Guest Author: Katrina Woodward, MS, CCC-SLP, CDP
The ability to eat and drink is easily taken for granted. Surprisingly, one in 25 adults per year in the United States experience disruptions in their swallowing abilities. Knowing where to begin diagnosing a swallowing disorder and the process involved in treatment can seem daunting, however, you have a major ally that will help walk you through the process, a speech-language pathologist (SLP).
What do you do if you are having difficulty eating or drinking?
If you or a loved one is experiencing swallowing difficulties, the first step is to make an appointment with your doctor. They will be able to evaluate your symptoms and give you a recommendation on the next steps.
Before your visit to your doctor, one useful tool to help advocate for a swallowing disorder or dysphagia evaluation from your doctor is the Eating Assessment Tool (EAT-10) self-report developed by Dr. Peter Belafsky in 2008 (Bernardes, 2022). This resource is available at the end of this article. The information provided by this tool is helpful for a comprehensive dysphagia evaluation which will assess the presenting signs of swallowing difficulties (like coughing) and deliver reported complaints of swallowing dysfunctions.
If your doctor deems it appropriate, they will provide you with a doctor’s order for a speech-language pathologist (SLP). The title of speech-language pathologist can be misleading, but this person is a trained expert in assessing and treating upper aerodigestive tract disorders and can perform an evaluation for dysphagia.
What exactly is an SLP?
An SLP is a master’s-degree level specialist trained to assess and treat disorders of speech, language, voice, fluency, cognition and swallowing in all ages, from birth through geriatrics. Speech-language pathologists practice in educational and medical settings. They are licensed by the state they practice in and are certified by the American Speech-Language-Hearing Association (ASHA). ASHA awards SLPs with a Certificate of Clinical Competence upon completing a nine-month clinical fellowship.
How does an SLP help someone with swallowing difficulties?
An SLP will identify, describe, and treat the functional problems behind the swallowing difficulty. The problem can occur anywhere in the swallowing pathway, from the mouth to the stomach. Sometimes this difficulty is related to swallowing and breathing mistiming, weakness or impaired sensation of the oral or throat musculature, or a combination of these challenges.
What happens during a swallow evaluation?
A comprehensive swallowing assessment includes both non-instrumental and instrumental procedures (ASHA.org).
A non-instrumental procedure is sometimes referred to as a bedside swallow evaluation or a clinical swallow exam. The clinical swallow exam may include:
- A review of the patient’s medical history and medications by interview and chart review
- A discussion of presenting complaints, level of activity, weight, appetite, and typical meals the client eats at home
- An assessment of the client’s oral strength and function, dentition and mouth care, respiratory rate, voice quality and volume, cough strength and cued swallows (saliva swallows)
- Watching the client eat and drink, even take medications, to assess for signs of swallowing difficulties like coughing, throat clearing, changes to their vocal quality, or belching
During the process of evaluating the client while they are eating, the SLP will continually ask targeted questions like, “Does it feel like the food is sticking?” or, “Are you having any pain when swallowing?”
To complement the non-instrumental assessment, the biofeedback from an instrumental test (which visualizes the anatomy and swallow function via endoscopy or via X-ray while the patient is eating) can optimize strategy training and foster client and caregiver understanding of recommendations for diet changes to foods and liquids. Because we can’t see what is happening on the inside when a person swallows, an SLP will recommend a flexible endoscopic evaluation of swallowing (FEES) or a videofluoroscopic swallowing study (VFSS) when there is a need to determine effective treatment strategies. Just like a doctor may perform an ultrasound or an X-ray depending on what they need to visualize, the SLP will select the appropriate test based on the presenting complaints and the clinical swallow exam findings.
How does the SLP meet individual needs?
Following the assessment, the SLP will discuss a functional dysphagia diagnosis and prognosis. Rating the severity of the swallowing problem is key to measuring improvements, and there are many validated tools for rating the severity of dysphagia.
Next, the SLP will plan treatment, including goals of swallowing therapy. This two-way discussion results in a plan of care which may include recommendations for:
- Textural diet modifications
- Thickened liquids to slow the flow rate of drinks
- A repeat instrumental assessment of swallowing using endoscopy (FEES) or X-ray (VFSS) after an interval of treatment
- Rehabilitation exercises for strengthening swallowing muscles
- Strategies to facilitate airway protection when eating and drinking
The SLP provides education to the client and their caregivers, supporting them through transitions in care to give them the knowledge and tools needed to manage their swallowing difficulties. When food modifications are recommended, the type of food modification may be prescribed according to the International Dysphagia Diet Standardization Initiative (IDDSI) framework. Read more about IDDSI here.
There are commercially available thickened drinks and thickening products for ease of use in managing dysphagia across care settings.
Your SLP is your partner in dysphagia management.
In successful dysphagia management, the SLP needs to recognize the client’s goals. The SLP should know what is important to the client. For example, the SLP will ask questions such as, “What were your favorite things to eat before you had swallowing difficulties?” or, “What type of support do you need to modify the texture of your food and drinks?” Successful partnerships in dysphagia management mean that both the client and the SLP are invested in treatment recommendations and outcomes.
Dysphagia management is a process, never a one-and-done session. SLPs empower their clients with the right tools and knowledge for decision-making. They are vested in a client’s goals and best interests, which is part of a successful partnership with an SLP.
Eating Assessment Tool (EAT-10)
Circle the appropriate response below (0 = No problem 4 = Severe):
| 1. My swallowing problem has caused me to lose weight: | 0 | 1 | 2 | 3 | 4 |
| 2. My swallowing problem interferes with my ability to go out for meals: | 0 | 1 | 2 | 3 | 4 |
| 3. Swallowing liquids takes extra effort: | 0 | 1 | 2 | 3 | 4 |
| 4. Swallowing solids takes extra effort: | 0 | 1 | 2 | 3 | 4 |
| 5. Swallowing pills takes extra effort: | 0 | 1 | 2 | 3 | 4 |
| 6. Swallowing is painful: | 0 | 1 | 2 | 3 | 4 |
| 7. The pleasure of eating is affected by my swallowing: | 0 | 1 | 2 | 3 | 4 |
| 8. When I swallow, food sticks in my throat: | 0 | 1 | 2 | 3 | 4 |
| 9. I cough when I eat: | 0 | 1 | 2 | 3 | 4 |
| 10. Swallowing is stressful: | 0 | 1 | 2 | 3 | 4 |
Total EAT-10:_____________
A score of 3 or higher may indicate a swallowing disorder. It is recommended that you share this information with your physician.
Katrina Woodward, MS, CCC-SLP, CDP is a speech-language pathologist with 19 years of specialty experience evaluating and treating adult and geriatric patients with cognitive-communication deficits and dysphagia. A consummate professional, a proven leader, a dedicated mentor, and a patient advocate with a passion for evidence-based practice, Katrina currently serves as vice president for SDX Dysphagia Experts, consultant to Roche Dietitians, Massachusetts Speech-Language-Hearing Association vice president for education and planning, and a US & Territories IDDSI Reference Group volunteer and co-chair of the communications and newsletter committee. Katrina’s opinions and advice are her own. Katrina is a paid consultant to Roche Dietitians. Roche Dietitians serves as a paid consultant to Kent Precision Foods Group, Inc., producers of the Thick-It® brand family of products.
Always seek the advice of a physician or other qualified health provider before making a diet modification and with any questions you may have about a medical condition or treatment. The information contained herein is for informational purposes and is not intended to be a substitute for professional medical advice, diagnosis, or treatment in any manner.