The role of occupational therapy in the management of feeding and swallowing disorders.
The role of occupational therapy in feeding and swallowing evaluation and treatment has declined over the past two decades. Up until late 1970s and early 1980s, in many parts of the Western world, occupational therapists conducted swallowing assessments and treatment in adult and pediatric populations. With the adoption of Modified Barium Swallow Study or Video-fluoroscopy as a diagnostic tool, feeding and swallowing assessment and treatment has predominantly become associated with speech and language pathology. This viewpoint article addresses the past, present, and future of occupational therapy's role in swallowing evaluation and feeding training of adult and pediatric populations.
Feeding, swallowing, Modified Barium Swallow Study (MBSS), Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
Paul, S., & D'Amico, M. (2013). The role of occupational therapy in the management of feeding and swallowing disorders. New Zealand Journal of Occupational Therapy, 62(2), 27 - 31.
The role of occupational therapy in feeding and swallowing evaluation and treatment has a long standing history but it has declined over the past two decades (AOTA, 2007, 2008). Although occupational therapists training and domain of concern are an ideal fit for feeding and swallowing evaluation and treatment, this role has largely been taken over by other professionals such as speech-language pathologists (SLP) and special education teachers (Gibbons, Williams, & Reigel, 2007; Williams, Witherspoon, Kavask, Patterson, & McBlain, 2006). The purpose of this paper is to reflect on the past, analyze the present and offer suggestions for the future of occupational therapy's role in the feeding and swallowing assessment and treatment of adult and pediatric populations.
Occupational therapy traditionally works with patients in a collaborative manner to facilitate independence and increase functional skills through 'patient--centered care' based on meaningful occupations. Feeding oneself is a basic activity of daily living (ADL), one which is addressed in numerous ways. For example, through sensorimotor training, proper body positioning and posture, adaptive equipment, body maneuvers, and swallowing techniques. Since eating is an essential and lifelong activity, occupational therapists work with patients with various disabilities and special needs from infancy through to older age.
Literature points to evidence that patients who are more independent in feeding skills have a healthier body weight, and suffer from fewer nutritional problems in comparison to those who are dependent on others to help them eat (Colonel et al., 2008; Poels, Brinkman-Zijlker, Dijkstra, & Postema, 2006). Lack of quality intervention in this human function can lead to long term problems resulting in higher healthcare costs. A study by Franklin and Rodger (2003) showed how feeding difficulties can also have a major effect on the patient's family, friends, and caregivers. Patients who received feeding retraining therapy improved in personal independence, and required less medical attention and fewer staff to meet their needs (Franklin & Rodger, 2003).
Dysphagia, the medical term for swallowing difficulties, affects a substantial number of adults and older populations. An estimated 15 million people in the United States alone have a current diagnosis of dysphagia and nearly 60,000 die each year from complications associated with feeding and swallowing disorders (Roy, Stemple, Merrill, & Thomas, 2007; Singh & Hamdy, 2008). People with stroke, traumatic brain injury, and other neuromuscular conditions tend to have a higher percentage of feeding/ swallowing difficulties than others and at meal time they often need some assistance with set up, positioning, assistive devices, and/or swallowing intervention involving musculature of tongue, face and neck (Porter et al., 2001). Some people require total assistance, such as tube feeding or a personal assistant (White et al., 2008). Furthermore, sometimes people with dementia and cognitive issues need feeding retraining or personal assistance, especially as cognition declines (Dolhi & Rogers, 2001).
Many different conditions such as cerebro-vascular accident (CVA), Parkinson's disease, Amyotrophic Lateral Sclerosis (ALS), Alzheimer's disease, and other neuromuscular conditions cause dysphagia. People with conditions such as arthritis involving the head and neck, chronic obstructive pulmonary disease (COPD), severe neck and back pain, and high level spinal cord injury (SCI) may show symptoms of dysphagia (Roy, et al., 2007). Many adults report that their quality of life has diminished due to feeding and swallowing dysfunction. For example, meals take longer to eat and require more effort. Being self conscious of their eating/feeding related problems can limit a persons' lifestyle and opportunities for social participation and enjoyment (Roy et al., 2007; Westergren, 2006). Adults experiencing dysphagia usually have a strong desire to regain normal or near normal function and with the help of a qualified multidisciplinary team, independence in self feeding can be attained. In this paper, the authors argue that occupational therapists should be an integral member of the multidisciplinary team. With an extensive knowledge of human function, ADL retraining, and a holistic approach to personal care occupational therapists are well qualified to assess and treat patients with feeding and swallowing dysfunction.
History and evolution of feeding and swallowing evaluation
The multidisciplinary study of 'swallowing and swallowing disorders' has evolved over the past thirty years, but the coordinated assessment and treatment of patients with swallowing disorders began in the late 1970s when the Modified Barium Swallow Study (MBSS) also sometimes called a Video-fluoroscopy was introduced. Up until that time, in many parts of the western world, occupational therapists were conducting swallowing assessments and treatment of adults and children. Since the introduction of MBSS, assessment and treatment has become predominantly associated with speech-language pathology. The reasons for this shift are not clear, but it can be assumed that knowledge of the anatomy and physiology of the aerodigestive tract is more advanced by virtue of the study of speech, language, and voice disorders (Palmer, Drennan, & Baba, 2000).
The MBSS, or swallow study, is a radiologic examination of swallowing function that uses a special movie-type x-ray called fluoroscopy. For that reason it is done collaboratively between a radiologist and speech-language pathologist. The speech pathologist directs the order and sequence of food or liquid trials given during the exam; the radiologist operates the fluoroscopy equipment, verifies the presence or absence of aspiration, before discussing the findings with the speech pathologist. Often the speech-language pathologist bears the primary responsibility for documenting and conveying the results to other health professionals involved with the patient, and recommending treatment (e.g. a specific diet) (Palmer, Drennan, & Baba, 2000).
The patient's participation during feeding evaluation is very important. However, it can be a problem for patients who are non-ambulatory and/or have poor postural control. In such instances an occupational therapist and speech-language pathologist may work collaboratively to achieve the best position for the patient. Although MBSS is widely considered the 'gold standard' diagnostic tool for oral and pharyngeal dysphagia, a newer tool called Fiberoptic Endoscopic Evaluation of Swallowing (FEES) is gaining popularity among physicians (Langmore, 2006).
With FEES, a flexible endoscope is passed though the nostril so that the larynx can be viewed directly from above. The patient is then given food or liquids mixed with food colouring so that the swallowing process can be observed. FEES has the advantage of being radiation free and can be used both diagnostically and therapeutically. It can be done during an evaluation and/or a treatment session and even gives the patient visual feedback about the problem with swallowing. Also, the equipment is more portable than the fluoroscopy equipment (Menon, 2011). These two factors, the portability and convenience of FEES, make it a preferred method for studying swallowing disorders.
Even though feeding and swallowing evaluation has, to a large degree, moved into the practice of speech-language pathology, occupational therapists still have a considerable role to play in the treatment of feeding and swallowing dysfunction. It is normal procedure in many areas of medicine and allied health services for new subspecialties to emerge in response to developing knowledge or skill. Occupational therapy can continue to grow while allowing this natural progression of knowledge development in another professions' domain. Accordingly, the authors are not implying that occupational therapists should try to hold on to this field of practice for historical reasons but rather because we have the potential to make a significant contribution to this critical area of human function. In a study which explored the experience of families caring for children with feeding disorders, Franklin and Rodger (2003) found that intervention from occupational therapists improved the parents' knowledge and understanding. The results indicated that this positively influenced the child's progress and independence.
Feeding and swallowing issues in infant population and the role of occupational therapy
Feeding disorders are fairly common among infants with developmental delays and other sensorimotor and neurological diagnoses. Many hospitals and neonatal intensive care units (NICUs) use an interdisciplinary team consisting of speech-language pathologist, occupational therapist, registered dietician, pediatrician, physical therapist, dentist, ear-nose-throat specialist and gastroenterologist to address feeding issues in very young children (Ayoob & Baressi, 2007).
Suck/swallow/breath (SSB) synchrony is an action pattern that coordinates sucking, swallowing, and breathing to help us eat and breath without choking. This action pattern develops as the fetus matures and by birth the newborn begins sucking and swallowing automatically (Smith, 2007). Premature infants and infants with developmental delays often have imbalance in their SSB rhythm that subsequently influences other areas of their development.
New mothers tend to get distressed when their infant lacks feeding skills and this subsequently affects the mother's self-confidence, energy levels and psychological well-being (Caretto, Topolski, Linkous, Lowman, & Murphy, 2000). Occupational therapy's holistic and patient-centered philosophy is especially suited to providing patient-family-centred care to the mother and her infant in a neonatal intensive care unit. By educating the mother about the infant's specific problems and offering ways to treat, adapt, and compensate for these problems, occupational therapists can reduce the mother's distress and empower her with knowledge of how to care for her baby (Caretto et al., 2000). Similarly, treatment of infants with oral-motor issues, food aversion, sensory processing issues, sucking deficits, swallowing dysfunction, positioning/posture intervention, feeding deficits secondary to developmental delays, recommendations for adaptive equipments, all fall within the domain of occupational therapy (Williams et al., 2006). By working together, occupational therapists and speech-language pathologists can correct problems with the SSB synchrony and feeding/swallowing issues and in that way help the infant to progress towards normal development.
Similarly, many medical conditions affect a child's ability to physically place food in their mouths as well as biting, chewing, or swallowing functions. Children with Cerebral Palsy, Downs syndrome, developmental delays, sensory integration difficulties, oral motor control problems, prematurity and other neuromuscular and neurological conditions may be at risk of oral motor dysfunction, pharyngoesophageal dyskinesia, gastroesophageal reflux, aversive feeding behaviour, tongue thrusts, and low body weight (Clark et al., 2007; Redstone & West, 2004; Rommel, De Meyer, Feenstra, & Veereman-Wauters, 2003). Occupational therapy intervention can help these children to develop self-feeding skills, improve their ability to chew and swallow, and thus meet their nutritional needs.
Examples of intervention in feeding and swallowing problems among children
Proper chewing of food can be a problem for children, along with tongue and lip position. Swallowing food before it has been chewed adequately may lead to gagging or choking. Tongue posture in swallowing varies considerably in children 2, 3, and 4 years of age (Sheppard, 2008; Williams et al., 2006) while children who display tongue thrusts can cause food and drink to be pushed out of their mouths. Gibbons, Williams, and Reigel (2007) addressed this issue through an oral-motor and behaviour approach for a young 6-year old child with tongue thrusts. As part of treatment stage one, the therapy began by brushing the middle of the child's tongue with a Nuk brush with thickened rice cereal. The Nuk brush flattened the child's tongue while depositing the food on each side of the tongue and the child tried to control a tongue thrust. The second stage of treatment included presenting liquids on a spoon and biting food. Third stage introduced food on a plastic coated infant spoon which was pressed gently on the mid-section of the tongue to prevent a tongue thrust (Gibbons et al., 2007). By the end of the treatment period, the child was able to sit upright in his high chair, and eat mashed foods without a lot of tongue thrusts (Gibbons et al, 2007.)
Equally, Eckman, Williams, Reigel, and Paul (2008) evaluated an occupational therapy intervention with two children who exhibited chewing problems. The intervention consisted of an oral-motor and behaviour approach which entails providing low textured food, and then gradually increasing the texture of the food and the size of bite. Initially, the food was placed in the child's mouth on top of their molars and they were instructed to bite and chew. When the child chewed the food before swallowing, the therapist provided rewards such as the child's favourite food or toy along with verbal encouragement. If they swallowed it whole before chewing or spat out the food, the therapist would place another piece of food on their molars and try again. Preferred liquids were presented to the child after each bite. By the end of a three week treatment period the children in the study improved their chewing, increased the variety and texture of foods eaten, established open-cup drinking and were able to be weaned-off the use of a gastrointestinal tube (Eckman et al., 2008).
Pediatric settings and the role of occupational therapy in feeding/swallowing issues
Pediatric populations present with numerous feeding and swallowing related conditions in need of intervention. For example, many pediatric occupational therapists practice in school-based settings with children of preschool and school age (Kardos & Whote, 2005). Within these settings, occupational therapists conduct assessments, engage with the multidisciplinary team to design intervention plans, and provide direct interventions (Wehrmann, Chiu, Reid, & Sinclair, 2006). A typically developing 3-year-old preschool student is usually expected to participate safely and efficiently in eating activities (Sheppard, 2008). In addition, it is assumed the child will be able to regulate his or her eating and drinking adequately to maintain nutrition and hydration during the school day. A child with a swallowing or feeding disorder is simply unable to meet these expectations (Sheppard, 2008). Working in a multidisciplinary team the occupational therapists role, along with that of the speech-language pathologist, is to design and implement a feeding, eating, and swallowing program for children within the school context.
Typically, various techniques are used to undertake an initial feeding evaluation. Analysis usually begins with checking the position of the tongue since studies have shown that tongue position varies by age and gender. Schwartz, et al. (2001) showed that children were able to identify the type of food they are about to eat by its visual appearance and this may have significance since different textures of food and liquids affect the position of the tongue. Even though the tongue and lips can take multiple positions, when food is approaching their lips, children within the same age range positioned their tongue and lips in a similar fashion. These positions included 'tongue on top of teeth', 'tongue behind teeth', 'lips pursed', and 'puckering of the corners of their mouths' (Eckman, et al., 2008; Schwartz, et al., 2001). Each of these positions needs to be explored and analyzed for their effect on the child's ability to chew and swallow.
Multidisciplinary approach to management of feeding and swallowing disorders
The nature of feeding and swallowing disorders often calls for a multidisciplinary team approach (Homer, Bickerton, Hill, Parham, & Taylor, 2000). A retrospective chart review by Williams et al., (2006) examined the work of a team that included an occupational therapist, speech-language pathologist, and a dietician. The goal was to address issues related to feeding and swallowing disorders, nutrition, and sensorimotor function. The intervention was diagnosis-specific and the patient's progress was evaluated by all members of the team. When the patient's returned for their first follow-up assessment, 75% of the initial goals had been achieved. The researchers claimed that this outcome validated the effectiveness of an multidisciplinary approach to the management of feeding and swallowing disorders (Williams et al., 2006). To put this claim into context, a speech-language pathologist works on oral-motor control while an occupational therapist focuses on the skills involved in bringing food to the mouth, motor planning skills, eye-hand coordination, positioning, muscle strength and range of motion. Of equal importance, a dietician is an expert on food and nutrition and can offer advice on what to eat in order to achieve a specific health related goal. All these health professionals' skills are underpinned by increasing the patient's confidence and effective family and caregiver training.
Occupational therapists are often asked to perform feeding evaluations and retraining in skilled nursing facilities. This may be due to improved recognition of the fact that cognition plays a major role in feeding and swallowing and occupational therapists are skilled at incorporating cognitive components into ADL training (Schroeder, Daniels, McClain, Cory, & Foundas, 2006). Equally, it may be that many nursing homes do not have a fulltime speech-language pathologist on staff. Occupational therapists who carry out this role are supporting patients in a critical occupation. Essentially, patients benefit when occupational therapists collaborate with speech-language pathologists, physical therapists, dieticians and nursing staff to address feeding and swallowing disorders, therapeutic positioning, adaptive devices and family/caretaker involvement. In fact, it can be said that such an approach would be an effective way to address complex biological, psychosocial, cultural, and environmental needs.
Research, advocacy & interdisciplinary collaboration
Most occupational therapists understand that feeding, eating, and swallowing are complex activities that require a coordinated effort from motor, sensory, and cognitive systems. As such, treatment requires specialized knowledge and training. Therefore it follows that the key to effective management of feeding and swallowing dysfunction should involve multiple disciplines, family members and caregivers. Whereas speech language pathology has made remarkable progress with their therapies and produced evidence to show that, there is a paucity of occupational therapy research regarding feeding and swallowing intervention even though a strong evidence-base is critical to the growth and survival of every health profession. Consequently, the authors contend that since feeding and swallowing is a vital ADL function, occupational therapy programs should be teaching students the fundamentals of feeding-eating-swallowing management. Clinicians who do not feel competent to practice in a particular field will avoid that area of practice.
Since eating is an essential daily function, occupational therapists have a significant role to play in providing skilled intervention for patients who are experiencing feeding, eating, and swallowing dysfunction. Whereas the author(s) acknowledge the importance of the role speech-language pathologists and other professions have in swallowing/feeding assessment and intervention they also advocate that occupational therapy is crucial to motivate, remediate, educate, restore, modify, and adapt this daily activity to achieve a more successful outcome. Therefore, the author(s) recommend introducing this topic to entry level occupational therapy education, so that future clinicians may be encouraged to practice and/or specialize in feeding-eating-swallowing management.
In conclusion, learning to feed oneself again after a life changing event or medical condition has impacted on the ability to eat can be a daunting task. The authors of this viewpoint article want to challenge occupational therapists to reflect on their role in feeding-eating-swallowing evaluation and management and to reiterate the importance of the role in occupational therapy practice.
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Stanley Paul & Mariana D'Amico
Stanley Paul, MD, PhD, OTR/L
Associate Professor Division of Occupational Science & Therapy Keuka College, Kueka Park New York, USA Email: email@example.com
Mariana D'Amico, EdD, OTR/L, BCP
Associate Professor Department of Occupational Therapy Georgia Regents University Augusta, GA, USA
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|Title Annotation:||VIEWPOINT ARTICLE|
|Author:||Paul, Stanley; D'Amico, Mariana|
|Publication:||New Zealand Journal of Occupational Therapy|
|Date:||Sep 1, 2013|
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