Effects Of Positioning Of Complex Seating Systems (Tilt-in-space Wheelchairs) On Swallow Performance In Adults With Dysphagia And Severe Brain Injury Sarah Haynes Head of Speech and Language Therapy

Background Patient population Postural management Dependency (Langmore1998) Traditional dysphagia practice (Shannahan et al 1993, Davies 1994, Avery- Smith 1997) Optimal? ( Stambolis et al 2003) Research

Aim Identify whether changes in wheelchair positioning affect swallowing performance in adults with dysphagia and severe brain injury by: Increasing/ decreasing swallowing efficiency in pharyngeal phase Affecting risk of laryngeal penetration and aspiration Providing estimates of direction and magnitude of effect of posture on swallowing function and on risk of aspiration

Positions in Tilt-in-space 90 0 upright 20 0 tilt back 90 0

Inclusion Criteria Recruitment: 26 Age : Single incident neurological insult FEES referral TIS History of aspiration / risk Sit 90 0 flexion

Methodology FEES assessment (8 x 5ml boluses) Position: tilt or upright Blind rated Primary outcome measure: Composite swallow efficiency score: 8 point P-A scale (Rosenbek 1996,Colodny 2002) Secondary outcome measures: Including head position

Results In 20 0 Tilt N= 21 improved swallow efficiency Reduced swallow delay Residue site: vallecula and pyriform sinuses In 90 0 upright N= 4 improved swallow efficiency Increased pharyngeal swallow delay Silent aspiration Residue all sites ( Murray 1996) NB: N=1 both good

Comparing Swallowing Efficiency in Upright and 20 0 Tilt Back

Results Mean composite swallow efficiency score in upright and tilt back positions + 1 SD. * Swallow efficiency (composite score= CS) Upright CS= tilt back CS= T Test = ( P <0.05) Reduced score in tilt = swallow success.

Results LOT post injury, age, gender, aetiology, or tracheostomy status Head position Tilt =statistical significance Beneficial effect on swallow efficiency

Comparison of swallow efficiency in upright and 20 0 tilt back in individual participants

Benefits of 20 0 Tilt Oral phase and gravity (Inagaki et al 2007) Pharyngeal response time Pharyngeal residue Risk and incidence of aspiration Reduced physical effort/ hypertonicity (Herman & Lange 1999, Ekberg 1986, Morris & Klein 2000) Respiration (Chan et al 1999, Morton et al 2002) Immediate effects (Gisel 2000)

Practical Importance Clinical applications Challenge traditional practice One size does not fit all! Evidence for FEES and videofluoroscopy Tilt-in-space prescription NBM Reduce LOS/ acute admissions? (Field & Weiss 1989)

Recommendations Consider alternative position Instrumental swallowing examinations 20 0 tilt back 90 0 upright Prior to feeding Team assessment Optimum position for eating Limitations of study

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