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ABSTRACT
Learning Outcomes: As a result of this activity, the reader will be able to (1) demonstrate an understanding of
dysphagia as a potential social disability, (2) demonstrate an understanding of how dysphagia can be assessed and
treated via the components of the ICF, and (3) demonstrate an understanding of how viewing dysphagia through
the ICF framework can enhance dysphagia management.
T he exact prevalence and incidence of centage, in some cases the majority, of the
dysphagia is not known but it is estimated that caseload for speech-language pathologists who
prevalence may be as high as 22% in those older work in medical settings. Speech-language
than 50 years of age; 10 million individuals in pathologists work with persons with difficulties
the United States are evaluated each year for in the oral and pharyngeal stage of the swallow,
swallowing difficulties.1 Dysphagia assessment which includes from entry of food into the
and intervention accounts for a significant per- mouth until the time food enters the esophagus.
1
Associate Professor and Chair, Department of Commu- Disability and Health (ICF) in Clinical Practice; Guest
nication Sciences and Disorders, Saint Louis University, Editors, Estella P.-M. Ma, Ph.D., Linda Worrall, Ph.D.,
St. Louis, Missouri. and Travis T. Threats, Ph.D.
Address for correspondence and reprint requests: Travis Semin Speech Lang 2007;28:323333. Copyright #
T. Threats, Ph.D., Department of Communication Sciences 2007 by Thieme Medical Publishers, Inc., 333 Seventh
and Disorders, Saint Louis University, 3750 Lindell Blvd., Avenue, New York, NY 10001, USA. Tel: +1(212) 5844662.
St. Louis, MO 63108 (e-mail: threatst@slu. edu). DOI 10.1055/s-2007-986529. ISSN 0734-0478.
The International Classification of Functioning,
323
324 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 28, NUMBER 4 2007
Of all the disorders speech-language path- actual feasting occurs, is characteristic of most
ologists evaluate and treat, dysphagia is the rites of passage. . ..Often saying We eat to-
most medical in a traditional sense of a medical gether is saying, We trust each other, even
disorder being one that could potentially result if we are not members of the same tribe or
in death. Dysphagia can result in aspiration kin. This is as true for the Nyakyusa of
pneumonia, malnutrition, dehydration, de- Tanzania as for teenagers in a U.S. high
creased functioning of the pulmonary system, school cafeteria. The meanings we attach to
and inability to take medications orally. De- eating and drinking, and swallowing are con-
creased saliva production can also increase the nected to our most cherished activities and
likelihood of oral bacteria developing in the oral remind us of the intangibles of human ex-
cavity and spreading to the rest of the body. istencetrust dependence, social worth, and
The World Health Organization (WHO) loveand, therefore, become integral to how
defines health as the complete physical, men- we see ourselves as individuals and in relation
tal, and social well-being and not merely the to others (p. 102103).
absence of disease or infirmity.2 In the case of
Table 1 Body Structures Codes: Swallowing Table 3 Body Functions Codes: Influences on
Eating/Drinking Behaviors
s320 Structure of mouth s330 Structure of pharynx
Teeth s3300 Nasal pharynx b110 Consciousness b140 Attention functions
Gums s3301 Oral pharynx functions
s3202 Structure s340 Structure of larynx b117 Intellectual b144 Memory functions
of palate functions
s3203 Tongue s3400 Vocal folds b1301 Motivation b147 Psychomotor
s3204 Structure of lips s398 Structures involved functions
in voice and speech, b1302 Appetite b156 Perceptual
other specified functions
s3208 Structure of s399 Structures involved b1303 Craving b1644 Insight
mouth, other specified in voice and speech, b1670 Reception of b1646 Problem-solving
unspecified language
s3209 Structure of b2102 Quality of vision b 255 Smell function
b250 Taste function
Activities and Participation (e.g., successfully priate food consistency is available, to other
eating the food to the mouth), Environmental effects such as the support and attitudes of
Factors (e.g., lighting in room, pleasantness of family members. For example, Attitudes of
eating partners), and Personal Factors (e.g., food health professionals is a code in the ICF and
preferences) need to be realized by all members may affect whether a given patient is even
of the interdisciplinary team, regardless their deemed appropriate for dysphagia intervention,
discipline specific goals for the patient. If the such as with frail elderly patients.
individual spills half of the food getting it from Attitudes and support of all persons in the
the plate to the mouth, or spills half of the food clients environments are influenced by culture.
from the mouth while chewing, the result is still One of the signatures of any culture is what
increased chance of malnutrition. In addition, if foods are consumed and how they are con-
the individual has trouble with one or both sumed. The effect may be that two people
activities, the clients ability to eat appropriately with technically the same severity of dysphagia
in social settings is severely compromised. Such may function very differently because of their
a person might avoid eating with others with the culture. For example, in cultures that favor large
given intervention. In its annex discussing the ical examination itself, the Body Functions
ethical use of the ICF, the ICF states that the codes dealing with the oral stage of the swallow
ICF codes should be assigned with full knowl- can be evaluated, as well as some indications of
edge of the persons whose behavior is being the pharyngeal-stage swallow. Depending upon
evaluated, with the person having the right to how the clinical assessment is done, the capacity
object. The ICF emphasizes the autonomy qualifiers of the Activities and Participation
aspect of health care ethics. In the use of the items regarding overall eating and drinking
ICF, there are several ethical dilemmas that behavior could be evaluated. However, if the
could occur in dysphagia management. For person is fed the food by the clinician, then
example, if a person has a cognitive-communi- eating style cannot be evaluated. Another lim-
cative disorder along with dysphagia, the itation is that in the medical setting, persons
speech-language pathologists might be likely often are not given the usual foods and drinks
to attribute his or her refusal to follow dyspha- they consume. More detailed background ques-
gia recommendations to decreased insight and tions of the person and/or their significant
thus an impairment rating would be warranted others about eating and drinking behaviors
There are several measures that look being stuck in throat, difficulty chewing, and
broadly at eating proficiency. One measure drooling (b51051, b5102, b5103). Examples of
that has been used by speech-language pathol- Activities and Participation behaviors on this
ogists to evaluate overall eating and drinking assessment measure include the following lim-
behaviors is the ASHA National Outcomes itations or restrictions secondary to the dyspha-
Measurement System for Swallowing.8 This is gia: (1) not going out to eat, (2) restrictions on
a seven-level scale that ranges from Individual social life, (3) changes in work or leisure, (4)
is not able to swallow anything safely by avoidance of social gatherings such as holidays,
mouth. Compensatory strategies are effec- (5) suspected role changes in family, (6) no
tively used when needed to The individuals longer enjoying or desiring to eat, and (7) taking
ability to eat independently is not limited longer to complete meals.
by swallow function7 (p. 35). Other global
assessments of eating and swallowing in-
clude Wisconsin Speech-Language-Hearing Environmental and Personal Factors
Associations Functional Outcome Assess- Assessment in Dysphagia
room, as well as mislabeled food, which reduced assessment can be used to focus dysphagia
her ability to enjoy mealtimes. A personal factor treatment (p. 274).7
alluded to is that the resident previously liked
spicy foods and now must eat bland nursing
home food. These factors alone might contrib- CASE EXAMPLE
ute to poor eating, but with such patients there Dr. D, a 67-year-old man, has a new stroke that
is often at minimum an underlying oral-stage has caused a mild to moderate oral-stage dys-
dysphagia. The combination of having more phagia secondary to an infarct in his motor
mechanical difficulty with chewing and manip- cortex of his left frontal lobe. Last year, he
ulation of the bolus and eating under less than had two mild strokes, which affected his left
desirable circumstances may have a negative prefrontal lobe and his left temporal lobe,
synergistic effect on nutrition and hydration. resulting in a mild cognitive communicative
Even when the importance of Environ- disorder characterized by impairment of higher
mental and Personal Factors components is level abstract thinking and problem solving,
acknowledged, there are still no agreed upon and difficulty making new verbal memories.
chewing (b5102), oral manipulation of food that will allow him to eat smaller meals with-
and control of bolus (b5103). Body Functions out risking malnutrition. Eating smaller meals
impairments secondary to his previous stroke might lessen the effect of seeming to take
include higher abstract thinking (b1640), longer to finish meals than his eating com-
problem solving (1646), development of panions.
long-term memories (b1441), and insight Regarding coffee drinking, if Dr. D can
into difficulties (b1644). A potential Activities learn to keep his head down and take small sips,
and Participation limitation includes recrea- he may be able to continue this behavior. Since
tion and leisure activity (d920). Relevant en- he has demonstrated that he coughs when
vironmental factors would be the support and liquids are in the airway or being aspirated, the
attitudes of his spouse and relatives toward his patient can practice his drinking of coffee using
modification of his diet (e310, e410). Relevant the different strategies with the clinician in the
personal factors would include his previous therapy room. To get across the possible neg-
occupation, high socioeconomic level status, ative effects of aspirating liquids such as coffee,
and his family situation. The key to full assess- the clinician could use his personal factor of
Body Functions impairment (e.g., the amount Functional Approach. New York: Thieme; 2000:
of delay of the onset of the pharyngeal swallow). 262275
Only by looking at the patient with dysphagia 8. American Speech-Language-Hearing Association.
holistically can these real-life outcomes be real- National Outcomes Measurement System
(NOMS): Adult Training Manual. Rockville Pike,
ized. Whether speech-language pathologists MD: ASHA; 2003
continue to work with persons with dysphagia 9. Wisconsin Speech-Language and Hearing Associ-
(and get reimbursed for the activity) depends on ation. FOAMS: Functional Outcome Measure of
whether these outcomes can be achieved. Swallowing Ability. Madison, WI: Wisconsin
Speech-Language-Hearing Association; 1996
10. Skeat J, Perry A. Outcome measurement in
dysphagia: not so hard to swallow. Dysphagia
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11. McHorney AC, Bricker ED, Kramer AE, et al.
1. ASHA. ASHA Communication Facts: special The SWAL_QOL outcomes tool for oropharyng-
populations: dysphagia-2006 Edition. Available at: eal dysphagia in adults: I. Conceptual foundation
http://www.asha.org/members/research/reports/ and item development. Dysphagia 2000;15(3):115