Transcript Don*t Burn Your Tongue..Hot Topics in Dysphagia

Don’t Burn Your Tongue..Hot Topics in
Dysphagia: Free Water Protocol and sEMG
Adult Swallowing EBP Group
EBP Extravaganza
13th December 2012
Presentation Outline

-
Free Water Protocol
Clinical question
What is the free water protocol
Good oral hygiene is critical
CAPs
CATs
Clinical Application
Presentation Outline




sEMG
Clinical question
What is sEMG?
CAPs
CATs
Clinical Application
What’s next for Adult EBP Swallowing?
Acknowledgements
References
Free Water Protocol: Clinical Question

In patients with dysphagia what are the benefits
and complications of implementing the free
water protocol?
Free Water Protocol: What is it?
A protocol to regulate the provision of water to
patients known to aspirate thin fluids.
 Strict guidelines are outlined with regards to suitability
of the patient (e.g. Not suitable for patients with
extreme coughing).
 It involves:

- Strict oral hygiene
- Water is permitted between meals (not during or until 30
minutes after).
- No water given with medications.

AIM: Increase quality of life, hydration and compliance,
whilst maintaining safety.
Free Water Protocol:
Good Oral Hygiene is Critical
Dysphagia & pneumonia: a complex relationship (Langmore 1998)
Colonisation (altered oropharyngeal flora):
Aspiration into lungs
Host resistance
Pneumonia
Free Water Protocol CAPs





Carlaw, C., Finlayson, H., Beggs,K.,Visser,T., Marcoux, C., Coney,
D. & Steele, C.M. (2011) Outcomes of a pilot water protocol
project in a rehabilitation setting. Dysphagia (published on-line).
Scott, A., & Benjamin, L. (2010). Implementation of a free fluid
protocol in an aged care facility. In Roddam, H., & Skeat, J. (eds).
Embedding evidence based practice in speech and language therapy.
West Sussex: Wiley-Blackwell.
Karagianis, M.J.P., Chivers, L., Karagianis, C. (2011). Effects or oral
intake of water in patients with oropharyngeal dysphagia. BMC
Geriatrics, 11:9.
Panther, K. (2005).The Frazier Free Water Protocol. Swallowing
and Swallowing Disorders, March:4-9.
Garon, B., Engle, M., & Ormiston, C. (1997). A randomised control
study to determine the effects on unlimited oral intake of water
in patients with identified aspiration. Journal of Neurological
Rehabilitation, 11: 139-148.
Free Water Protocol CAP summary
Article
Level
Participant
Method
Outcome
measures
Results
Support
Carlaw et. al
(2011)
2
16
Randomisation
Fluid intake
Increase
Yes
CVA Spinal
cord
SwallQoL
Improved
Adverse event
Nil
TBI
Immediate and
delayed
implementation
26
Implemented FWP
Adverse event
Nil
Yes
Control group –
usual care
Fluid intake
Increased
Inconclusive
SwallQoL
Improved
Experimental group
– implemented
FWP
Adverse event
14.3%
developed
asp pneu
Implemented FWP
Aspiration
Pneumonia
2
participants
Yes
Implemented FWP
Averse events
Nil
Yes
Fluid intake
Increased
Scott &
Benjamin
(2010)
4
Karagianis
et. al (2011)
3
ACF
76
Subacture
and mixed
etiologies
Panther
(2005)
4
Garon et. al.
(2007)
2
234
Acute rehab
20
Stroke
rehabilitation
Free Water Protocol: CAT

In patients with dysphagia, what are the benefits
and complications of implementing the Free
Water Protocol?
Four studies using a free water protocol with medically stable participants in
the rehabilitation and residential aged care settings found nil evidence of
adverse events while benefits such as increased fluid intake and
improved quality of life measures were indicated. Due to methodological
limitations of the study involving acute patients, there is insufficient
evidence to support the use of the Free Water Protocol in acute settings.
Free Water Protocol: Clinical Applications
Importance or oral hygiene
 Considering your site when implementing the
protocol
 Considering patients when implementing the
protocol
 The need for MBS

sEMG: Clinical Question

Does sEMG change outcomes for patients with
dysphagia in stroke or head and neck disease?
sEMG: What is it?

Biofeedback
- The use of equipment to measure body functions that
are not monitored consciously.

sEMG (surface Electromyography)
- Biofeedback device that evaluates the electrical
activity produced by muscles through electrodes
placed on the skin.
sEMG CAPs

Crary, M.A., Giselle, D., Carnaby, M., Groher, M.E., & Helseth, E. (2004).
Functional benefits of dysphagia therapy using the adjunctive sEMG
biofeedback. Dysphagia,

Huckabee, M.L. & Cannito, M.P. (1999). Outcomes of swallowing
rehabilitation in chronic brainstem dysphagia: A retrospective evaluation.
Dysphagia,

Newlove, S. (2006). A case study examining the effectiveness of surface
electromyography biofeedback in dysphagia rehabilitation and
SWAL_QOL quality of life outcome measure. (Research Project,
University of Auckland).

Crary, M.A. (1995). A direct intervention program for chronic neurogenic
dysphagia secondary to brainstem stroke. Dysphagia, 10:6-8.

Crary, M.A., & Baldwin, B.O. (1997). Surface electromyographic
characteristics of swallowing in dysphagia secondary to brainstem stroke.
Dysphagia,
sEMG CAP summary
Article
Level
Participant
Method
Outcome
measures
Results
Support
Crary et. al.
(2004)
4
45 – total
Retrospective outcome
study
FOIS
Stroke Improved
Yes for stroke
25 – stroke
20 H & N
# Rx sessions
Cost benefit
Huckabee &
Cannito
(1999)
4
Bryant (1991)
4
Newlove
(2006)
10 brainstem
CVA
Retrospective outcome
study
MBS (Pre & Post)
Oral intake scale
No for H & N
More Rx
Beneficial
Improved by 1
point
Yes
Improved by 4
points
4
1H&N
1 CVA
Case study of therapy
outcomes
Case study of therapy
outcomes
Descriptive
swallowing
outcomes
Improved
secretions
MBS (Pre & Post)
No sig.
difference
Diet progress
Swal-QoL
Yes
Commenced
intake
Yes
Improved diet
Sig.
improvement
for patient not
carer
Crary et. al.
(2004)
4
45 – total
25 – stroke
20 H & N
Retrospective outcome
study
FOIS
# Rx sessions
Cost benefit
Stroke Improved
More Rx
Beneficial
Yes for stroke
No for H & N
sEMG: CAT

Does sEMG change outcomes for patients with
dysphagia in stroke or head and neck disease?
The effectiveness of sEMG biofeedback in improving outcomes for patients
with stroke or head and neck disease is not clear. Currently the evidence
is limited and methodologically diverse but does indicate possible benefits
for sEMG as an adjunct to swallowing therapy in these populations.
Further research comparing traditional dysphagia therapy, with
traditional dysphagia plus sEMG biofeedback will be required before
definitive and reliable conclusions can be made.
sEMG: Clinical Applications
Stronger evidence for use in stroke population
than H & N population although documented
benefits in both.
 Can be useful tool for carefully selected
patients to add to their therapy program.
 Adjunct to dysphagia therapy.
 sEMG does not replace therapy!

What’s next for the adult swallowing EBP
Group?
Brand new CATs for 2012 – watch the EBP
website.
 Brand new leaders for 2012:
- Rosanne Russell:
[email protected]
- Eryka Arteaga
[email protected]

Acknowledgements

Thank you to all the hard working Adult
Swallowing EBP group members.
References

Carlaw, C., Finlayson, H., Beggs,K., Visser, T., Marcoux, C., Coney, D. & Steele, C.M. (2011) Outcomes of
a pilot water protocol project in a rehabilitation setting. Dysphagia (published on-line).

Crary, M.A., Giselle, D., Carnaby, M., Groher, M.E., & Helseth, E. (2004). Functional benefits of dysphagia
therapy using the adjunctive sEMG biofeedback. Dysphagia,

Crary, M.A., & Baldwin, B.O. (1997). Surface electromyographic characteristics of swallowing in dysphagia
secondary to brainstem stroke. Dysphagia,

Crary, M.A. (1995). A direct intervention program for chronic neurogenic dysphagia secondary to
brainstem stroke. Dysphagia, 10:6-8.

Garon, B., Engle, M., & Ormiston, C. (1997). A randomised control study to determine the effects on
unlimited oral intake of water in patients with identified aspiration. Journal of Neurological Rehabilitation,
11: 139-148.

Huckabee, M.L. & Cannito, M.P. (1999). Outcomes of swallowing rehabilitation in chronic brainstem
dysphagia: A retrospective evaluation. Dysphagia,

Karagianis, M.J.P., Chivers, L., Karagianis, C. (2011). Effects or oral intake of water in patients with
oropharyngeal dysphagia. BMC Geriatrics, 11:9.

Langmore, S.E., Terpenning, M.S., Shork, A., Chen, Y., Murray, J.T., Lopatin, D., Loeshe, W.J. (1998).
Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia, 13: 69-81.

Panther, K. (2005). The Frazier Free Water Protocol. Swallowing and Swallowing Disorders, March:4-9.

Newlove, S. (2006). A case study examining the effectiveness of surface electromyography biofeedback in
dysphagia rehabilitation and SWAL_QOL quality of life outcome measure. (Research Project, University
of Auckland).

Scott, A., & Benjamin, L. (2010). Implementation of a free fluid protocol in an aged care facility. In
Roddam, H., & Skeat, J. (eds). Embedding evidence based practice in speech and language therapy. West
Sussex: Wiley-Blackwell.