1. Don’t Burn Your Tongue..Hot Topics in Dysphagia: Free Water Protocol and sEMG Adult Swallowing EBP Group EBP Extravaganza 13 th December 2012

2. Presentation Outline Free Water Protocol - Clinical question - What is the free water protocol - Good oral hygiene is critical - CAPs - CATs - Clinical Application

3. Presentation Outline sEMG - Clinical question - What is sEMG? - CAPs - CATs - Clinical Application What’s next for Adult EBP Swallowing? Acknowledgements References

4. Free Water Protocol: Clinical Question In patients with dysphagia what are the benefits and complications of implementing the free water protocol?

5. Free Water Protocol: What is it? A protocol to regulate the provision of water to patients known to aspirate thin fluids. Strict guidelines are outlined with regards to suitability of the patient (e.g. Not suitable for patients with extreme coughing). It involves: -Strict oral hygiene -Water is permitted between meals (not during or until 30 minutes after). -No water given with medications. AIM: Increase quality of life, hydration and compliance, whilst maintaining safety.

6. Free Water Protocol: Good Oral Hygiene is Critical Dysphagia & pneumonia: a complex relationship (Langmore 1998) Colonisation (altered oropharyngeal flora): Aspiration into lungs Host resistance Pneumonia

7. Free Water Protocol CAPs Carlaw, C., Finlayson, H., Beggs,K., Visser, T., Marcoux, C., Coney, D. & Steele, C.M. (2011) Outcomes of a pilot water protocol project in a rehabilitation setting. Dysphagia (published on-line). Scott, A., & Benjamin, L. (2010). Implementation of a free fluid protocol in an aged care facility. In Roddam, H., & Skeat, J. (eds). Embedding evidence based practice in speech and language therapy. West Sussex: Wiley-Blackwell. Karagianis, M.J.P., Chivers, L., Karagianis, C. (2011). Effects or oral intake of water in patients with oropharyngeal dysphagia. BMC Geriatrics, 11:9. Panther, K. (2005). The Frazier Free Water Protocol. Swallowing and Swallowing Disorders, March:4-9. Garon, B., Engle, M., & Ormiston, C. (1997). A randomised control study to determine the effects on unlimited oral intake of water in patients with identified aspiration. Journal of Neurological Rehabilitation, 11: 139-148.

8. Free Water Protocol CAP summary ArticleLevelParticipantMethodOutcome measures ResultsSupport Carlaw et. al (2011) 216 CVA Spinal cord TBI Randomisation Immediate and delayed implementation Fluid intake SwallQoL Adverse event Increase Improved Nil Yes Scott & Benjamin (2010) 426 ACF Implemented FWPAdverse eventNilYes Karagianis et. al (2011) 376 Subacture and mixed etiologies Control group – usual care Experimental group – implemented FWP Fluid intake SwallQoL Adverse event Increased Improved 14.3% developed asp pneu Inconclusive Panther (2005) 4234 Acute rehab Implemented FWPAspiration Pneumonia 2 participants Yes Garon et. al. (2007) 220 Stroke rehabilitation Implemented FWPAverse events Fluid intake Nil Increased Yes

9. Free Water Protocol: CAT In patients with dysphagia, what are the benefits and complications of implementing the Free Water Protocol? Four studies using a free water protocol with medically stable participants in the rehabilitation and residential aged care settings found nil evidence of adverse events while benefits such as increased fluid intake and improved quality of life measures were indicated. Due to methodological limitations of the study involving acute patients, there is insufficient evidence to support the use of the Free Water Protocol in acute settings.

10. Free Water Protocol: Clinical Applications Importance or oral hygiene Considering your site when implementing the protocol Considering patients when implementing the protocol The need for MBS

11. sEMG: Clinical Question Does sEMG change outcomes for patients with dysphagia in stroke or head and neck disease?

12. sEMG: What is it? Biofeedback -The use of equipment to measure body functions that are not monitored consciously. sEMG (surface Electromyography) -Biofeedback device that evaluates the electrical activity produced by muscles through electrodes placed on the skin.

13. sEMG CAPs Crary, M.A., Giselle, D., Carnaby, M., Groher, M.E., & Helseth, E. (2004). Functional benefits of dysphagia therapy using the adjunctive sEMG biofeedback. Dysphagia, Huckabee, M.L. & Cannito, M.P. (1999). Outcomes of swallowing rehabilitation in chronic brainstem dysphagia: A retrospective evaluation. Dysphagia, Newlove, S. (2006). A case study examining the effectiveness of surface electromyography biofeedback in dysphagia rehabilitation and SWAL_QOL quality of life outcome measure. (Research Project, University of Auckland). Crary, M.A. (1995). A direct intervention program for chronic neurogenic dysphagia secondary to brainstem stroke. Dysphagia, 10:6-8. Crary, M.A., & Baldwin, B.O. (1997). Surface electromyographic characteristics of swallowing in dysphagia secondary to brainstem stroke. Dysphagia,

14. sEMG CAP summary ArticleLevelParticipantMethodOutcome measures ResultsSupport Crary et. al. (2004) 445 – total 25 – stroke 20 H & N Retrospective outcome study FOIS # Rx sessions Cost benefit Stroke - Improved More Rx Beneficial Yes for stroke No for H & N Huckabee & Cannito (1999) 410 brainstem CVA Retrospective outcome study MBS (Pre & Post) Oral intake scale Improved by 1 point Improved by 4 points Yes Bryant (1991)41 H & NCase study of therapy outcomes Descriptive swallowing outcomes Improved secretions Commenced intake Yes Newlove (2006) 41 CVACase study of therapy outcomes MBS (Pre & Post) Diet progress Swal-QoL No sig. difference Improved diet Sig. improvement for patient not carer Yes Crary et. al. (2004) 445 – total 25 – stroke 20 H & N Retrospective outcome study FOIS # Rx sessions Cost benefit Stroke - Improved More Rx Beneficial Yes for stroke No for H & N

15. sEMG: CAT Does sEMG change outcomes for patients with dysphagia in stroke or head and neck disease? The effectiveness of sEMG biofeedback in improving outcomes for patients with stroke or head and neck disease is not clear. Currently the evidence is limited and methodologically diverse but does indicate possible benefits for sEMG as an adjunct to swallowing therapy in these populations. Further research comparing traditional dysphagia therapy, with traditional dysphagia plus sEMG biofeedback will be required before definitive and reliable conclusions can be made.

16. sEMG: Clinical Applications Stronger evidence for use in stroke population than H & N population although documented benefits in both. Can be useful tool for carefully selected patients to add to their therapy program. Adjunct to dysphagia therapy. sEMG does not replace therapy!

17. What’s next for the adult swallowing EBP Group? Brand new CATs for 2012 – watch the EBP website. Brand new leaders for 2012: - Rosanne Russell: Rosanne.Russell@sswahs.nsw.gov.au Rosanne.Russell@sswahs.nsw.gov.au - Eryka Arteaga Eryka.Arteaga@royalrehab.com.au Eryka.Arteaga@royalrehab.com.au

18. Acknowledgements Thank you to all the hard working Adult Swallowing EBP group members.

19. References Carlaw, C., Finlayson, H., Beggs,K., Visser, T., Marcoux, C., Coney, D. & Steele, C.M. (2011) Outcomes of a pilot water protocol project in a rehabilitation setting. Dysphagia (published on-line). Crary, M.A., Giselle, D., Carnaby, M., Groher, M.E., & Helseth, E. (2004). Functional benefits of dysphagia therapy using the adjunctive sEMG biofeedback. Dysphagia, Crary, M.A., & Baldwin, B.O. (1997). Surface electromyographic characteristics of swallowing in dysphagia secondary to brainstem stroke. Dysphagia, Crary, M.A. (1995). A direct intervention program for chronic neurogenic dysphagia secondary to brainstem stroke. Dysphagia, 10:6-8. Garon, B., Engle, M., & Ormiston, C. (1997). A randomised control study to determine the effects on unlimited oral intake of water in patients with identified aspiration. Journal of Neurological Rehabilitation, 11: 139-148. Huckabee, M.L. & Cannito, M.P. (1999). Outcomes of swallowing rehabilitation in chronic brainstem dysphagia: A retrospective evaluation. Dysphagia, Karagianis, M.J.P., Chivers, L., Karagianis, C. (2011). Effects or oral intake of water in patients with oropharyngeal dysphagia. BMC Geriatrics, 11:9. Langmore, S.E., Terpenning, M.S., Shork, A., Chen, Y., Murray, J.T., Lopatin, D., Loeshe, W.J. (1998). Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia, 13: 69-81. Panther, K. (2005). The Frazier Free Water Protocol. Swallowing and Swallowing Disorders, March:4-9. Newlove, S. (2006). A case study examining the effectiveness of surface electromyography biofeedback in dysphagia rehabilitation and SWAL_QOL quality of life outcome measure. (Research Project, University of Auckland). Scott, A., & Benjamin, L. (2010). Implementation of a free fluid protocol in an aged care facility. In Roddam, H., & Skeat, J. (eds). Embedding evidence based practice in speech and language therapy. West Sussex: Wiley-Blackwell.