Research
Dysphagia
Completing a thorough bedside screening or evaluation is a crucial first step in the management of patients who are at risk for dysphagia. McHorney et. al, 2002, express the potential repercussions if not treated in their research; high mortality rates, dehydration, malnutrition, or aspiration pneumonia.  Additionally, they state that dysphagia can have an effect on social and psychological health. The goal of CASE’s bedside dysphagia evaluation is to identify patients at risk for aspiration as a step prior to advanced clinical assessment. Speyer (2013) concurs that bedside screening tools need to be easy to administer, be non-invasive, avoid distress to patients, and be quick.  CASE’s bedside dysphagia evaluation fits these criteria to a tee! Most research on dysphagia concurs that there are certain components that should be part of any dysphagia evaluation: The medical and patient history taking (which is found prior to the bedside evaluation in CASE); the assessment of cognition and communication abilities (which follows the bedside dysphagia evaluation in CASE); the evaluation of the oral, laryngeal, and pharyngeal anatomy, and the oral intake assessment (Holland et. al., 2011).  CASE covers these areas in the beginning paragraphs of the assessment.

The patient history is an essential component of the evaluation.  We must gather information on diseases associated with or that result in dysphagia, as well as any respiratory issues or medication use that may affect swallow function.  Medical charts or patient history may also describe previous pneumonia or weight loss (Speyer, 2012).  CASE also covers observations that occur and may be relevant to swallow function during the meal (i.e. fatigue, tongue thrust, secretions, etc.).  It is also important to include trials of liquids and solids for the majority of bedside dysphagia evaluations.  You want to explore consistencies, volumes, as well as maneuvers and positioning to determine the most effective strategies for the patient (Speyer, 2012).  With CASE, you can include these strategies and comments that you found effective at the time of the bedside evaluation.  For example, the chin tuck was included, as it has been shown that “The chin tuck effectively eliminated predeglutitive aspiration of thin liquids. The chin tuck posture effects the pharyngeal swallow by improving airway protection through narrowing of the airway entrance, positioning the tongue base and epiglottis toward the posterior pharyngeal wall, widening the vallecular space, decreasing distance between the larynx and hyoid and mandible, and reducing the potential depth of penetration and aspiration of material” (Welch et al., 1994; Bulow et al., 2001).  Additional recommendations as recommended by the Royal College of Speech and Language Therapists are: Adjustments to the placement, size, consistency and temperature, taste and texture of the bolus, as well as changes in pacing, utensil, and frequency and timing may be necessary (Taylor-Goh, 2005).
 
If patients fail the screening, further assessment is required.  In our recommendation section, we not only included other professionals, but other clinical dysphagia evaluations to ensure this important follow up was included. According to the Royal College of Speech and Language Therapists, "A videofluoroscopic or fibre-optic endoscopic evaluation of swallowing should be carried out if necessary (and if there are no clinical contraindications) to improve visualization of the upper aerodigestive tract, assess aspiration and residue, facilitate techniques and therapeutic strategies to reduce aspiration and improve swallowing efficiency, compare baseline and post-treatment function, and to further diagnose (Taylor-Goh, 2005). Additionally, tools, such as ultrasound or scintigraphy, can be used to evaluate distinct areas of swallowing function; therefore, using more than one technique or tool will be necessary to achieve a full picture of the patient's deficits (Taylor-Goh, 2005).


Motor Speech
Assessment in terms of motor speech function should cover a range of areas.  In the CASE assessment, topics such as: Automatic speech, isolated syllables, words, words of increasing length, sentences, diadokinesis tasks, phonatory efficiency, oral reading, oral mechanism, and prosody are explored.  This is based on the research of Darley et al., 1975 that noted dysarthria could affect phonation, resonance, articulation or prosody as the result of damage to the central or peripheral nervous system. When assessing motor speech functions, Wertz et al (1984) has also suggested that prosody is affected in patients with conditions such as apraxia.  In an article titled Speech, Language, and Swallowing Disorders in the Older Adult, Ashley et al. (2006) discusses how individuals with apraxia can have fairly intact ‘automatic speech’, which makes it a key part of a motor speech assessment so clinicians are able to adequately differentially diagnose.  Ardran and Kemp (1970) discuss oral-motor assessment, which was used a basis for the oral mechanism portion of the CASE oral motor subtest.  Duffy (2005) also noted that the examination of speech and motor programming should include maximum phonation time, diadochokinetic rates, isolated sound and syllable production, words in simple and complex syllable structures, words of increasing length, automatic/frequent words or phrases and contextual speech. The National Institute for Deafness and Other Communication Disorders (2005) also supports using speech tasks that include repeating a set of words of increasing length or reading sentences of increasing length and complexity. Didokinesis norms were obtained from Fletcher, S.G. (1972) and phonatory efficiency norms were obtained from Hirano, Koike, & VonLeden (1968).  

Reading
In 2009, the National Early Literacy Panel conducted a meta-analysis of over 500 research articles and determined: letter matching, phonological awareness, print awareness, decoding, reading comprehension, segmentation of words, naming objects rapidly, and even writing and spelling one’s name were all predictive of literacy achievement.  Additionally, research by Bradley & Bryant, 1983; Bruck, 1992; Fletcher 1972, Lindamood, Bell, & Lindamood, 1992 support and underscore the importance of phonological awareness in the assessment and remedial instruction of disabled readers.

Pragmatics 
​Pragmatics involves using language, changing language, and following rules as they relate to the social culture (Social Language Use (Pragmatics), 2014).  The CASE assessment explores the topics of: Emotions, Situations, Humor, Sarcasm, Figurative Language, Social Conventions, and Conversational Skills. Emotions were covered based on a variety of research supporting deficits in this area due to brain injury.  Patients with right hemisphere impairments may have difficulty understanding the emotion provided by the communication partner (Blonder et. al, 1995).  Fainsilber and Ortony (1987) concluded that people use figurative language, such as metaphors, for describing intense emotions. Ortony (1975) explains that metaphors can evoke vibrant descriptions of the physical experience of emotion, while Gibbs et al. (2002) states that metaphors also convey more subtle shades of emotion. Individuals with impaired ability to understand and interpret emotions would then have difficulty with these aspects of pragmatic language.  Individuals from different cultures may also have difficulty understanding nuances of pragmatics such as social conventions.  Garcia (2004) discusses the importance of pragmatics on English language learners to understand and interpret a speaker’s intentions and feelings, and further, to respond appropriately. Bara et al. (2000), Leitman et al. (2006), Rajendran et. al. (2005), and Channon et al. (2005 & 2007) concur that patients with traumatic brain injury (TBI), schizophrenia, autism, and dementia have demonstrated deficits interpreting sarcasm from contextual cues.  When this social language skill is compromised, the impaired individual may have difficulty understanding the implied criticism (McDonald, 1999) where the speaker’s comments are implied to be callous (Dews & Winner, 1995); however, the impaired individual may perceive their comments as polite (Jorgensen, 1996).  Conversational skills in right hemisphere damage may be related to pragmatic functions such as: turn taking, topic maintenance (Van Lancker, 1997). Van Lancker also goes on to remark that understanding of humor, and non-literal meanings can also be impaired as a result of damage to the right hemisphere. Prosodic difficulties also arise in the form of monotonous speech (Pell, 2006), and an abnormal rate of speech (Blonder et. al, 1995).


Non-Verbal
CASE’s non-verbal section was designed to assist the therapist in determining the non-verbal patient’s ability level and guide the therapist towards a communication system that would best suit the patient.  The first subtest is comprised of gesture imitation.  Iverson and Thal (1998) describe gestures as “actions produced with the intent to communicate and are typically expressed using fingers, hands, and arms, but can also include facial features and body motions.”  The CASE app assesses basic gestures (i.e. closing eyes on command shaking head, and holding up fingers).  The Handbook of Augmentative and Alternative Communication (1997) states that it is important to assess current ability to use gestures “Nonverbal communication modalities serve to supplement the client’s use of verbal communication.”  The patient will need to be able to point or gesture to the appropriate pictures or symbols for the next set of subtests as we move into receptive ID of objects.  The handbook further suggests that it is imperative the patient is able to discriminate between picture symbols. Pictures in the CASE app come in a field size of 3 and 6.  The minimum field size is 3 to rule out chance.  As we move up to a field size of 6, the pictures become smaller.  For patient’s who can read, the following subtests, also in a field of 3 and 6, will provide a basic understanding of the patient’s reading ability level.  This was included in the non-verbal section as well so therapist’s can get a quick idea if pictures or words would be the best access method for the patient. For individuals who are non-verbal, but are not able to utilize gestures, the eye gaze subtest can provide a very basic starting point to determine if further investigation into a potential eye gaze device may be beneficial to the patient.  It can also be used in conjunction with a head mounted laser pointer.  This is in a field of 1 and 2.  In the field of one, there is only one picture in the field with the rest of the boxes empty.  This is to determine if the patient is able to hear a direction to look at an object and if the eyes go towards that part of the screen.  When we increase the field size to two, the middle box remains empty so the patient will either need to look left or right.  This next step is probed to determine if the patient can discriminate when there is a distractor image in the field.  This is also tested with the pictures further away from one another. 



References
Ardran, G. M. & Kemp, F. H. (1970), Some important factors in the assessment of oropharyngeal function, Developmental Medicine and Child Neurology, 12, 158-166. 

​Ashley, J., Duggan. M., Sutcliffe, N., & Geriatr, C. (2006) Speech, Language, and Swallowing Disorders in the Older Adult.  James J. Peters Veterans Affairs Medical Center, 291 – 310.


Bara, B.G., Bucciarelli, M., & Geminiani, G.C. (2002) Development and decay of extra-linguistic communication. Brain and Cognition, 43(1), 21–27.

Blonder, L. X., Pickering, J. E., Heath, R. L., Smith, C. D. & Butler, S. M. (1995). Prosodic characteristics of speech pre- and post-right hemisphere stroke, Brain and Language, 51(2), 318–335.

Bradley, L., & Bryant, P. (1983). Categorizing sounds and learning to read: A causal connection. Nature, 301, 419-421.

Bruck, M. (1992). Persistence of dyslexics’ phonological awareness deficits. Developmental Psychology, 28, 874-886.

Bulow, M., Olsson, R. & Ekberg, O. (2001). Videomanometric analysis of supraglottic swallow, effortful swallow, and chin tuck in patients with pharyngeal dysfunction. Dysphagia, 16, 190–195.

Champagne, M., Virbel, J., Nespoulos, J.L., & Joanette, Y. (2003). Impact of right hemispheric damage on a hierarchy of complexity evidenced in young normal subjects. Brain and Cognition, 53,152–157. 

​ Channon, S., Pellijeff, A., & Rule, A. (2005). Social cognition after head injury: Sarcasm and theory of mind. Brain and Language. 93, 123–134. 

​ Channon, S., Rule, A., Maudgil, D., Martinos, M., Pellijeff, A., & Frankl J, (2007). Interpretation of mentalistic actions and sarcastic remarks: Effects of frontal and posterior lesions on mentalizing. Neuropsychologia, 45, 1725–1734. 

​ Dews, S., & Winner, E. (1995). Muting the meaning: A social function of irony. Metaphor and Symbolic Activity, 10(1), 3–19.

Darley F.L., Aronson, A.E., & Brown, J.R. (1975). Motor Speech Disorders. Saunders: Philadelphia.


Fainsilber, L., & Ortony, A. (1987). Metaphorical uses of language in the expression of emotions. Metaphor and Symbolic Activity, 2,239–250.


Fletcher, S.G. (1972). Time-by-count measurement of diadochokinetic syllable rate. Journal of Speech and Hearing Research, 15, 763-770. 


Garcia, P. (2004) Pragmatic Comprehension of High and Low Level Language Learners. Teaching English as a Second Language-Electronic Journal, 8(2) Retrieved from http://tesl-ej.org/ej30/a1.html 

Gibbs, R.W. Jr., Leggitt, J. S., & Turner, E. A. (2002). What’s special about figurative language in emotional communication? In S.R. Fussell (Ed.) The verbal communication of emotions: Interdisciplinary perspectives (pp.125–149). Mahwah, NJ: Lawrence Erlbaum Associates.


Glennen, S., & DeCoste, D. (1997). The handbook of augmentative and alternative communication. San Diego, CA: Singular Pub. Group.

Hirano, M., Koike, Y. & VonLeden, H. (1968) Maximum phonation time and air usage during phonation. Clinical study. Folia Phoniatr (Basel), 20(4), 185-201.


Holland, G., Jayasekeran, V., Pendleton, N., Horan, M., Jones, M. & Hamdy, S. (2011). Prevalence and symptom profiling of oropharyngeal dysphagia in a community dwelling of an elderly population: A self-reporting questionnaire survey. International Society for Diseases of the Esophagus.24(7), 476-80.


Iverson, J. & Thal, D. (1998). Communicative transitions: There’s more to the hand than meets the eye. In A. Wetherby, S. Warren, & J. Reichle (Eds.), Transitions in prelinguistic communication. (pp. 59-86). Baltimore: Brookes.

Jorgensen, J. (1996). The functions of sarcastic irony in speech. Journal of Pragmatics, 26(5), 613–634.

Leitman, D.I., Ziwich, R., Pasternak, R., & Javitt, D.C. (2006). Theory of Mind (ToM) and counterfactuality deficits in schizophrenia: Misperception or misinterpretation? Psychological Medicine, 36(8), 1075–1083.

Lindamood, P. C., Bell, N., & Lindamood, P. (1992). Issues in phonological awareness assessment. Annals of Dyslexia, 42, 242-261.


Martin, I. & McDonald, S. (2004). An exploration of causes of non-literal language problems in individuals with Asperger Syndrome. Journal of Autism and Developmental Disorders, 34(3), 311–328.  

​McDonald, S. (1999). Exploring the process of inference generation in sarcasm: a review of normal and clinical studies. Brain and Language, 68, 486–506.


McHorney, C.A., Robbins, J., Lomax, K., et al. (2002). The SWAL-QOL and SWAL-CARE outcomes tool for oropharyngeal dysphagia in adults: III. Documentation of reliability and validity. Dysphagia17, 97–114.


National Early Literacy Panel (2009). Developing Early Literacy: Report of the National Early Literacy Panel. Washington, DC: National Center for Family Literacy


National Institute on Deafness and Other Communication Disorders (2005). Apraxia of speech. Retrieved from http://www.nidcd.nih.gov/health/voice/apraxia.asp.

Ortony, A. (1975). Why metaphors are necessary and not just nice. Educational Theory, 25, 45–53.


Pell, M.D. (2006). Cerebral mechanisms for understanding emotional prosody in speech. Brain and Language, 96(2), 221–234.


Rajendran, G., Mitchell, P. & Rickards, H. (2005). How do individuals with Asperger Syndrome respond to nonliteral language and inappropriate requests in computer-mediated communication? Journal of Autism and Developmental Disorders, 35(4), 429–443.

Social Language Use (Pragmatics). (2014). American Speech Language and Hearing Association (ASHA). Retrieved from http://www.asha.org/public/speech/development/Pragmatics/

Speyer, R. (2012). Behavioural Treatment of Oropharyngeal Dysphagia: Bolus Modification and Management, Sensory and Motor Behavioural Techniques, Postural Adjustments, and Swallow Manoeuvres. Dysphagia Medical Radiology, 477-491

Speyer R. (2013). Oropharyngeal Dysphagia Screening and Assessment. Otolaryngologic Clinics of North America. 46(6), 989-1008.

​Taylor-Goh, S. (2005). Royal College of Speech & Language Therapists clinical guidelines. Bicester: Speechmark Publishing.

Van Lancker, D. (1997). Rags to Riches: Our increasing appreciation of cognitive and communicative abilities of the human right cerebral hemisphere. Brain and Language, 57, 1–11. 


Welch, M. V., Logemann, J. A., Rademaker, A. W., & Kahrilas, P. J. (1993). Changes in pharyngeal dimensions effected by chin tuck. Archives of Physical Medicine Rehabilitation,74, 178–181.


Wertz, R.T., LaPointe, L.L, & Rosenbek, J.C. (1984). Apraxia of speech: The disorder and its management. New York: Grune and Stratton.

Comprehensive Adult Speech-Langu​age Evaluation CASE