3 4 5
Do vou use this attribute?
Nevet OccasionaUy Aiways
......................... 44. Vertical tongue range ........ 1 2 3 4 5
In vour o~inion. is this attribute needed? Definitely Ptobably Not
Not Not Sure Probably Definitely
........ 45. Lateral tongue range .......................... 1 2 3 4 5
46. Tongue seal with alveolar ridge .........
47. Presence of bolus residue .......-.....-...-. 2 3 4 5
1 (Oral phase with food continued)
48. Location of bolus residue .........-..--... -- 0
Do vou use this attribute?
Never Occdondly Always 1
49. Amount of bolus residue ....... . -.. . . .... ... 2 3 4 5 l
In vour oninion. is this attn'bute needed? Definitely Probably hTot
Not Not Sure Probably Defiaitely
50. Oral bolus spillage ...................-----.S... [7 0 0
56. Other oral clinical areas with food that should be included (Please specaB below):
-........... 1 2 3 4 5
l
! 5 1 . Awarmess of bolus or saliva ....-.......a 0 . . . 52. Drooling ...........................-.-.-.-.. - ........ [7 0 53. Presence of secretions ..........-.-......--.-. 0 0 0 54. Origin of secretions ............,.. -.......-. 0 0 [7 55. Mandibular mastication movements ..O ...
Pharyngeal Phase: n i s phase refers to pharyngeal movements, bolus control and sensation. and timing.
. .... .. -1 2 3 4 5
........... 1 2 3 4 5
........... 1 2 3 4 5
.........-.. i 2 3 4 S
........ 1 2 3 4 5
Do vou use tbis attribute? In vour o~inion. is this attribute needed? 7 Definiteiy Probably Not
Never OccasioniUy Always 1 Not
54. Extent of Iaryngeal elevation ..... ........ 0 0 n...I ........ 1
55. Delayed laryngeal elevation . , . . . . . . .. . . . . . o...I-. ...... 1
56. Nasal regurgitation ........-.....-.-.-.. --..-... 0 0 n...I ...-.-.. 1
5 7. Throat clearing ......... ... ........ .. . .. . .-..- .... 0 0 ...l..- ..--. 1
Not
2
2
2
2
2
2
Sure Probably Definitely
3 4 5
3 4 5
3 4 5
3 4 5
3 4 5
3 4 5
(Pharyngeal phase with food cczntinued) I
Do vou use this attribute? n our O inion is bis attribut n Defmitely Probably Not
Never Occasionaiïy ~ l w a y s A D e f i n i t e l y
60. D ysphonia (wet/gurgly voice quality) 0 0 1 2 3 5
6 1 . Noisy breathing .................................. 0 0 0 1 2 3 4 5
62. Repeated nvailows with one bolus .... ..-I..-...-. 1 2 3 4 5
63. Delayed pharyngeal swaliow ............ ...... 1 2 3 4 5
64. Respiration and wailow c y d î ....... 2 3 4 5
65. Other pharyngeal dinicul areas that should be included Pleuse spec& below):
Esophageai Phase: This phase refeers to en- of food Nit0 pha?ynrflom esophagus.
Do vou use this attnbute?
Never Occasionaiiy Aiways
58. Other esophageai clinicai areas that should be included. (Please speci@ below):
DeFinitely Probably Not Not Not Sure Probably Definitely
56. Reflux symptoms .............................-. 0 0
57. Nocturnai cougbuig ............................ 0 0
57.Do you administer instrumental assessments of dyspbagia? NO.. ............. O ............... FNo, sk@ to top of page 13. Yes ............. O
............. 1 2 3 4 5
............ 1 2 3 4 5
Section B: The Instrumental Assessment
Read Fùst: In Section B the focus wiü now change toward questions about instrumental assessrnent . You are to indicate ifyou use the at@i%ute in your instnmiental assessment of dysphagia . Then, regardless of whether you use the amibute. give your opinion ifthe attriute is needed in an assessrnent of swallowing . Please select 9ne response for -ch of these two questions by placing a mark in the apprqiate box & a circle aromd the appropriate number .
Oral Phase: This phuse refeers to oral motion and sensation .
Do vou use this attributel In vour odnion . is this attribute needed? Probably Not
Never Occasionally Always Not Sure Probably Definitely
........ ... Lip closure ......................................... 0 0 i 2 3 4 5
........................ DeIayed oral initiation 0 0 ... l........ 1 2 3
... ........ Tongue control ................................... 0 0 / 1 2 3
........ Lateral tongue seal to alveolar ndge .. 0 ... 1 2 3
........ ... Vertical longue range ......................... i 2 3
......... Anterior-porterior tongue range O ...1........ 1 2 3
Tongue target for /t7ch7W ................... 0 0 0
Lateral tongue range on chewing ....... .../........ 1 2 3
........... 1 2 3
... Bolus manipulation and propulsion
15 . Other oral phase instrumental areas that should be included . (Please specie below):
........... 1 2 3
Tongue p~mping rn - ................................
Tongue thmst ............................. ..... [71 0 0 Dry swallows to clear residue ............ 0 0 0
....... Delayed oropharyngeal initiation [71 14 . Oral transit time ................................. 0 C] 0
........... 2 3
............ 1 2 3
1 2 3
........... 1 2 3
........... 1 2 3
Pharyngeal Phase: This phase refers to pharyngeal motions. timing. sensory. and bohs direction .
Do vou use tbis attribute? In vour obinion . is this attnbute needed? IDefinitely Probsbiy Not
1 6 . Velopharyngeal ciosure ..................... 0 17 . Base of tongue range of motion .........
18 . Posterior pharyngeal wall motion ...... 1 9 . S ymmetry of pharyngeal wall mot ion0
Never Occasionally Always
20 . Laryngeal vestibule closure ...............
Not
. 2 1 Laryngeal vocal fo~d closure ............ 0 ................... ........ 22 . Hyoid motion .... 0
23 . Laryngeal motion ............................... ln 24 . Epiglottic deflection ................ ., ......... CI 35 . Cricopharyngeal opening ................... 0 26 . Coordination of sîmctural movement q
27 . Nasal regurgîtation ............................. O 28 . Presence of pharyngeal bolus residue q 29 . Symmetry of bolus residue ...............
30 . Estimate amount of bolus residue .....
3 1 . Delayed pharyngeal swalIow onset .... 32 . Pharyngeai transit time .................... .. 0 33 . Total swallow duration ...................... O
Not
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Sure Probably
(Pharyngeal phase instrumental coniinued)
................... . 34 Laryngeal penetration ..... LI
Do vou use this attributel
Never Occasionllly Always
3 5 . Timing of laryngeal aspiration ..........
In vour orrinion . is this rittribute needed? Dehiteiy Probably Not
Not Not Sure Probably Definitely
36 . Amount of aspiration. in %'s .............
37 . Amount of aspiration, in categories ...
3 8 . Aspiration / Penetration Scale ............
39 . Oropharyngeal Swailow ~ f f i c i e n c ~ ...
40 . Sensation to touch or air pulse ........... 41 . Response to nasal reflux .................... 0 42 . Response to pharyngeal residue .........
43 . Response to penetration ..................... 0 44 . Response to aspiration ....................... 0 45 . E ffec tiveness of response ................... 0 46 . Structural Abnormalities .................... 0 47 . Respiration and swallow cycle .......... U
48 . M e r pharyngeal phase instrumental areas that should be identifie d. (Pieme specifi belo w):
Esophageal Phase: This phare refers to bolus misdirection stmcturalproblems .
........ 49 . Diverticulum ....................... ., ............. m...[ 1
Do vou use tbis attribute?
Never Occasionaiïy Always
........ 50 . Cervical osteophytes ................... .... 1 2 3 4 5
In vour o~inion . is this ettribute n d e d ? Definitely Probably Not Not Not Sure Probably Definitely
(Esophageal phase instrumental continued)
Do vou use tbis attribute?
5 1. Esophageal web .......................... .,.,... . 0 0 0 - - a
52. Esophageal stenosis .................... ...-... 0 0 0 - - a
53. Cncopharyngeal bar.. ..... .. ... ............. .. 0 0 0 --•
54. Back flow .................... ., ................... O 55. Esophageal stasis ...............................
56. Esophageal dismotility ....................... 0 5 7. Gastroesophageal reflux.. ... .. .............. 0
In vour oninion. is tbis attribute needed? Definitely Probably Not
Not Not Sure Probably Defiaitely
58. Otlrer esophageal hstrumentul areas that should be idennie& (Please spect%i) below):
Read First: In Section C the focus will change toward questions about your practice and patients. Please provide the most appropriate answer(s) for each question.
Section C : Practice and Patient Characteristics
1. What are the ages of your patients? (Check all that are appropriate.) O - 2 years .................................................... 3 - 6 years
O ....................................................
7 - 18 years O
.................................................. 19 - 65 years
0 ................................................
66 - 79 years or more O
.................................... 80 years or more
0 ............................................ O
2. What are the most common etiologies of your patients? (Check all that are appropriate.)
Acute neurological ......................................... Progressive neurological ................................ Neuro surgical ................................................. Head and Neck Cancer ..,
17 .... ....................
Psyc hogenic O
................................................... Systemic Diseases.
O .........................................
Esophageal Disorders O
................................ Iatrogenic ..
O .................. ................................
Respiratory Di sorders O
.................................... O .................. O .................. O ..................
Other (Please speciQ: O
)
......... Transplant Surgeries ............ Thoracic Surgeries
.............. Cardiac Surgeries
3. Of aii the patients that you see, approximately what percent have dysphagia? 1 - 25% .......................................................... 25 - 50%
O ........................................................
50 - 75% O
........................................................ 75 - 100%
O ...................................................... O
4. In what setting do you primarily practice? (Check only one) Acute Inpatient Hospital ................................ Rehabilitation Inpatient Hospital
O ...................
Skilled Nursing Facility O
................................. C hronic Care Inpatient Facility
O .....................
Community Inpatient Hospital O
...................... Hospital C h i c Outpatient
cl .............................
Private Practice Outpatient O
............................ Other (Please specie:
O ... 1
5. 1s your setting affüiated witb a teaching institution? - NO. .............. Yes ............. ü
1 choices provided.
6. In your practice, is each of the foiiowing instrumentation techniques auailable for you to use, either independentty or in coiiaboration with others?
Never Occasionaily Always
................................. Auscultation Computerized Laryngeal Analysis
.................... Fiberoptic endoscopy Fiberoptic endoscopy with air..
5 .....
.................................... Manometry Oxygen Saturation Monitor
B ..........
Repetitive Oral Suction Swallow . ..................................... Uitrasound
Videofluoroscopy
i O
.......................... None ............................ .. .............. 0
n Other (Please specifjc 1
7. In your practice, is each of the following professionals available for collaboration in dysphagia clinical assessment?
Occasionally Always
......................................... Dieti tian Gas troenterology ....................... ... .
O Neurology
O ......................................
Nursing cl
.......................................... Occupational Ther ap y
CI ...................
O t o l ~ g o l o g y O
............................. Phy siotherap y
O ................................
Psychology O
.................................... Pulmonology
cl .................................
Radiology O
..................................... Respüatory Therapy
0 ......................
Social Work ......... O
............. ............. None ......................... .. ................... 0
n Other (Please speciQ: )
8. In your practice, is each of the foliowing professionals mailable for collaboration in dysp hagia insfrume~zt~ assessment?
Never OccasionaNy Always
.... ......................... Dietitian ......,. Gastroenterology
[71 .........................
Neurology .... O
................. ................ Nursing ...................... .. ...............
O O
................... Occupational Therapy OtolaryIlgology
O .............................
Physiotherapy O
................................ Psychology
O ..................................
Pulmonology O
................................ O -
.... ....... .................... Radiology .. .. Respiratory Therapy
O ...................... O
................................... Social Work None ..
ü ..................... .................... O
Other (Please specifjc
Which of the foiiowing instrumentation techniques do vou use to assess dysphagia?
Never OccasionaUy Always
............ Auscultation .................. .... Computerized Laryngeal Analysis Fiberoptic endoscopy .................... Fiberoptic endoscopy with air ...... Manornets. .................................... LI Oxygen Saturation Monitor .......... Repetitive Oral Suction Swallow .O Ultrasound ..................................... Video fluoroscop y
0 ..........................
None ................................. .... ......... O O
Other (Please speci@: 1
10. If you do not use videofiuoroscopy, sk@ to question #Il. Otherwise, if you do use videofluoroscopy, do you:
Never Occasiondfy Always
a) Interpret your own results? .................. b) Use g m e - b y - h e analysis?
O ...........
c) Use a timer? O
......................................... cl d) Use protocol to aâminîster foods? .....O e) Use a protocol to prepare textures? ..... f) Use comrnercially prepared textures? ..
h) Introduce treatment strategie s?
El g) Provide range from liquids to solids? .O
........... O i) Assess benefit of treatment strategies?
1 1. Of all your patients during the past year, on what bercent did you actuaUy administer a clinical assessment?
(Enter %)
12. Of all your patients during the past year, on what Dercent did you actualïy administer an instrumental assessment?
(Enter %)
13. Of a11 your inoatients during the past year, how long after you received an initial referral did you administer a complete or partial clinical assessment?
(Enter days)
14. Of al1 your oupatients during the past year, how long after you received an initial referral did you administer a complete or partial clinical assessment?
15. Of all your in~atients during the past year, bow long after it was deemed necessary did you administer an instrumental assessment?
(Enter days)
16. Of all your outrrdents during the past year, how long dter it was deemed necessary did you administer an instrumental assessment?
(En ter days)
17. Of aii your patients who received cfinical evaluations during the past year, on what percent did you admlnister clinical food testing?
(Enter %)
18. Of all your patients who received cfinicul evaluations during the past year, on what percent did you administer an instrumental assessment?
(Enter %)
19. Of aii your patients who received instrumental evaluations during the past year, on what oercent did you a administer a çlinical assessment?
(Enter %)
20. Of all those you deemed necessary for re-assessment, what percentage was re-assessed by either you or another?
(Enter %)
2 1. Of your total caseload, what percent have dysphagia? (Enter O h )
22. After the assessment is completed, do you tben provide the recommended treatment or management?
0
No ............... Yes
O ............. O
23. Do you think a physiological dysphagia severity outcome is needed? NO ............... Yes .............
24. Do you think policy or guidelines for oropharyngeai dysphagia assessrnent are needed?
No ............... Yes
O .......-..... O
25. Would you randomize patients with trace aspiration to treatment versus no treatment?
No ............... 0 Yes ............. O
26. Are you currentlv seeing patients with dysphigia? No ............... Yes
O ............. O
27. In what province or state do you practice?
28. Where did you complete your final university training? Name of institution:
City of institution::
29. Ln what year did you cornpiete you fmd university training?
30. List al1 of your academic and professional initiais. (e.g. MA, S-LP(C), CCCSLP, CASLPO-Reg.)
3 1. How many years have you been actively practicing? (round years to nearest whole)
32. How maay hours do you usually work per week? (round hou- to nearest whole)
1 33. Of the past 52 weeks, how many weeks did you work? 1 (round weeks to nearest whole)
34. During the past year, how manyptients did you see? (round weeks to nearest wbole)
Your contribution to this e f f o ~ is greatly appreciated
161
APPENDM IV Covering Letter For Canadian Speech-Language Pathologists
&h FACULTY OF MEDICINE Department of speech-Language Pathology UNIVERSITY O F TORONTO
Tanz Neuroscience Building 6 Queen's Park Crescent West Toronto, Ontario M5S 3H2 ~ e l e ~ h o n e (416) 978-2770 Fax: (416) 978-1596 E-MaiI: speech-pa th& toron to.ca
Ine Cancdion October 27, 1998 Association of Speech- Lunguage Patho l~~~sr s and .4 udiologisr endorses this research Dear «FName» «LName»
This research MII be presented ut lhe 1998 con ference o /he American Speech- Language-Hecwing .-lsroaCIation in S n .-honio. ïX
1 am writing to invite your participation in the Clinical Decision-Making study that we are conducting at the University of Toronto. This research originated fiom my work with a dysphagia outcome task force fimded by the Swallowing Special Interest Division of the Amencan Speech and Kearing Association. It will f o m the basis of a Masters thesis in clinical epidemiology and serve to refine a newly developed questionnaire. Once standardized, the questionnaire will be administered as a large-scale study with the purpose of describing speech-language pathologists' practices in the assessment of oropharyngeal dysphagia across Canada and the United States.
In speech-language pathology there are several different ways of assessing a swallowing disorder. For example, clhicians routinely choose between videofluoroscopic and endoscopic instrumentation, between a case history screening and clinical exarn with test swaIlows, between standardized and individuall y customized protocols, between commercial1 y available textures and institutionally prepared food textures, arnong other choices. The Amencan national association indicates that beyond 50% of clinical time in medical settings is now being devoted to the assessment or treatment of dysphagia (Communication Facts, 1 997).
Unfortunately, we know very little about the practice patterns of speech- Ianguage pathologists, and even less about their opinion of relevance for one assessment technique versus the other. The information fiom the large-scale survey is designed to help speech-Ianguage pathologists in adrninistenng assessments and to lead to improvements in the practicaI education that speech-Ianguage pathology students receive. Furthemore, the more we understand about the realities of clinical practice, the better we can advise government and institutional policy makers on services which best meet patient needs. Study results would also Iead to friture clinical studies investigating the e ffect iveness of speech-language pathology assessment in identimng swallowing conditions.
We realize that speech-Ianguage pathologists are extremely busy. Your participation in this study will take upproximatety 30 minutes. We wilI
be sending you a summaary of study findings as an expression of our appreciation for taking tirne to help with this important study. Anaiysis will only be in statistical or summary form and any summary tables or results will be presented in a fashion to assure that individual practices could not be identified. Completion of this methodologïcai research will enable us to lay the groundwork for the large-scaie survey, which would be the f h t to descnie dysphagia assessrnent practice patterns.
Further details are presented in the enclosure. Ptease complete and retum the questionnaire and the response card separately. Receipt of the response card will indicate your participation while ensuring anonymity of your responses. For your convenience, al1 retum mail has been prepared with self-addressed envelopes and postage.
Thanlc you very much for your assistance!
S incerely,
Rosemary Martino Femie, MA, S-LP(C), CASLPO(Reg.) Speech-Language Pathdogist, Clinical Epiderniology Student Lecturer, Faculty of Medicine S-LP Academy Associate
Gaylene Pron, Ph.D. Epidemiologist, Thesis Supervisor Departments of Medical Imaging. Public Health Science, Clinical Epidemiology and Health care Research
Nicholas Diamant, M.D. Gastroenterologïst, Thesis Committee Member Departments of Medicine, Physiology, Playfair Neuroscience, Speech- Language Pathology
Sue Bondy, Ph.D. Epidemiologist, Thesis Committee Member Institute for Clinical Evaluative Sciences and Department of Public Health Science
Enclosures: 1. Survey of Speech-Language Pathologists' Practices in the Assessment
of Oropharyngeai Dysphagia. 2. Self-addressed, Stamped Postcard 3- Self-addressed, Stamped Return Envelope
APPENDIX V Envelope
a) Return Envelope
Cornmernorative s-P
Rosemary Martino Fernie, MA Clinical Epidemiology S tudent University of Toronto Faculty of Medicine Department of Speech-Language Pathology Tanz Neuroscience Bldg., Room#l 1 1 6 Queen's Park Crescent Toronto, Ontario M5S 3H2 CANADA
b) Misdirected Label
I f this package has been misdirected, Please open and send back starnped
postcard
APPENDIX VI Return Postcard
a) Front F m
Dear Participant, You have been sent a survey about clinical decision making. Retumiog this card will allow confïdentiality for your survey responses. Please check the appropriate box below before you mail it back to the researchers.
[71 1 completed the mail survey and sent it back under separate cover.
171 1 no longer practice in dysphagia and therefore have not completed the survey.
[71 This package bas been misdirected.
Sincerely,
Rosernary Martino Fernie, MA Speech-Language Patho logist Clinical Epidemio logy Student
6) Buck Face:
Respondent ' s Narne and address.
Cornmernorative Stamp
Rosemary Martino Femie, MA Clinical Epidemiology Student University of Toronto Faculty of Medicine Departrnent of Speech-Languge Pathology Tanz Neuroscience Bldg., Room#l11 6 Queen's Park Crescent Toronto, Ontario MSS 3H2 CANADA
APPENDM VI1 Ethics Approval Letter
167
University of Toronto
OFFICE OF RESEARCH SERVICES
PROTOCOL REFERENCE #4 145 October 26, 1998
Dr. Gaylene Pron Medical Imaging Faculty of Medicine Fitzgerald Bldg, Room 88 150 College St- University of Toronto
Dear Dr. Pron:
Re: "Clinical Decision Making: What Factors Are hponant?' by Dr. G. Pron (supervisor), Ms. R. M. Fernie (student)
We are writing to advise you that a Review Committee composed of Dn. M. Bacchus and Professor R. Hutchinson has granted approval to the above-named research study.
L
The approved revised survey coverhg lettering is enclosed. (Note: Comments of one reviewer are enclosed for your information.)
During the course of the research, any significant deviations fiom the approved protocol (that is, any deviation which would lead to an increase in risk or a decrease in benefit to human subjects) andlor any unanticipated developments within the research should be brought to the attention of the Office of Research Services.
Best wishes for the successful completion of your project.
Yours sincerely, n Susan Pilon Executive Officer Human Subjects Review Committee
SP/m Enclosures Cc: Ms. R M. Feniie (Speech Pathology), Prof B. Dickens, Prof. C. Bombardier (Clinical Epiderniology), Dr. H. Skinner, Prof. P. Square
Simcoe Hall 27 King's ColIege Circle Toronto Ontario M5S I A 1 Telephone 416/ 978-2163 Fax 416/ 97i-U)10
APPENDIX VIII Test Retest Covering Letter
169
FACULïY OF MEDICINE Department of Speech-hnguage Pathology UNIVEIIST'N OF TORONTO
Tanz Neurosaence BuiIding 6 Queen's Park Crescent West Toronto, Ontario A455 3H2
December 8th, 1998 TeIephone (416) 97û-2770 Fax: (416) 978-1596 E-Maii: [email protected]
'Iliank you so much for agreeing to participate in this methodological research on S peech-Language Pathologists' practices in the assessment of oropharyngeai dy sp hagia. By cornpleting our survey for a second tirne, you will allow us to asses the reliability of this questionnaire. The presence of reliability is a necessary pre-requisite in the development of a11 valid questionnaires.
In order to keep this research methodologically sound, we ask that you not refer to any notes from when you fint completed ihis survey or try to recall any of your previous responses. It is important to us that we detemiine whether the wording and format of this ques t io~ai re is capable of eliciting similar responses.
Attached you will find a second copy of out s w e y and a stamped self-addressed envelope.
Once again, we thank you for helping us to develop a tool by w s c h we will use to describe clinical practice patterns in dysphagia assessment. Your participation is greatly appreciated!
Rosemary Martino Fernie, MA, S-LP(C), CASLPO(Reg.) Speech-Language Pathologist, Clinical Epidemiology Snident Lecturer, Faculty of Medicine S-LP Academy Associate
Gay lene Pron, Ph.D. Epiderniologist, Thesis Supervisor Departments of Medical imaging, hbl ic Health Science, Clinical Epidemiology and Health care Research
Nicholas Diamant, M.D. Gastroenterologist, Thesis Cornmittee Member Departments of Medicine, Physiology, Playfair Neuroscience, Speech-Language PathoIogy
Sue Bondy, Ph.D. Epidemiologist, Thesis Commîttee Member Institute for Clinical Evaluative Sciences and Department of P ublic Health Science
![Interventions for oropharyngeal dysphagia in acute …...1332 Quality of life post‑intervention reetrialsreportedthisoutcome[42, 47].Meta-36, analysisofdatafromtwostudiesshowednoevidence](https://img.pdfslide.us/doc/110x75/5fdcafcc73280938ad1fac55/interventions-for-oropharyngeal-dysphagia-in-acute-1332-quality-of-life-postaintervention.jpg)
