HOW I

HOW I FINDING THE REVIEW THE

REVIEWING (1):
ANNETTE KELLYS CLIENTS ARE AT THE HEART OF HER ENTHUSIASM FOR REVIEWING AND CRITICALLY APPRAISING THE LITERATURE AND THEY ARE REAPING THE BENEFITS.

LITERATURE TO CHANGE
REVIEWING (1) FINDING THE EVIDENCE REVIEWING (2) IMPROVING STUDY DESIGN REVIEWING (3) MATCHING PRACTICE TO THEORY
LITERATURE REVIEWS TELL US HOW A PARTICULAR ISSUE HAS BEEN EXAMINED ALREADY, AND WHAT STAGE OUR KNOWLEDGE IS AT. THEY EITHER PROVIDE US WITH EVIDENCE FOR OR AGAINST, OR DEMONSTRATE THAT THE CASE IS NOT PROVEN. THEY PREVENT REINVENTION OF THE WHEEL AND, USED WELL, GUIDE US IN DEVISING MORE TARGETED AND ROBUST STUDIES. IN ADDITION TO THEIR DAY JOBS, OUR CONTRIBUTORS ARE ALL MSC STUDENTS AT THE UNIVERSITY OF NEWCASTLE-UPON-TYNE. THEY CONSIDER HOW LEARNING TO SEARCH FOR EVIDENCE AND CRITICALLY APPRAISE IT HAS CHANGED THEIR PRACTICE. ANNETTE KELLY IS A SPEECH AND LANGUAGE THERAPIST AND LEAD CLINICIAN FOR HEAD AND NECK AND AIRWAY DISORDERS AT THE ROYAL NATIONAL THROAT NOSE AND EAR HOSPITAL, GRAYS INN ROAD, LONDON WC1X 8DA, TEL. 020 7915 1480. FROM JUNE 2005, SHE WILL BE THE SPEECH AND LANGUAGE THERAPY LEAD CLINICIAN FOR HEAD AND NECK AT THE HEAD AND NECK ONCOLOGY UNIT, UNIVERSITY COLLEGE LONDON. MARGARET YOUNG IS WITH THE SPEECH AND LANGUAGE THERAPY DEPARTMENT, SOUTH WING, MANOR HOSPITAL, MOAT ROAD, WALSALL WS2 9PS, TEL. 01922 721172 EXTENSION 6266, E-MAIL SPEECHTHERAPY@WALSALLHOSPITALS.NHS.UK. PIPPA HALES IS A SPEECH AND LANGUAGE THERAPIST WITH ADDENBROOKES NHS TRUST, CAMBRIDGE. LORNA GAMBERINI IS A SPEECH AND LANGUAGE THERAPIST WITH MORECAMBE BAY PRIMARY CARE TRUST. RITA OLIVER IS A SPEECH AND LANGUAGE THERAPIST WITH THE SPECIALIST LEARNING DISABILITY SERVICE IN CHESTERFIELD, E-MAIL RITA.OLIVER@CHESTERFIELDPCT.NHS.UK.

EVIDENCE
started to think about using evidence-based practice a few years ago when a motivated (but frustrated) patient turned to me mid-therapy session and said With respect, is there any evidence that this really works, and how long do I need to do this for? Up until then, I had operated on a largely cookbook approach, following a recipe of diagnosis (using a combination of observation and standardised assessments) and well-worn therapy approaches. While I had always reviewed therapy outcomes at regular intervals, I had never really thought to question whether what I was doing was based on good quality evidence. There is a growing emphasis on evidence-based practice in our profession and we are increasingly asked to justify our methods and their outcomes, not just to patients but also to students, professional colleagues and even financial managers. That patient was a young professional who had just undergone extensive surgery and radiotherapy treatment for a large oropharyngeal cancer. In addition to dealing with the side affects of his oncology treatment and the impact of this on his work and relationships, I was asking him to carry out a heavy regime of daily exercises, and his exasperation was completely understandable. His question really made me think - is there any evidence that these exercises improve function in head and neck patients? For how long is therapy necessary and relevant after head and neck oncology treatment? Are there any markers that predict long-term functional prognosis? Initially, I thought that searching the literature for relevant publications to answer a clinical question would be easy. I discovered however that it can be

PRACTICE

LORNA GAMBERINI SAYS I have been surprised by the horrifying gap in the evidence base for an awful lot of the things that we do in everyday practice because its always been done that way. Although it feels like a terrible chore at first to critically appraise papers, the skills to do so develop very quickly, especially if you have a good source book to fall back on (such as Greenhalgh, 2001). Two of my literature searches have been of particular clinical relevance. 1) the use or otherwise of topical anaesthesia for fibreoptic nasendocopy - having completed a nasendoscopy course and being faced with consultants who have opposing views, I found the evidence justified spraying the nose. 2) the effect of reflux on the voice - I now feel much more confident about educating medical staff, including GPs, about certain patients need for reflux medication if reflux is causing globus or dysphonia.

24

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

HOW I

extremely frustrating and time-consuming if done in a haphazard way. My initial searches tended to yield either no articles at all or several thousand, the majority of which were useless to me. Honing the search to yield a handful of relevant and high quality publications was proving beyond my skills, and I was fortunate enough to be given some one-to-one training by an expert research librarian. This really opened my eyes to the value of using a consistent and systematic search strategy. For example, I discovered that while the Medline database is huge and contains most medical journals, it is an American database and therefore may miss out some European publications. Running the search through a European medical database such as Embase may pick up a few relevant additional publications. Relatively few speech and language therapy topics seem to be covered by Cochrane reviews but, given the quality of these systematic reviews, its generally worth taking a look. Finally, I have found it useful to widen the search to include databases such as the nursing and allied health database CINAHL that index therapy (rather than medical) journals. My librarian gave me lots of advice on the databases most relevant to my field of work (head and neck oncology and ENT).

tions can be directly downloaded and printed off which can save weeks of waiting if your library doesnt hold the journals you need. Again, Greenhalghs book provides a good basic overview of steps to critically appraising a paper.

Journal clubs
With the ever-increasing demands on our professional time, finding time to search the literature sometimes seems impossible and literature searches often get put at the bottom of the to do list. However, given the hours we spend treating patients and the time we ask patients to invest in carrying out therapy at home, taking an hour or two to work out whether this time is being spent usefully is easily justified. Journal clubs are probably the answer therapists can take it in turns to search the literature for evidence to answer a real clinical question or to support an assessment or therapy method. Sharing the results of literature searches limits the time investment required to practice in an evidence-based way, and avoids therapists reinventing the wheel. With reference to the patient with supraglottic cancer I discovered that, while there were few relevant papers with sufficient subject numbers to provide strong evidence to answer his question, the combined available evidence suggested that effortful swallowing manoeuvres (such as the Mendelsohn and the effortful swallow) do improve swallowing efficiency in patients with head and neck cancer. Giving him this information seemed to offer him the extra motivation he needed to commit to the intensive therapy programme of Shaker exercises, base of tongue exercises and effortful swallowing manoeuvres. At six months post-oncology treatment he was managing a normal diet and maintaining his weight without supplementary feeding. Work published since that time (Perry et al, 2003) suggests that the head and neck cancer patients communication and swallowing function at six months may be predictive, indicating that intensive therapy in the first few months after oncology treatment is a worthwhile investment to maximise long-term function. With regards to the patient considering partial arytenoidectomy and cordectomy, my search at that time revealed few studies that systematically evaluated voice and swallowing outcomes after similar surgery. The limited evidence available (and anecdotal evidence from similar cases treated at our hospital) suggested that her voice would be weaker and breathy after the surgery but her swallowing should be unaffected in the long term. She was keen to get rid of her tracheostomy and, after weighing up the options, chose to have the surgery to improve her breathing. Her airway improved significantly and she remains tracheostomy-free. Her swallowing was unaffected by the surgery but, as predicted, her voice was breathy and low in volume due to persistent air escape on phonation. Her voice had improved a few months after the surgery, although it will never be as strong and loud as her previously normal voice. Overall, she reported that she was happy with the outcome of her decision. In summary, there are three simple strategies that have helped me to develop an evidence-based approach to my clinical practice: a. Using the research librarian in my Trust library - the teaching session was only two hours long but has saved me many hours of frustrating and fruitless searching. b.Using the databases that are most relevant to my clinical population and work. I try to avoid relying on only one database (even for a quick search) as Ive discovered this often misses out valuable publications. c. Using a systematic search method, rather than entering random search terms into the database. This has had the added bonus of making me really think about clinical question I want answered, rather than just vaguely searching for any articles published about a broad subject area.

Patient-centred
The librarian taught me to use a quick, patient-centred search strategy based on the acronym PICO: Patient, Intervention, (Comparison), Outcome. For example, a patient with a bilateral vocal fold palsy contemplating undergoing partial arytenoidectomy to improve her airway asked me how the procedure would impact on her voice and swallowing function, compared to the option of retaining her tracheostomy. In this case, I carried out the search using the following strategy: Patient: Bilateral vocal fold palsy Intervention: Arytenoidectomy: Partial arytenoidectomy: Partial cordectomy; Comparison: Tracheostomy Outcome: Swallowing, Voice. When searching a database, the librarian suggested brainstorming all the relevant synonyms for search terms, such as swallowing, deglutition, dysphagia, deglutition disorders remembering to use American terminology where appropriate. For tips on making searching easier and more productive, I have found Tricia Greenhalghs book How to Read a Paper invaluable as she breaks searching down into easy steps, giving plenty of relevant examples. Completing a successful search that yields a manageable number of highly relevant publications is very satisfying. However, thats only the beginning, and getting the papers from the library (or asking the librarian to order them in) and then reading them with some critical appraisal of the methodology and results can be pretty time-consuming. Fortunately, many recent publica-

RITA OLIVER COMMENTS, There is a certain amount of reticence amongst radiologists and speech and language therapists in acute sectors when people with learning disabilities are referred for videofluoroscopic swallowing assessments. It is an expensive procedure which involves many professionals, and my aim was to provide evidence to justify developing the videofluoroscopy clinic for this client group. Although there is a dearth of research studies regarding videofluoroscopy and learning disabled clients, careful review of available literature, critical evaluation of reliability of other assessment tools like cervical auscultation and pulse oximetry, and considering other patient groups (stroke, elderly dementia) has enabled me to confidently make the case for videofluoroscopy assessments and identify the clients who are most likely to benefit. Armed with the knowledge, I have been able to establish closer working links and ensure my clients are getting the treatment that is evidence based and in their best interest.

References
Greenhalgh, T. (2001) (2nd ed) How to Read a Paper. The basics of evidence based medicine. BMJ Books. Perry, A.R., Shaw, M.A. & Cotton, S. (2003) An evaluation of functional outcomes (speech, swallowing) in patients attending speech pathology after head and neck cancer treatment(s): results and analysis at 12 months postintervention. Journal of Laryngology & Otology 117 (5):368-81.

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

25

HOW I

REVIEWING (2):

IMPROVING

STUDY DESIGN
IF A SINGLE CLINICAL ASSESSMENT WAS AS GOOD AS A MORE TIME-CONSUMING INVASIVE TEST, WOULDNT YOU WANT TO KNOW? MARGARET YOUNG REVIEWED THE LITERATURE TO ENSURE THAT HER STUDY DESIGN WOULD PROVE WHETHER OR NOT THE MODIFIED EVANS BLUE DYE SWALLOWING TEST IS NECESSARY FOR PEOPLE WITH A TRACHEOSTOMY.

may be subsequently aspirated. In studies where patients have been assessed with both fluids and diet in one assessment session (ONeil-Pirozzi et al, 2003) and only suctioned once following each consistency, the evidence from the suctioning may have been invalidated by the previous bolus. Variables such as cuff status (Brady et al, 1999; Peruzzi et al, 2001) have not been controlled and the amounts of blue dye used may not have been sufficient to be clearly seen on suctioning (Brady et al, 1999). The amount and consistency of each bolus are not always fully described (Belafsky et al, 2003; Donzelli et al, 2001) or controlled (Peruzzi et al, 2001).

Clear identification
Dikeman & Kazandjian (1996) suggest that the blue dye swallowing assessment should involve giving the patient one amount (teaspoons / sips) and one consistency (pured / soft / semi-solid) at each session. This allows for clear identification of what amount and consistency the patient has either passed or failed the assessment on and informs the therapists management decisions. In a study where regular suctioning was carried out following the administration of one amount and one consistency, Belafsky et al (2003) report a high level of acuity for the Modified Evans Blue Dye test, with an overall sensitivity* of 82 per cent when compared to FEES. However, the assessment procedure for pured diet was not described and the raw data was not provided. The modified blue dye test carried out in these studies was by a number of different health professionals and a formal assessment procedure was not always used, although this has been recognised as being possibly influential when carrying out this test (Peruzzi et al, 2001). Would the accuracy of the modified blue dye test improve if it were carried out as a structured test of function by dysphagia trained speech and language therapists who not only evaluate the evidence from suctioning but also use their clinical judgement before reaching a decision as to diet and fluids?

he Modified Evans Blue Dye swallowing test is used to identify gross aspiration in tracheostomy patients. It is a simple, available and inexpensive assessment tool. However, a drawback is that it is time-consuming. The procedure, if optimally performed over several sessions, can take from 48 to 72 hours (Dikeman & Kazandjian, 1995). It can delay the commencement of oral diet and fluids and also the subsequent removal of the nasogastric tube. So, do speech and language therapists need to carry it out to identify a tracheostomy patient at risk of aspiration or can their clinical judgement interpret tests of function (Tippett & Siebens, 1996) without the aid of the blue dye? At Manor Hospital, Walsall, West Midlands, we decided to carry out a preliminary investigation into whether a dysphagia trained speech and language therapist, using a clinical bedside swallowing assessment, is able to predict with the same accuracy the risk of aspiration without using blue dye. I turned to the literature for information that would help with the design of the study. The Modified Evans Blue Dye procedure is based on the Evans Blue Dye Test that involved adding dye to a patients saliva followed by suctioning through the tracheal tube (Cameron et al, 1973). It then became the modified test when it was added to diet and fluids (Thompson-Henry & Braddock, 1995). The dye is easily distinguishable from other secretions and, if suctioned from the trachea, can signal a link between the oral cavity and the trachea that should not occur when swallowing (Dikeman & Kazandjian, 1995). The modified test is recommended as a screening assessment (Brady et al, 1999; Belafsky et al, 2003; Donzelli et al, 2001; Peruzzi et al, 2001) to identify both the risk of aspiration and the need for formal diagnostic evaluations such as videofluoroscopy or fiberoptic endoscopic evaluation of the swallow (FEES). This is as a result of studies that have questioned the accuracy of the modified test. In 1995, Thompson-Henry & Braddock reported that the Modified Evans Blue Dye test was unable to identify aspiration when compared with the results of videofluoroscopy and FEES. However, this study was small (with only five patients), it was retrospective, and it had inconsistent time delays between the two procedures with no explanation of the oral status of the patients between the two procedures. In studies where a simultaneous comparison was made between the Modified Evans Blue Dye test and either FEES or videofluoroscopy, the modified test failed to identify approximately 50 per cent of the patients who had aspirated. However, patients were only suctioned once (Donzelli et al, 2001; ONeil-Pirozzi et al, 2003; Peruzzi et al, 2001) or only when aspiration was observed on videofluoroscopy (Brady et al, 1999). Dikeman & Kazandjian (1995) suggest that suctioning should be carried out more than once, which reflects Cameron et als procedure (1973). They report that this is particularly important with thicker consistencies to identify any pharyngeal residue that
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

Prospective study
We conducted a six month prospective, consecutive study of adult patients in the high dependency unit with a tracheostomy tube. All patients included were breathing independently and had a deflated cuff. They were assessed using blue dye in the bolus by a speech and language therapist with at least one years experience. Only one consistency (fluids / pured diet) and one amount (teaspoons / sips) were used at each assessment session. Following each assessment, the therapist wrote a prediction in her case notes as to whether the results of the suction - carried out by the nursing team - would be positive (blue dye suctioned) or negative (no blue dye suctioned). After the speech and language therapist left the ward, the patient was suctioned and then suctioned again within the hour. The results of suctioning were documented in the patients bedside nursing document. Recommendations regarding oral or non-oral diet / fluids were based on the evidence from suctioning (if blue dye was suctioned) or on the therapists recommendations if she had concerns regarding the possibility of aspiration. We compared the positive and negative results from suctioning with the predictions made by the speech and language therapists to determine the accuracy of their clinical judgement. Our results identified all patients who tested positive (blue dye recovered from the tracheostomy site when suctioned) resulting in 100 per cent sensitivity* for our predictions on teaspoons of water and diet. Specificity** was lower (87 per cent for water and 92 per cent for diet) which reflects a number of positive predictions made by the therapist that were not confirmed by suctioning. In these cases, the therapist had made her recommendations based on her prediction, not the evidence from suctioning. There are no results for other amounts and consistencies because either the patient did not have a negative result or they were transferred from the high dependency unit and no longer met the criteria for the study. The clinical swallowing assessment and the Modified Evans Blue Dye test are not gold standard assessment procedures but they may be the only assessments available on a high dependency unit. However, this study has identified that a clinical swallowing assessment carried out by a dysphagia trained speech and language therapist can accurately predict a risk of aspiration in this client group. Evidence from the therapists case notes and the ward documentation confirmed that the

26

HOW I

patients in this study who had a negative result from the clinical swallowing assessment progressed successively from non-oral to normal diet and fluids. Following this study, I presented the results to the adult team in Walsall. After discussion, we decided that in future tracheostomy patients would be assessed using the clinical swallowing assessment without the aid of blue dye. This allows patients with only minimal or no dysphagia to commence diet and fluids after only one assessment procedure.
*Sensitivity is used here in its research sense, meaning the percentage of true positives identified. Similarly, here **specificity refers to the percentage of true negatives identified. In this study, it was most crucial to have excellent sensitivity.

References
Belafsky, P.C., Blumenfeld, L., LePage, A. & Nahrstedt, K. (2003) The accuracy of the Modified Evans Blue Dye test in predicting aspiration. The Laryngoscope 113 November: 1969-1972. Brady, S.L., Hildner, C.D. & Hutchins, B.F. (1999) Simultaneous videofluoroscopic swallow study and Modified Evans Blue Dye procedure: An evaluation of blue dye visualization in cases of known aspiration. Dysphagia 14: 146-149.

Cameron, J.L., Reynolds, J. & Zuidema, G.D. (1973) Aspiration in patients with tracheostomies. Surgical Gynecology Obstetrics 136: 68-70. Dikeman, K.J. & Kazandjian, M.S. (1995) Communication and swallowing management of tracheostomized and ventilator-dependent adults. Singular Publishing Group. Donzelli, J., Brady, S., Wesling, M. & Craney, M. (2001) Simultaneous Modified Evans Blue Dye procedure and video nasal endoscopic evaluation of the swallow. The Laryngoscope 111 October: 1746-1749. ONeil-Pirozzi, T.M., Lisiecki, D.J., Momose, K.J., Connors, J.J. & Milliner, M.P. (2003) Simultaneous modified barium swallow and blue dye tests: A determination of the accuracy of blue dye test aspiration findings. Dysphagia 18: 32-38. Peruzzi, W.T., Logemann, J.A., Currie, D. & Moen, S.G. (2001) Assessment of aspiration in patients with tracheostomies: Comparison of the bedside colored dye assessment with videofluoroscopic examination. Respiratory Care 46 (3): 243-247. Thompson-Henry, S. & Braddock, B. (1995) The Modified Evans Blue Dye procedure fails to detect aspiration in the tracheostomized patient; Five case reports. Dysphagia 10: 172-174. Tippett, D.C. & Siebens, A.A. (1996) Reconsidering the value of the Modified Evans Blue Dye test: A comment on Thompson-Henry and Braddock (1995). Dysphagia 11: 78-81.

REVIEWING (3):

MATCHING PRACTICE

TO THEORY
IS THE GAG REFLEX RELATED TO SWALLOWING? DOES AN ABSENT GAG REFLEX SUGGEST DYSPHAGIA? PIPPA HALES SORTS OUT THE FACT FROM THE FICTION - AND FINDS THE FULL STORY IS YET TO UNFOLD.

t basic dysphagia courses speech and language therapists are being taught that the gag reflex is not related to swallowing. So why is it that speech and language therapists continue to assess the gag reflex and doctors continue to refer to speech and language therapy following the discovery of an absent gag reflex (Leder, 1996; Perry, 2001)? The gag reflex is a protective response triggered by a foreign stimulus with the purpose of ejecting it (Leder, 1997). The response to this stimulus has been observed as a lowering of the mandible, forward and downward movement of the tongue, and pharyngeal and velar constriction (Leder, 1996). There is some discrepancy as to the neural control of the gag reflex. Most papers agree that the motor portion of the gag is controlled by the vagus nerve and that sensory innervation involves the glossopharyngeal nerve. However, there is apparent indecision as to whether the superior laryngeal branch of the vagus nerve is also involved in the afferent pathway (Leder, 1997; Hamdy et al, 1998; Bleach, 1993; Aviv et al, 2002). Studies show that speech and language therapists do assess the gag reflex. One study examining the consistency of clinical assessments across clinicians found that 58 per cent of the speech and language therapists surveyed indicated that they usually or always assess the gag reflex (Mathers-Schmidt & Kurlinski, 2003). Members of the medical profession also assess the gag reflex in relation to swallowing. One study looked at the screening methods used to identify dysphagia in acute stroke patients (Perry, 2001). They found that doctors were the only profession in the study to include the gag reflex as part of the swallow screen.

The procedure used to assess the gag reflex is varied. One study assessed the gag reflex at bedside by holding a cotton swab against the posterior oropharyngeal wall for up to ten seconds or until a gag was elicited, yet in their laryngoscopic assessment they elicited the gag by touching the laryngoscope against the epiglottis or laryngeal vestibule (Kaye et al, 1997). Another study used a tongue blade to touch the base of the tongue, soft palate, uvula and posterior pharyngeal wall to elicit the reflex (Leder, 1996). One prospective study examined the accuracy of six clinical indicators in determining the frequency of aspiration in acute stroke patients (Daniels et al, 1998). A bedside assessment was followed up by videofluoroscopy. They found that an absent gag reflex was significantly related to aspiration. The paper fails to mention what proportion of the 55 subjects assessed had a normal gag reflex and were still dysphagic. Another study looked at the role of flexible laryngoscopy in assessing aspiration in 105 patients (Kaye et al, 1997). Both bedside assessment and videofluoroscopy were compared against flexible laryngoscopy. They concluded that an absent gag reflex is correlated with aspiration, however, the results of this study appear to have been misinterpreted. The bedside examination found that the gag reflex was absent in 14.3 per cent of subjects, yet just 8.7 per cent of all subjects aspirated during the flexible laryngoscopy. When assessed again using videofluoroscopy 31.4 per cent of the subjects aspirated. They later state that an absent gag reflex was found to be a weak risk factor for aspiration. As the three assessments were not carried out simultaneously, the reliability of the results has clearly been affected. One further paper studied 70 patients with bilateral strokes using neurologic and videofluoroscopic assessment to determine the characteristics associated with dysphagia (Horner et al, 1990). This study found that those subjects with an abnormal gag reflex (62.6 per cent) aspirated more often than those with a normal gag reflex (29.6 per cent). They found an abnormal gag reflex to be a significant, independent predictor of aspiration. In this study, however, the authors define an abnormal gag reflex to include asymmetric, diminished, delayed or hyperactive, potentially overstressing the significance of the results relating to the abnormal gag reflex.

Healthy subjects
One study looked at pharyngeal sensation and the presence of the gag reflex in 140 healthy subjects (Davies et al, 1995). They found that the gag reflex was absent bilaterally in 43 per cent of their elderly subjects and 26 per cent of their young subjects. They concluded that, as the majority of stroke patients are over the age of 65 and that they observed an absent gag reflex more frequently in this age group, it should no longer be considered a useful bedside test of swallowing after acute stroke.
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

27

HOW I

Another study, carried out retrospectively, examined 120 neurological patients using bedside examination, indirect laryngoscopy and videofluoroscopy to establish if a link between an absent gag reflex and aspiration exists (Bleach, 1993). No correlation was found. The design of this study could have been improved if the three assessments had been performed simultaneously; however, as a retrospective study it was well designed, enhancing the value of its results. One further paper studied patients referred for a swallowing assessment as a result of an absent gag reflex to determine if its absence predicts dysphagia (Leder, 1996). This found that 36 per cent of the subjects were non dysphagic and concluded that an absent gag reflex does not predict dysphagia. However, the design of the study was not entirely appropriate to its aim; for example, some of the clinical indicators used to predict dysphagia have since been proven to be unreliable, such as wet, gargling voice quality (Warms & Richards, 2000). It also failed to state whether the subjects were actually followed up objectively with a videofluoroscopy or whether this was purely suggested as a possible assessment option. The sample size was also small with just 14 subjects. The most powerful observation of this review is the marked inconsistencies across every area of the topic. Firstly it is clear that the gag reflex continues to be tested to assess swallow function. Secondly it is apparent that there is no clear, defined method for assessing the gag reflex and finally - and perhaps more fundamentally - there is little agreement as to what is being assessed when the gag reflex is tested. This inconsistency is a reflection of the inconsistencies across the available literature and the quality of research surrounding this topic. This will not improve until quality research is carried out. Until then there is insufficient evidence to support us including the gag reflex in our dysphagia assessments. This evaluation supports the view that we should reconsider what we are teaching dysphagia students. We currently teach them that the gag reflex is not related to swallow function; instead we should be presenting the existing research and encouraging them and our colleagues to examine and challenge the evidence supporting their clinical practice.

References
Aviv, J.E., Spitzer, J., Cohen, M., Ma, G., Belafsky, P. & Close, L.G. (2002) Laryngeal adductor reflex and pharyngeal squeeze as predictors of laryngeal penetration and aspiration. Laryngoscope 112 (2): 338-41. Bleach, N.R. (1993) The gag reflex and aspiration: a retrospective analysis of 120 patients assessed by videofluoroscopy. Clinical Otolaryngology & Allied Sciences 18 (4): 303-7. Daniels, S.K., Brailey, K., Priestly, D.H., Herrington, L.R., Weisberg, L.A. & Foundas, A.L. (1998) Aspiration in patients with acute stroke. Archives of Physical Medicine & Rehabilitation 79 (1): 14-9. Davies, A.E., Kidd, D., Stone, S.P. & MacMahon, J. (1995) Pharyngeal sensation and gag reflex in healthy subjects. Lancet 345 (8948): 487-8. Hamdy, S., Aziz, Q., Rothwell, J.C., Hobson, A. & Thompson, D.G. (1998) Sensorimotor modulation of human cortical swallowing pathways. Journal of Physiology 506 (Pt 3): 857-66. Horner, J., Massey, E.W. & Brazer, S.R. (1990) Aspiration in bilateral stroke patients. Neurology 40 (11): 1686-8. Kaye, G.M., Zorowitz, R.D. & Baredes, S. (1997) Role of flexible laryngoscopy in evaluating aspiration [comment]. Annals of Otology, Rhinology & Laryngology 106 (8): 705-9. Leder, S.B. (1996) Gag reflex and dysphagia. Head & Neck 18 (2): 138-41. Leder, S.B. (1997) Videofluoroscopic evaluation of aspiration with visual examination of the gag reflex and velar movement [comment]. Dysphagia 12 (1): 21-3. Mathers-Schmidt, B.A. & Kurlinski, M. (2003) Dysphagia evaluation practices: inconsistencies in clinical assessment and instrumental examination decisionmaking. Dysphagia 18 (2): 114-25. Perry L. (2001) Screening swallowing function of patients with acute stroke. Part one: Identification, implementation and initial evaluation of a screening tool for use by nurses. Journal of Clinical Nursing 10 (4): 463-73. Warms, T. & Richards, J. (2000) Wet voice as a predictor of penetration and aspiration in oropharyngeal dysphagia. Dysphagia 15: 84-88.

news extra
Valuing people with autism
The National Autistic Society is expressing concern that adults with Asperger syndrome are deemed too able to access services. The charity says the 2001 plan Valuing People states, Adults with Asperger syndrome or higher functioning autism are not precluded from using learning disability services, and may, where appropriate, require an assessment of their social functioning and social skills in order to establish their level of need. In practice, they say this is not happening, and that local authorities should be held to account when their eligibility criteria exclude people with autism. Meanwhile, the Society says it has been successful in its efforts to ensure that the pre-legislative report by the Parliamentary Joint Committee on the Draft Mental Health Bill distinguishes the core condition of autism from mental health issues which may be co-morbid. It believes this will reduce the chances of inappropriate treatment and detention. www.nas.org.uk Foundation for People with Learning Disabilities. The aim of the green paper Independence, Well-being and Choice is to find ways of evaluating services and of giving people more control over their own lives and choice in the services they receive. Suggestions include each authority having a Director of Adult Social Services, training for family carers and individuals having more control over their own budgets. Hazel Morgan, Co-Director of the Foundation for People with Learning Disabilities emphasises that Individualised funding is an exciting way forward, but people with learning disabilities and their families will need good support to access it. The consultation is available in a variety of formats, including an easy-read booklet from Mencaps accessibility department, with an accompanying CD. Replies to the consultation should be in by 28th July 2005. Full details on www.dh.gov.uk. of specialist services, the report notes that in too many instances brain scans and swallowing checks are not being done. Only two-thirds of patients have documented evidence that multidisciplinary working is happening, and poor communication is also still a major issue. The report says that patients and carers need more adequate information about causes, treatment and prognosis, as well as advice on preventing another stroke. The Audit, funded by the Healthcare Commission, was carried out on behalf of the Intercollegiate Stroke Group by the Royal College of Physicians Clinical Effectiveness and Evaluation Unit. It is the first audit of stroke to involve 100 per cent participation for hospitals in England, Wales and Northern Ireland and to have results published for each NHS Trust. www.rcplondon.ac.uk

Concern over swallowing checks

The Stroke Association has expressed grave concern that one third of stroke patients in England, Wales and Northern Ireland in 2004 had no record of being checked for dysphagia following admission to hospital. Although the National Sentinel Audit for Stroke 2004 records a dramatic improvement in the provision

Are your rewards too sweet?

The British Dental Health Foundation has reacted angrily to the suggestion in an article on the government website Teachernet that sweets could be included in a package of rewards for good behaviour. The Foundation says that sugary foods should be limited to mealtimes wherever possible and rewards that affect a childs oral health should never be given in school.

Consultation shows good intentions

A government consultation on social care for adults shows good intentions according to the

28

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005