1. Introduce the concept of how evidence-based practice guides treatment decisions. 2. Discuss general factors that influence therapy decisions. 3. Provide examples from the three major classes of therapeutic interventions for dysphagia. 4. Discuss how the evaluation results will affect treatment planning. 5. Present a decision tree for selecting and implementing dysphagia therapy. Assuming the clinician wants to review the evidence pertaining to a clinical question, the next step would be to consult relevant databases using key search terms that might help answer those questions. Terms such as “posture,” “swallowing,” “outcomes,” and “treatment” might be used in the initial search. Finding the relevant evidence can be accomplished by using databases such as MEDLINE or PubMed, or Web sites that summarize data such as the Cochrane Library or the American College of Physicians. Typing terms in a Web search such as “evidence based” and “clinical trials” can lead to other relevant databases. Government-based Web sites such as www.guideline.gov (National Guideline Clearinghouse) can be a useful starting point in an evidence-based search. If the search is directed toward a specific disease such as Parkinson’s, accessing a specific organization’s official Web site also is a valuable point of departure. Because the study’s design often determines the relative strength of the evidence, it is important to know what constitutes weak evidence for any given outcome and what constitutes stronger evidence for the same outcome. Table 12-1 presents a classification system for grading levels of evidence according to the study’s design characteristics. For instance, the highest level of evidence (grade A or 1) is associated with study designs that are randomized, controlled trials (RCTs). A lower grade (grade D or 5) is associated with studies that report on a series of patients. Investigators who use the RCT design to study a question are bound by much stricter criteria to answer their question. In general, these criteria try to eliminate any bias in the study that might shed doubt on the believability of the results. Some of these criteria include a large sample size in an experimental and control group with subjects assigned randomly, measurements made by investigators who are blinded to the study, and accounting for the outcomes of all study subjects at the end of the experiment. Study designs at levels B, C, and D may meet some of these criteria, but not all of them. The fewer criteria met, the weaker the evidence. In general, a clinician would have more confidence in studies graded at grade A than at grade D. Therefore the applicability of the findings from RCTs would be applied clinically with more confidence than findings from studies that reported on similar outcomes with a case series design. Such criteria can help the clinician decide which diagnostic or treatment approach might fit the patient and how much confidence to place in the outcome. An extensive discussion of each level of evidence and its corresponding characteristics is beyond the scope of this chapter. Readers are referred to The Handbook of Evidence-Based Practice in Communication Disorders for a thorough discussion.1 TABLE 12-1 Classification System for Grading Levels of Evidence RCT, Randomized controlled trial. Adapted from Oxford Centre for Evidence-Based Medicine, 2001. Beyond specific goals of treatment, clinicians must consider the nature of the swallowing deficit and the treatment options available to them and the patient (NOTE: these are not always the same). Box 12-1 summarizes some issues that might be addressed regarding the swallowing deficit. A basic question might revolve around feeding versus swallowing processes: Are there physical or cognitive factors that preclude successful feeding but that do not interfere with swallowing function? Are both of these factors present and, if so, do they interact in a positive or negative manner? Certain dysphagia-causing diseases might demonstrate differences between voluntary or involuntary motor processes. If differences are present, are there swallowing activities that may be used to tap into voluntary versus involuntary motor processes? Stage of deficit is an artificial delineation often used for convenience. Are the swallowing deficits primarily located within the oral, oropharyngeal, pharyngeal, or esophageal component? Clinicians must also remember that not only are these “stages” artificial, but that the swallowing mechanism is interactive—events occurring in one anatomic area have the potential to affect performance in another area (see Chapter 2). A difficult clinical task can be attempting to separate the specific swallowing deficit from any compensatory activities used by individual patients. For example, consider the patient who attempts to swallow but immediately begins to expectorate, or a patient who demonstrates a pattern of multiple, incomplete swallows interspersed with throat clearing, resulting in only a minute amount of material actually swallowed. Does this pattern reflect a specific pattern of impaired physiology? Does it reflect the presence of compensations intended to protect the airway, or are there other possibilities? In some cases, this distinction may not be important. However, in others, it may be important to understand what might be changed as a result of therapy versus what might not be changed. This consideration may affect the decision to engage in therapy and, if so, the direction of therapy. The severity of dysphagia is a more complex concept than might first be imagined. How is the severity of dysphagia graded? Some clinicians and investigators have used impairment of swallowing physiology based on instrumental examination,2 whereas others have used more functional measures such as amount of food or liquid taken by mouth.3,4 Some clinicians may believe that patients who take no food by mouth also have the poorest swallowing physiology. Unfortunately, this is not always the case. Patient status may change over time, and some patients who receive only nonoral feeding may actually have adequate swallowing physiology to ingest some food or liquid by mouth. Thus severity of dysphagia should not be considered a unitary concept because many factors are involved.
Treatment Considerations, Options, and Decisions
EVALUATING EVIDENCE
Evidence Grade
Level of Evidence
Type of Evidence
A
1a
Systematic review of RCTs
1b
Individual RCT
1c
All or none
B
2a
Systematic review of cohort studies
2b
Individual cohort study
2c
Outcomes research
3a
Systematic review of case-control studies
3b
Individual case-control study
C
4
Case series (and poor-quality case-control and cohort studies)
D
5
Expert opinion without critical appraisal or based on physiology or “first” principles
GENERAL TREATMENT CONSIDERATIONS
PATIENT-SPECIFIC TREATMENT
Treatment Considerations, Options, and Decisions
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