Implementation of the VA Intensive Dysphagia Treatment Program: A Mixed-Methods Evaluation.

The Department of Veterans Affairs (VA) Intensive Dysphagia Treatment program serves a critical role in facilitating improvements to quality of care, standardization of outcomes, and increased access to structured therapy for Veterans with dysphagia. It has been implemented at 26 sites nationally and continues expanding. An explanatory sequential mixed-methods design was utilized for program evaluation to identify barriers and facilitators to implementation as reported by speech-language pathologists (SLPs) participating in the program. All 23 IDT program SLPs were invited to participate in an online survey. SLPs were asked to describe etiologies referred for SLP evaluation, most and least clinically useful program aspects, and characteristics of patients recommended for therapy. Qualitative interviews/focus groups were then conducted with 9 SLPs at 3 facilities with varying levels of program experience. Transcripts underwent systems engineering framework informed deductive thematic analysis. Interview/focus groups revealed overall positive feedback. Barriers included data entry challenges and provider understanding of long-term program goals, while facilitators included program structure enabling increased patient follow-up, outcomes tracking, and training in new treatment modalities. Through this evaluation process, program leadership garnered actionable feedback to improve further implementation of the IDT program. Ongoing efforts will further improve data entry, site onboarding procedures, and program communication.

Evaluation and Treatment of Mild Traumatic Brain Injury Through the Implementation of Clinical Video Telehealth: Provider Perspectives From the Veterans Health Administration.

BACKGROUND: Substantial numbers of U.S. military veterans who served in recent conflicts experience mild traumatic brain injury. Data suggest that as many as 25% of veterans do not have a comprehensive traumatic brain injury evaluation to determine a diagnosis and develop a plan to treat symptoms. Technologies like clinical video telehealth offer a potential means to overcome travel distance and other barriers that can impact veteran receipt of a comprehensive traumatic brain injury evaluation after a positive screening; however, little is known about implementing clinical video telehealth in this context. OBJECTIVE: To examine the perspectives of Veterans Health Administration health care providers on implementing clinical video telehealth technology for the assessment and treatment of mild traumatic brain injury among veterans of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn. DESIGN: Qualitative; semistructured interviews. SETTING: Veterans Health Administration Polytrauma System of Care. PARTICIPANTS: Twenty-six providers who participated in a Veterans Health Administration Rehabilitation and Prosthetic Services Teleconsultation Pilot Project for administering comprehensive traumatic brain injury evaluations over clinical video telehealth. METHODS: Semistructured interviews that used content-analytic techniques to assess provider experiences implementing clinical video telehealth for veterans with traumatic brain injury, including inhibiting factors and best practices to administer comprehensive traumatic brain injury evaluations. RESULTS: The most commonly reported inhibiting factors to implementing clinical video telehealth for traumatic brain injury evaluation and treatment included scheduling, setting up the clinic, and conducting physical examinations over a virtual modality. To enhance clinical video telehealth implementation, participants described best practices including establishing solid communication and relationships with staff, building rapport with patients, and recognizing the unique needs of patients with traumatic brain injury. CONCLUSIONS: Implementing clinical video telehealth programs involves coordinating multiple steps with providers at different sites, highlighting the need for effective communication. Provider-patient communication also emerged as vital to successful clinical video telehealth implementation. These findings suggest that providers would benefit from efforts to build communication competencies. LEVEL OF EVIDENCE: Not applicable.

Evidence-based systematic review: Oropharyngeal dysphagia behavioral treatments. Part I--background and methodology.

Evidence-based systematic reviews (EBSRs), in conjunction with clinical expertise and client values, are invaluable tools for speech-language pathologists and audiologists. This article provides an overview of the levels-of-evidence scheme used by the American Speech-Language-Hearing Association (ASHA) to conduct systematic reviews. The goal of ASHA reviews is to provide a tool to help clinicians determine the best treatment course for their clients. We present a collaborative project between ASHA's National Center for Evidence-based Practice in Communication Disorders and the Department of Veterans Affairs (VA) that examined seven behavioral swallowing treatments for disordered and nondisordered populations. The methodology used in a series of reviews conducted by ASHA and the VA will be discussed, including the development of clinical questions, search parameters, inclusion/exclusion criteria, and literature search results. Findings from the series of reviews as well as the practical applications of EBSRs will be reported in subsequent articles in this series.

Evidence-based systematic review: Oropharyngeal dysphagia behavioral treatments. Part II--impact of dysphagia treatment on normal swallow function.

This article is the second in a series of evidence-based systematic reviews. Data reported cover the impact of dysphagia behavioral interventions on swallow physiology in healthy adults. The behavioral treatments investigated were three postural interventions--side lying, chin tuck, and head rotation--and four swallowing maneuvers--effortful swallow, the Mendelsohn maneuver, supraglottic swallow, and super-supraglottic swallow. A systematic search of the dysphagia literature was conducted in 14 electronic databases. Seventeen studies meeting the inclusion criteria were evaluated for methodological quality with the American Speech-Language-Hearing Association's levels-of-evidence scheme and were characterized by research stage (i.e., exploratory, efficacy, effectiveness, cost-benefit/public policy research). Effect sizes were calculated when possible. All studies were exploratory research ranging from two to five of seven possible quality markers. The majority of studies (8 of 17) investigated effortful swallow. Three studies examined the Mendelsohn maneuver, chin tuck, supraglottic swallow, and super-supraglottic swallow and two studies addressed head rotation. No study addressed side lying. For non disordered populations, the existing evidence demonstrates differential effects of postural changes and maneuvers on swallowing physiology. Some effects reinforced existing recommendations for the applications of the interventions, while others suggested new ways that the treatments may impact swallow function. Avenues for future research are suggested.

Evidence-based systematic review: Oropharyngeal dysphagia behavioral treatments. Part III--impact of dysphagia treatments on populations with neurological disorders.

This evidence-based systematic review (EBSR) is part of a series of reviews examining the state of the research regarding behavioral interventions for dysphagia. This EBSR focuses primarily on dysphagia secondary to neurological disorders (e.g., brain injury, stroke, Parkinson's disease, and dementia). The seven behavioral treatments investigated were three postural interventions (side lying, chin tuck, and head rotation) and four swallowing maneuvers (effortful swallow, Mendelsohn, supraglottic swallow, and super-supraglottic swallow). We systematically searched the dysphagia literature from March 2007 to April 2008 using 14 electronic databases. Seven studies met the inclusion and exclusion criteria and were evaluated for methodological quality and stage of research. Of the included studies, only two were judged to be efficacy research; the remaining five were considered exploratory. Methodological quality of studies ranged from one to seven out of eight possible quality markers. Five of seven treatment interventions were addressed by at least one study. No studies were found to address the effortful swallow or the super-supraglottic swallow. Currently, limited evidence from seven studies shows the potential effects of dysphagia behavioral interventions for select groups of individuals with neurologically induced dysphagia. Further research is needed to evaluate the effectiveness of these and the remaining interventions with various populations with neurological disorders.

Evidence-based systematic review: Oropharyngeal dysphagia behavioral treatments. Part IV--impact of dysphagia treatment on individuals' postcancer treatments.

This evidence-based systematic review (EBSR) is part of a series of reviews investigating swallowing behavioral treatments for individuals with dysphagia. This EBSR focuses primarily on individuals with dysphagia postcancer treatments. The seven behavioral interventions under review included three postural interventions (side lying, chin tuck, and head rotation) and four swallowing maneuvers (effortful swallow, Mendelsohn, supraglottic swallow, and super-supraglottic swallow). We systematically searched the dysphagia literature from March 2007 to April 2008. Six studies that met the inclusion and exclusion criteria were evaluated for methodological quality and characterized by research stage. Effect sizes were calculated when possible. All studies included were considered exploratory, with quality-marker scores ranging from 1 to 4 out of 7 possible markers. Five studies examined one or more of the four swallowing maneuvers, and one study addressed the chin-tuck posture. No studies addressed side lying or head rotation. Currently, limited evidence exists from six studies showing the positive effects of behavioral swallowing interventions for populations with structural disorder. Because of the range of structural deficits resulting from cancers and their treatments, further research is needed that evaluates specific intervention effectiveness.

Evidence-based systematic review: Oropharyngeal dysphagia behavioral treatments. Part V--applications for clinicians and researchers.

Evidence-based practice (EBP) involves the integration of three essential principles: (1) the current best available research, (2) the clinician's experience and expertise, and (3) the patient's values and preferences. This report is the last in a series that presents the culmination of a collaborative effort between the American Speech-Language-Hearing Association and the Department of Veterans Affairs to examine the state of the evidence on seven behavioral swallowing interventions. This article addresses how speech-language pathologists treating individuals with oropharyngeal dysphagia can incorporate EBP into their clinical decision-making process. A fictitious patient scenario is presented and discussed as an example of the clinical application of the findings from the three systematic reviews in this series on evidence for the use of behavioral swallowing interventions. Also, recommendations for researchers studying dysphagia treatment are discussed, with the overall goal of facilitating the generation of a stronger evidence base for clinicians.

Neuroplasticity and rehabilitation research for speech, language, and swallowing disorders.

PURPOSE: This article introduces a collection of consensus statements regarding the application of neuroplasticity principles to rehabilitation of dysphagia, dysarthria, apraxia, and aphasia.

Swallowing and dysphagia rehabilitation: translating principles of neural plasticity into clinically oriented evidence.

PURPOSE: This review presents the state of swallowing rehabilitation science as it relates to evidence for neural plastic changes in the brain. The case is made for essential collaboration between clinical and basic scientists to expand the positive influences of dysphagia rehabilitation in synergy with growth in technology and knowledge. The intent is to stimulate thought and propose potential research directions. METHOD: A working group of experts in swallowing and dysphagia reviews 10 principles of neural plasticity and integrates these advancing neural plastic concepts with swallowing and clinical dysphagia literature for translation into treatment paradigms. In this context, dysphagia refers to disordered swallowing associated with central and peripheral sensorimotor deficits associated with stroke, neurodegenerative disease, tumors of the head and neck, infection, or trauma. RESULTS AND CONCLUSIONS: The optimal treatment parameters emerging from increased understanding of neural plastic principles and concepts will contribute to evidence-based practice. Integrating these principles will improve dysphagia rehabilitation directions, strategies, and outcomes. A strategic plan is discussed, including several experimental paradigms for the translation of these principles and concepts of neural plasticity into the clinical science of rehabilitation for oropharyngeal swallowing disorders, ultimately providing the evidence to substantiate their translation into clinical practice.