Methods: Medical records, primary caregiver report, and clinical assessment were used to compile detailed case histories and assess current dysphagia and feeding skills.
Results: Both cases demonstrated heterogeneous oral motor and feeding outcomes, including delayed oral motor skills, restricted dietary variety, and difficult mealtime behaviors that contributed to protracted recovery of age-appropriate PO intake. Both children required ongoing diet and/or fluid modification and supplemental non-PO feeding via gastrostomy at the time of review, that is, 2-year post-injury.
Conclusions: Recovery from dysphagia post-alkali ingestion is protracted and complex. Dysphagia, delayed oral motor skills, and difficult mealtime behaviors may persist secondary to ingestion injury and its associated complications. These cases highlight the importance of considering early referral for feeding assessment and intervention to assist children and families with recovery. Progression through safe and effective oral (per os, PO) intake is needed, as well as provision of support for primary caregivers.
- Implications for Rehabilitation
Pediatric chemical ingestion injury can cause long-term dysphagia and long-term feeding difficulties
Initial injury severity does not reliably correlate with eventuating level of aerodigestive impairment.
Clinical and instrumental assessment is required to monitor swallow function to enable commencement of targeted rehabilitation when appropriate.
Early involvement of a feeding therapist is recommended to minimize the long-term effects on oral motor skill development, progression to age-appropriate diet, and provision of family-centered care.
Method: Studies published from 1 January 1990 to 19 July 2016 were identified using Medline, Cinahl, PsycINFO, Web of Science, email requests and cross citations. Studies were reviewed narratively in relation to identified themes.
Results: A total of 35 studies were included in the review. Themes identified were as follows: health conditions associated with dysphagia; mortality; health service use; practice and knowledge in supporting people with intellectual disabilities and dysphagia; intervention effectiveness and quality of life. Dysphagia is associated with respiratory infections and choking and may be under-recognised. Silent aspiration is common and may go unnoticed. Management practices exist, but there are few intervention studies and no randomised controlled trials (RCTs), and hence, the effectiveness of these is currently unclear.
Conclusion: Dysphagia is a key concern in relation to people with intellectual disabilities. There is urgent need for research on the management of dysphagia in people with intellectual disabilities, including mealtime support offered, positioning, dietary modification and impact on wellbeing.
- Implications for Rehabilitation
Dysphagia is common in people with intellectual disabilities, associated with serious health risks and may be under-recognised.
Caregivers of people with intellectual disabilities should be educated about dysphagia.
There is an urgent need for research on improving the management of dysphagia in people with intellectual disabilities.
Improved recognition and management of dysphagia may reduce the occurrence of associated health conditions and reduce hospital admissions and premature death in people with intellectual disabilities.
Methods: This algorithm is based on 30 years of clinical experience with DMD in a specialised Centre for Neuromuscular Disorders (Inkendaal Rehabilitation Hospital, Belgium) and is supported by literature where available.
Results: Dysphagia can worsen the condition of ageing patients with DMD. Apart from the difficulties of chewing and oral fragmentation of the food bolus, dysphagia is rather a consequence of an impairment in the pharyngeal phase of swallowing. By contrast with central neurologic disorders, dysphagia in DMD accompanies solid rather than liquid intake. Symptoms of dysphagia may not be clinically evident; however laryngeal food penetration, accumulation of food residue in the pharynx and/or true laryngeal food aspiration may occur. The prevalence of these issues in DMD is likely underestimated.
Conclusions: There is little guidance available for clinicians to manage dysphagia and improve feeding for young men with DMD. This report aims to provide a clinical algorithm to facilitate the diagnosis of dysphagia, to identify the symptoms and to propose practical recommendations to treat dysphagia in the adult DMD population.
- Implications for Rehabilitation
Little guidance is available for the management of dysphagia in Duchenne dystrophy.
Food can penetrate the vestibule, accumulate as residue or cause aspiration.
We propose recommendations and an algorithm to guide management of dysphagia.
Penetration/residue accumulation: prohibit solid food and promote intake of fluids.
Aspiration: if cough augmentation techniques are ineffective, consider tracheostomy.
Method: Initially, a pilot study was conducted to investigate the feasibility of ultrasound visual feedback during swallow tasks. The protocol was then replicated using a single-case experimental designed study to investigate therapeutic effect. Swallow, speech, and oromotor functions were measured across multiple baselines using an A-B-A intervention study design.
Results: During intervention, both participants were able to interpret ultrasound tongue images during swallow tasks. Following intervention, positive therapeutic effect was achieved with reduced frequency of aspiration and self-initiated swallow strategies. Generalization of intervention was evidenced by reduced bolus transit duration on videofluoroscopy and improved functional oral intake scores. Speech and oromotor functions remained stable throughout the study demonstrating experimental control.
Conclusions: This study establishes that ultrasound visual feedback is feasible in dysphagia rehabilitation following partial glossectomy. In addition, the predicted therapeutic effect specifically to swallow but not speech or oromotor functions were demonstrated.
- Implications for Rehabilitation
Partial glossectomy results in altered tongue shape, movement, and function which negatively impact on speech and swallowing
There is limited research evidence to support previously used speech pathology interventions (in particular, tongue range of movement exercises) to rehabilitate dysphagia following tongue cancer surgery
The tongue, and hence oral phase of swallowing, can be viewed by placing an ultrasound probe under the chin
Ultrasound scanning of the tongue is not invasive, can be repeated without dosage side effect. It’s also comfortable for the patient and if a portable probe and monitor are used, can be performed within a variety of clinical settings for assessment or therapy
This study shows specific therapeutic benefit following ultrasound visual feedback along with a motor learning approach to rehabilitate swallow function following partial glossectomy
Visual and verbal feedback that focus specifically on the motor movements undergoing adaptation (e.g., tongue wave movement, tongue elevation, bolus clearance) following partial glossectomy are recommended
Patients who are able to see the ultrasound monitor, hear the feedback given, are cognitively able to self-evaluate tongue movement, and remember intervention goals will most benefit from ultrasound tongue visual feedback in therapy
Clinicians also benefit from visualizing the tongue with ultrasound during assessment and therapy as a direct view reduces the subjectivity of rating task performance
Method: Published autobiographies narrating the author’s experiences of living with dysphagia following stroke were sourced. Ten autobiographies were retrieved and the texts were manually inspected. All references to eating, drinking and swallowing were extracted and pooled to form the data set. A qualitative approach using a six-step interpretive phenomenological analysis process was taken to analyze this data set.
Results: A wide range of interconnected themes emerged from the data, allowing further synthesis into six overarching super-ordinate themes. These six super-ordinate themes were: “physical consequences of dysphagia”; “process of recovery”; “coping and adjusting”; “changed relationships”; “society” and “control”.
Conclusions: This study highlights the unique contribution of autobiographical accounts in developing our understanding of living with dysphagia following stroke. The findings emphasize the significant emotional and social impact of dysphagia during the stroke recovery process and add further depth to our understanding of the experience of this clinical group.
- Implications for Rehabilitation
Autobiographical accounts often hold valuable first-hand information on patient perspectives and journeys, which when viewed through the eyes of a qualitative researcher, can add depth to our understanding of particular healthcare experiences.
Persons who experience dysphagia as a result of stroke travel a complex rehabilitation journey, involving the interaction of many physical, emotional and social considerations.
Healthcare professionals should be aware of not only the physical, but also the significant psychosocial consequences of living with dysphagia following stroke.
Further research is required in this field, so that the experiences of these persons can be better understood and findings can be used to contribute to high-quality and evidence-based service delivery.
Methods: Four major databases (PubMed, CINAHL, Cochrane Library and PsycINFO) were systematically searched from inception to September 2016 for qualitative studies that reported findings on the impact of primary brain tumor on social networks during adulthood. Twenty-one eligible studies were identified and appraised according to the Consolidated Criteria for Reporting Qualitative Research. Key findings of these studies were integrated to form superordinate themes.
Results: The metasynthesis revealed the core themes of: 1) Life disrupted; 2) Navigating the new reality of life; and 3) Social survivorship versus separation.
Conclusions: Multiple changes typically occur across the social trajectory of brain tumor, including a loss of pre-illness networks and the emergence of new ones. Understanding the barriers and facilitators for maintaining social connection may guide interventions for strengthening social networks and enhancing well-being in the context of brain tumor.
- Implications for rehabilitation
Social networks and roles are disrupted throughout the entire trajectory of living with brain tumor
Physical, cognitive and psychological factors represent barriers to social integration
Barriers to social integration may be addressed by supportive care interventions
Compensatory strategies, adjusting goals and expectations, educating friends and family and accepting support from others facilitate social reintegration throughout the trajectory of living with brain tumor
Method: Twenty-two participants including 16 rehabilitation clinicians and 6 persons living with a disability participated in four nominal group sessions. Participants were questioned on current or potential rehabilitation strategies carried out to enhance participation in shopping malls for persons living with a disability. Discussions were audio-recorded and qualitative content analysis was conducted.
Results: Participants mentioned strategies that were either carried out by the clinician, or in collaboration with other parties. The latter type of strategies was either carried out with the collaboration of the client, the interdisciplinary team, the relatives, or community organizations.
Conclusions: Rehabilitation clinicians have a role to play in preparing persons living with a disability to resume activities in a shopping mall. Additionally, therapeutic interventions in community settings may enhance the participation of rehabilitation clients in their everyday activities.
- Implications for rehabilitation
Many strategies are currently used in rehabilitation to prepare persons living with a disability to resume shopping activities.
Clinicians could implement shopping-oriented rehabilitation strategies with the client and/or with other rehabilitation partners.
Involving clients in activities related to shopping might enhance their participation in shopping malls after rehabilitation.
Rehabilitation clinicians can be facilitators for people living with a disability to reach optimal participation.
Design: We conducted focus groups (FGs) with 17 GPs.
Setting: Norwegian primary health care.
Subjects: 17 GPs who attended a 5 d course on leadership in primary health care.
Results: Our study suggests that the GPs experience a need for more preparation and formal training for the leadership role, and that they experienced tensions between the clinical and leadership role. GPs recognized the need to take on leadership roles in primary care, but their lack of leadership training and credentials, and the way in which their practices were organized and financed were barriers towards their involvement.
Conclusions: GPs experience tensions between the clinical and leadership role and note a lack of leadership training and awareness. There is a need for a more structured educational and career path for GPs, in which doctors are offered training and preparation in advance.
- KEY POINTS
Little is known about doctors’ experiences and views about leadership in general practice and primary health care. Our study suggests that:
There is a lack of preparation and formal training for the leadership role.
GPs experience tensions between the clinical and leadership role.
GPs recognize leadership challenges at a system level and that doctors should take on leadership roles in primary health care.
Design: Secondary analysis of cross-sectional data from the 2014 Commonwealth Fund International Health Policy Survey of Older Adults.
Setting: 11 western countries.
Subjects: Community-dwelling adults, aged 55 or older.
Main outcome measure: Assessment of goals and priorities.
Results: The final sample size consisted of 17,222 respondents, 54% of whom reported an assessment of their goals and priorities (AGP) by healthcare professionals. In logistic regression model 1, which was used to analyse the entire population, the determinants found to have moderate to large effects on the likelihood of AGP were information exchange on stress, diet or exercise, or both. Country (living in Sweden) and continuity of care (no regular professional or organisation) had moderate to large negative effects on the likelihood of AGP. In model 2, which focussed on respondents who experienced continuity of care, country and information exchange on stress and lifestyle were the main determinants of AGP, with comparable odds ratios to model 1. Furthermore, a professional asking questions also increased the likelihood of AGP.
Conclusions: Continuity of care and information exchange is associated with a higher probability of AGP, while people living in Sweden are less likely to experience these assessments. Further study is required to determine whether increasing information exchange and professionals asking more questions may improve goal setting with older patients.
- Key points
A patient goal-oriented approach can be beneficial for older patients with chronic conditions or multimorbidity; however, discussing goals with these patients is not a common practice.
The likelihood of discussing goals varies by country, occurring most commonly in the USA, and least often in Sweden.
Country-level differences in continuity of care and questions asked by a regularly visited professional affect the goal discussion probability.
Patient characteristics, including age, have less impact than expected on the likelihood of sharing goals.
Method: The paper uses vignettes to illustrate attention in patient-practitioner interaction.
Results: Attention is a precursor to understanding the patient as a unique individual and the problems the patient brings to the therapy experience.
Conclusions: The capacity of practitioners to attend to their patients has an impact on patient satisfaction and recovery.
- Implications for Rehabilitation
Attention is the precursor to establishing positive therapeutic alliances with patients.
It is essential to attend to the patient as a person with unique experiences, perspectives, and attitudes and to modify treatment based on the person’s priorities and desires.
Practitioners need to develop the interaction skills necessary to understand their patients as unique individuals.
Design: Cross-sectional method comparison study.
Setting: From April 2014 to February 2015, we included patients coming to the general practice clinic “Lægerne Sløjfen”, Aalborg, Denmark for a routine ECG. Patients with severe dementia, mental illness or poor ECG readings were excluded. After oral and written informed consent an ECG and PEM recordings were obtained simultaneously. The PEM recordings were analyzed by two general practitioners (GPs) in training and ECG recordings were evaluated by a senior GP and a cardiologist. Both the PEM and the ECG recordings were analysed blinded.
Subjects: Ninety-three patients were included and four were excluded due to poor ECG readings.
Main outcome measures: The sensitivity and specificity of PEM compared to a standard 12-lead ECG.
Results: Eighty-nine of the 93 (95.7%) patients had ECGs of a satisfactory technical quality and were included in the study. The sensitivity of diagnosing AF by PEM recordings was 86.7% and the specificity was 98.7% when compared to a 12-lead ECG. According to the cardiologist, the misclassification of three PEM recordings were due to interpretation errors and not related to the PEM recording per se.
Conclusions: The inexpensive portable PEM device recording diagnosed AF with a high sensitivity and specificity.
- KEY POINTS
Simple ECG monitors could be useful to identify atrial fibrillation and thereby lead to a better prevention of stroke.
The PEM device was easy to use and 95.7% of the recordings were technically acceptable for detecting atrial fibrillation.
The PEM device has a high sensitivity and specificity in detecting atrial fibrillation compared to a standard 12-lead ECG.
Further studies should evaluate the clinical usefulness of the PEM device, e.g. to detect intermittent atrial fibrillation.
Design: A prospective, multicenter inception cohort of 133 adult patients in the Paris area (France) who had received a severe traumatic brain injury were followed up postinjury at one and four years. Sociodemographic data, factors related to injury severity and one-year functional and cognitive outcomes were prospectively collected.
Methods: The main outcome measure was employment status. Potential predictors of employment status were assessed by univariate and multivariate analysis.
Results: At the four-year follow-up, 38% of patients were in paid employment. The following factors were independent predictors of unemployment: being unemployed or studying before traumatic brain injury, traumatic brain injury severity (i.e., a lower Glasgow Coma Scale score upon admission and a longer stay in intensive care) and a lower one-year Glasgow Outcome Scale–Extended score.
Conclusion: This study confirmed the low rate of long-term employment amongst patients after a severe traumatic brain injury. The results illustrated the multiple determinants of employment outcome and suggested that students who had received a traumatic brain injury were particularly likely to be unemployed, thus we propose that they may require specific support to help them find work.
- Implications for rehabilitation
Traumatic brain injury is a leading cause of persistent disablity and can associate cognitive, emotional, physical and sensory impairments, which often result in quality-of-life reduction and job loss.
Predictors of post-traumatic brain injury unemployment and job loss remains unclear in the particular population of severe traumatic brain injury patients.
The present study highlights the post-traumatic brain injury student population require a close follow-up and vocational rehabilitation.
The study suggests that return to work post-severe traumatic brain injury is frequently unstable and workers often experience difficulties that caregivers have to consider.
Design: A historical population-based cohort study.
Setting: The Danish CRC screening programme and general practice.
Subjects: The 376,198 individuals invited to the Danish CRC screening programme from 1 March to 31 December 2014.
Main outcome Measures: The diagnostic activity (consultations and haemoglobin measures) in general practice in the year preceding the screening invitation and the cumulated incidence of CRC in the year following the screening invitation.
Results: Screening participants had significantly higher diagnostic activity than non-participants. Individuals with a positive faecal immunochemical test (FIT) had higher diagnostic activity compared to individuals with a negative FIT, and a small increase in the months leading up to the invitation. Individuals with a screen-detected CRC had lower diagnostic activity than individuals with no CRC. In total, 308 (25.3%) of CRCs diagnosed in the invited population were diagnosed outside the screening programme. Non-participants with CRC more often had low socio-economic status, high comorbidity and stage IV CRC than participants with CRC.
Conclusions: There was a tendency that participants and those with a positive FIT had a higher diagnostic activity the year before the screening. This was not seen for those with CRC detected through screening. CRC must still be diagnosed in general practice in the invited population and non-participants are of special interest as they have higher risk of late stage CRC.
- Key Points
Current awareness:Individuals with colorectal cancer (CRC) in screening may be symptomatic and CRC may still occur outside screening in the invited population.
Most important points:The majority of individuals with CRC in screening cannot be expected to be diagnosed on symptomatic presentation in general practice
GPs have to be aware that CRC still occurs outside screening in the invited population
Non-participants with CRC are often deprived and have late stage CRC
Method: A narrative review was completed regarding integrative intervention that could potentially apply to aphasia population.
Results: Through this article we have explored various treatment options for integrative health care in aphasiology. Integrative treatments including brain specific antioxidants, progesterone and estradiol therapy, nutrition, synbiotic treatment, exercise, yoga, meditation and positive mood states have demonstrated positive changes in health and behavior in healthy aging or disorders such as stroke and aphasia. Offering integrative treatment for people with aphasia allows potential for high impact gains when combined with current speech language therapeutic practices.
Conclusion: This paper highlights the rehabilitation possibilities for aphasia therapy. Combining complementary and traditional treatment approaches could be viewed as one of the contemporary approaches to clinical practice and research for practitioners and health care systems.
- Implications for Rehabilitation
There has been very little research that explores the potential of various types of integrative treatment for individuals with aphasia.
An integrative approach to the treatment of aphasia has potential for future clinical application.
Combining treatment approaches could be viewed as a viable approach to clinical practice and in the health care system.
Method: An uncontrolled pre- and post-assessment design was employed to study the use of unmodified, low-cost, off-the-shelf smartphones combined with Internet-calendars as a compensatory memory strategy in community-dwelling patients with traumatic brain injury. Thirteen participants received a 6-week group-based intervention with pre-, post- and 2-month follow-up-assessments by questionnaires and by daily assessment of target behaviors for 2-week periods.
Results: Participants reported significantly fewer retro- and prospective memory problems on questionnaires after the intervention and at follow-up with large effect sizes. The performance of target behaviors, however, improved insignificantly with moderate effect sizes. There were no changes in quality of life or symptoms of emotional distress.
Conclusions: This study adds to a growing body of evidence that smartphones are a useful compensatory aid in rehabilitation of prospective memory that should routinely be considered in rehabilitation of traumatic brain injury patients.
- Implication for rehabilitation
Smartphones are easy-to-use and accessible assistive technology for compensatory memory rehabilitation to most traumatic brain injury patients.
By using low-cost, off-the-shelf devices, the technology becomes available to a broader range of patients.
By combining smartphones with Internet-based and cross-platform services (e.g., calendars, contacts) the participants are less device-dependent and less vulnerable to data loss.
Smartphones should routinely be considered as compensatory aid in rehabilitation of prospective memory of traumatic brain injured patients.
Objective: To examine the associations between patients’ self-rated health and their sleep problems, somatic health complaints, and unmet needs in interpersonal relationships.
Design: We collected data via questionnaires for this cross-sectional study from general practice.
Setting: Primary health care in Norway.
Subjects: 1302 consecutive patients participated.
Main outcome measures: The questionnaire included a single question about SRH, the Bergen Insomnia Scale (BIS), five questions on somatic health complaints, and three questions from the Basic Psychological Needs Scale (BPNS) pertaining to the relationships domain. We analyzed our data using ordinal logistic regression models.
Results: Our response rate was 74%. The prevalence of fair/poor SRH was 26%, with no gender differences. We revealed a significant association between increasing age and reduced SRH. The study showed that sleep problems and somatic health complaints were strongly associated with SRH, and unmet needs in relationships were also significantly and independently associated with reduced SRH in a full model analysis.
Conclusion: Sleep problems, somatic health complaints, and unmet needs in interpersonal relationships were all associated with reduced SRH. These factors are all modifiable and could be managed both within and outside a primary care setting in order to improve SRH.
- Key Points
There was a high prevalence of reduced SRH in clinical general practice
Sleep problems, somatic health complaints, and unmet needs in interpersonal relationships were all associated with reduced SRH
These predictors are all modifiable with a potential to improve SRH
Method: One hundred and sixty-six subjects with mild to moderate stroke were recruited and interviewed using the PS-SES. The principal axis factoring analysis was run to examine the factor structure, and internal consistency was assessed by computing Cronbach’s alpha coefficient.
Results: The final measure is a 35-item scale with six subscales: (1) managing home participation, (2) staying organized, (3) planning and managing community participation, (4) managing work/productivity, (5) managing communication, and (6) advocating for resources. The instrument demonstrated high internal consistency.
Conclusion: The PS-SES is a reliable measure offering unique information regarding self-efficacy in managing participation.
- Implications for Rehabilitation
Post-stroke participation requires complex management of resources, information, and strategies.
There is a gap in instruments that can assess self-efficacy in managing participation following a stroke.
The PS-SES is a valid tool measuring self-efficacy in using participation strategies in home, work, and community contexts.