SPH528 - Dysphagia Intervention Flashcards
1
Q
Targets for Dysphagia intervention (impairment):
- Lip closure
- Hold position/tongue control
- Bolus preparation/Mastication
- Bolus transport/Lingual Motion
- Initiation of pharyngeal swallow
- Soft palate elevation and retraction
A
- Laryngeal Elevation
- Anterior hyoid excursion
- Laryngeal Closure
- Pharyngeal Stripping Wave
- Pharyngeal Contractions
- Pharyngoesophageal Segment Opening
- Tongue Base Retraction
- Oesophageal Clearance
What about soft palate-tongue contact to prevent early spillage?
2
Q
Basic Exercise Principles that may be incorporated into Dysphagia Rehabilitation Programs:
*Overload -> Exercise at sufficient intensity, time, and frequency to challenge muscle and create muscle change
A
Increase total time or load used in training
3
Q
Basic Exercise Principles that may be incorporated into Dysphagia Rehabilitation Programs:
*Progression: Systematically increasing the intensity (load) and demands (time/frequency) spent in exercise
A
Continually and gradually increase the demands of the exercise activity applied – perform more repetitions, increase the load, go faster
4
Q
Basic Exercise Principles that may be incorporated into Dysphagia Rehabilitation Programs:
*Intensity – The load used in an exercise
A
Alter the amount pushed, pulled, or lifted in exercise
5
Q
Basic Exercise Principles that may be incorporated into Dysphagia Rehabilitation Programs:
*Adaptation – Repeatedly practicing a movement, skill, or task to alter muscle condition
A
Use continued (regular) practice of a particular exercise pattern
6
Q
Basic Exercise Principles that may be incorporated into Dysphagia Rehabilitation Programs:
*Reversibility – The effect of exercise training on muscle will be lost with lack of activity
A
“If you don’t use it, you lose it” – a maintenance plan is needed to prevent detraining
7
Q
Basic Exercise Principles that may be incorporated into Dysphagia Rehabilitation Programs:
*Specificity – Exercise should be specific to the goal
A
If your goal is to be a runner, then exercise should include running
8
Q
Basic Exercise Principles that may be incorporated into Dysphagia Rehabilitation Programs:
*Recovery – Rest between repetitions of movements or sets of strength-training exercises
A
Ensure sufficient rest between activity to reduce fatigue and stabilise muscle
9
Q
What is meant by INDIRECT rehabilitation techniques for swallowing?
A
Rehabilitation techniques with NO BOLUS
10
Q
Indirect techniques for rehabilitation of swallowing:
- Lingual strengthening (e.g., IOPI – readings of pressure and strength)
- Chin tuck against resistance (CTAR)
- Modified CTAR
- Shaker/head lift exercises
- Modified Shaker/head lift exercises (lean back in chair)
A
- Expiratory muscle strength training
- Inspiratory muscle strength training
- Masako exercise
- Mendehlson Manoeuvre (can use with bolus?)
- Vocal fold adduction exercises
- Therapeutic trials of oral intake (not indirect)
- Specific Programs (e.g., McNeill Dysphagia Therapy Program, Pharyngosize)
11
Q
Management of dysphagia is based on:
A
- Client wishes (what we think they want to get out of management may not be at all what THEY want to get out of management)
- Client history
- Client Risk (aspiration, choking, malnutrition, dehydration)
12
Q
Before getting started with dysphagia management, ask yourself:
1) What type of nutritional management?
2) Should therapy be instigated?
3) What specific strategies should be used?
(Logemann, 1998)
A
1) non-oral, oral or a combination? (with dietician)
2) Is the patient appropriate for rehab., or do they need management?
3) What will be appropriate for this person? What did we see on VFSS/FEES or at the bedside? What do we know about the cause of the impairment?
13
Q
What could be some therapy goals at the beginning?
A
- Re-establishment of oral feeding?
- Maintaining adequate nutrition/hydration?
- Improving (or maintaining?) swallowing safety?
- Reducing risk of aspiration and aspiration sequelae?
14
Q
Things to consider when setting goals:
A
- Diagnosis
- Prognosis
- Severity of dysphagia
- Cognition
- Comprehension
- Respiratory Function
- Caregiver support
- Motivation
- Medical and allied health team goals
- Short and long term objectives
15
Q
Compensation Vs Rehabilitation
A
Compensation: measures that provide immediate, but transient effect
Rehabilitation: restoration of previous function/abilities (some restoration rather than full restoration will be the most likely scenario for most patients)
16
Q
What are the aims of rehabilitation?
A
- To restore lost function, or return to a level that allows useful and constructive activity
- To try and fix/improve the underlying problem
-> Ax and subsequent diagnosis of the underlying problem must be accurate if you are to have an impact!
17
Q
Who is suitable for Rehabilitation of swallowing?
A
- Non-progressive disorders (slow progressive like Parkinson’s may be suitable to raise baseline)
- Cognitively able
- Communicatively able
- Motivated
18
Q
3 types of neuromuscular deficits:
A
1) Muscle spasticity / hyperfunction
2) Muscular weakness / hypofunction
3) Muscular incoordination / apraxia
19
Q
Characteristics and Rehab focus for Muscle spasticity/hyperfunction in dysphagia:
(Huckabee & Pelletier, 1999)
A
Movement inhibited:
*Pyramidal – spasticity, imprecise movements, difficult to initiate, ROM OK.
*Extrapyramidal – rigidity, consistent tension inhibited ROM
Rehab focus:
*Inhibition of spasticity, relaxation (reduce muscle tone)
*Potentially head lift/shaker and Mendelsohn’s (depends on presentation)
20
Q
Characteristics and Rehab focus for Muscle hypotonicity/flaccidity in dysphagia:
(Huckabee & Pelletier, 1999)
A
*Characteristic of CN lesion or cortical stroke
*Typically presents unilaterally (bilaterally -> spasticity)
*Weakness is main feature
Rehab focus:
*Mendelsohn’s, Masako, Effortful swallow
*OM and strengthening
21
Q
Characteristics and Rehab focus for Muscular dyscoordination in dysphagia:
(Huckabee & Pelletier, 1999)
A
*Results from improper sequencing of timing or muscle contraction, or planning deficits -> is there a swallowing apraxia???
Rehab focus:
*Focus on external cues to bring order to swallow, improving pattern of motor response (i.e. counting them in 1, 2, 3 swallow)
22
Q
In the acute stage post-stroke, patients will usually show some improvement in local processes (Early Recovery), due to resolution of:
A
- Post-stroke oedema
- Diaschisis (low activity/depressed function following insult -> “safe-mode”)
- Reperfusion of the ischemic penumbra
23
Q
In later recovery post-stroke, patients may show some improvement via CNS Reorganisation, due to:
A
Reorganisation of the brain. This is dependant on the lesion site and the surrounding brain tissue, and on remote locations that have structural connections with the injured area.
24
Q
- Oromotor therapy
- Valsalva swallow
- Masako manoeuvre
- Mendesohn manoeuvre
- Head lifting manoeuvre
- Expiratory Muscle training
- Vocal adduction exercises
- Therapeutic feeding/neurosensory stimulation
- Biofeedback (SEG, other techniques
- > all examples of what?
A
Rehabilitation techniques for swallowing
25
What are oromotor exercises?
A variety of exercises targeting different muscles/ muscle groups
- > evidence in inconclusive for functional carryover
* Based on principles of strength training (overload muscles, reps, increasing resistance)
* Needs to be specific, and incorporate muscles similar to target (ie swallowing)
26
* A rehabilitation technique for swallowing
* Targets decreased laryngeal elevation and reduced pharyngeal contraction.
* Increases BOT to posterior pharyngeal wall contact
* Can be both compensatory (immediate effect) and rehabilitative (lasting physiologic changes to swallow)
* Low evidence that it reduces the depth of laryngeal penetration of the bolus (small sample size)
Valsalva Swallow
* Ask person to swallow HARD. Really clench muscles of swallowing when they swallow.
* Trial under VFSS before instating
* Use for solid textures
27
* An INDIRECT rehabilitation technique for dysphagia
* CONTRAINDICATED WITH FOOD – no bolus
* Targets BOT to PPW contact; decreased strength of pharyngeal swallow -> in people with intact tongue, compensates for poor contact of BOT with PPW
The Masako Manoeuvre (“Tongue holding manoeuvre”)
* Ask the person to anchor their anterior tongue and swallow
* Do reps several times per day
* The further out the tongue is, the harder the exercise is.
* Check on VSFF that this is indicated (ie clear poor BOT to PPW contact)
28
* A rehabilitation technique for swallowing
* Done with a bolus
* Hard to teach – requires good patient cognition
* Targets reduced opening of cricopharyngeal sphincter, decreased laryngeal elevation or pharyngeal contraction.
* Aims to keep UES open for longer to decrease pooling in pyriforms
The Mendelsohn Manoeuvre
1. Take a small bite of food or sip of liquid
2. Hold the food in your mouth
3. Position index finger and thumb around your larynx
4. Swallow
5. Feel the elevation of the larynx when you swallow
6. when the larynx reaches its highest peak, hold it up for 5 seconds(using your muscles)
7. Release
8. Repeat steps 1-7 with each swallow
29
* An indirect rehabilitation technique for swallowing
* Targets reduced opening of cricopharyngeal sphincter, decreased laryngeal elevation or pharyngeal contraction
* INDIRECT – AN OROMOTOR EXERCISE – NO BOLUS!!
* can be physically taxing – may not get compliance
The Shaker (head lift)
Lie down and lift your head 3 times for 10 seconds each time (Emma – 30 seconds, Duffy – 60 seconds + 30 quick head-lifts). Shoulders flat on ground.
-> Evidence quite promising
30
* An indirect rehabilitation technique for swallowing
* INDIRECT – STRENGTH TRAINING – NO BOLUS!!
* Training the expiratory muscles through increased resistive load during inspiration and/or expiration.
* Uses a pressure threshold device which is calibrated to increase load.
* Indicated in people who present with swallowing problems related to expiratory muscle weakness.
* Improves the ability of expiratory muscles to generate enough force for ventilation and coughing (and clearance for laryngeal area).
* Increases hyoid movement, therefore improving UES opening.
Expiratory Muscle Training (EMST)
*Blow into a calibrated pressure threshold device (settings can be changed to increase/decrease resistance)
* Good for people with Parkinson’s Disease.
* Has been used in neuromuscular presentations and respiratory presentations.
* Regime lasts for 6 weeks, needs to be based on progressive overload/resistance (not clear exactly how – ambiguity in literature)
* Reduces penetration/aspiration (1 paper)
31
* An indirect rehabilitation technique for swallowing
* INDIRECT – NO BOLUS!!
* Used also for some voice clients
* Indicated in patients with poor VF closure
Techniques for vocal fold adduction (see: voice)
32
* A rehabilitation technique for swallowing
* Aim is to provide feedback to the patient on their swallow via instrumental means, so that they can change their swallow patterns.
Biofeedback
Includes: surface electromyography, ultrasound, endoscopy, auscultation, IOPI, FEES… anything at all which gives real-time feedback to the patient while they are swallowing.
*Exercises used: saliva swallows, manoeuvres, and strength exercises.
* No evidence of functional benefit (no change in diet type, penetration or aspiration scores) -> may be a function of limited studies done with diverse patients.
* Does increases hyoid displacement.
33
* A rehabilitation technique for swallowing
| * Aim is to stimulate sensory pathways and strengthen muscles through contraction.
Neuromuscular Electrical Stimulation (NMES)
*Application of electrical current to peripheral tissue
* effect on muscle retraining shows promise
* effect on sensory stimulation inconclusive
34
* Some consider this a rehabilitation technique for swallowing, BUT NO EVIDENCE of ongoing effect when the stimulus is removed -> only COMPENSATORY (with low evidence)
* Usually involves a frozen swab or cold mirror to stimulate faucial arches.
* May stimulate earlier swallow initiation, but only in first 1-2 swallows…
Thermo-tactile stimulation
*maybe 1-2 swallows improved, no continued effect -> not worth doing
35
Example of a rehabilitation regime during Inpatient rehab for speech and swallowing (Mr. Clancy)
Swallowing:
1) Oromotor exercises with particular focus on the tongue (3x day minimum)
2) Effortful swallow: practiced on every bolus of food
3) Masako (3 sets of 5-10 swallows, 3x per day PLUS shorter sets during the day per patient choice
4) Shaker exercise (3x per day, Lift head up 3 x with 10 second hold)
36
When we consider management we need to think about 3 things:
1. Client wishes
2. Client history
3. Client risk (aspiration, choking, dehydration, malnutrition)
37
What things might increase risk in a patient we are thinking about implementing a management plan for?
* Past history
* chair-side evidence
* Presence/absence of a carer
* Absence of knowledgeable and regular GP
* Reduction in overall health
38
Example of compensatory techniques used with Mr. Clancy.
| Swallowing
* Use of enteral feeding (PEG tube)
* Graded introduction of modified diet and fluids and a feeding regime
* Use of postural techniques through overall position and chin tuck
* Use of effortful swallow (both compensatory and rehabilitative)
* Use of self-monitoring (Mr Clancy taught to monitor for his own fatigue, through monitoring his vocal quality (gurgly voice post-swallow) and how his throat ‘felt’ -> to detect when his swallow became slower (taught through repeated practice) as a sign he’d had enough
39
What do compensatory techniques for dysphagia management aim to do?
**Patient needs good cognition to comply – if they won’t/can’t comply, it won’t work
To “redirect/improve the flow of food and eliminate symptoms such as aspiration (but no permanent changes to physiology of the swallow)
40
Some Compensatory techniques…
* Postural strategies
* Bolus Control Techniques
* Volitional airway protection strategies
* Changing food/fluid consistencies
* Prosthetic devices
41
Compensatory techniques: Postural techniques
| How to they work?
* Work by changing pharyngeal dimensions and redirecting food
* Changes to head/body posture can eliminate aspiration in 75-80% of cases
* Tend to be used short term (but not always)
* Should observe during VFSS to see the impact on this technique on aspiration and residue.
42
What do we need to consider, when thinking about whether postural techniques would be suitable as a management strategy for a patient’s dysphagia?
* Can they achieve normal (upright) posture? -> Provides a base for postural modifications.
* this needs to be evaluated and managed withing the team (PT and OT)
* Upright posture will improve the ability to self-feed, aid in airway protection and maximise comfort
43
Compensatory techniques: Postural techniques
| -Pharyngeal Posturing
* Chin tuck
* Head Rotation
* Head Tilt
* Side Lying
* Neck Extension
44
Compensatory techniques: Postural techniques
-Pharyngeal Posturing -> CHIN TUCK
* *MUST CHECK ON VFSS – not everyone’s anatomy reacts the same, not everyone does it the same (should put chin straight down, like a pivot. Don’t move neck forward)
* environmental cues: tray placed very close, dysphagia cup, straw (if not contraindicated)
To treat:
* delays in swallow
* poor tongue control
* reduced posterior tongue movement
* reduced airway closure
Works by:
* widens vallecular space
* narrows airway entrance
* pushes BOT back to PPW
* puts epiglottis in protective position
* *CONTRAINDICATIONS:
* poor oral closure (anterior spill)
* spillage into the piriforms for some people
*Poor laryngeal closure or elevation – be careful
Good evidence
45
Compensatory techniques: Postural techniques
-Pharyngeal Posturing -> HEAD ROTATION
* Rotate head to weaker side
* MUST CHECK ON VFSS
* Directs bolus down stronger side of pharynx through rotation of head to weaker side.
* Can be used in conjunction with a chin tuck.
- Less evidence than for chin tuck.
- lots of practice with clinician support
- Looks odd – people don’t like to do this in public
46
Compensatory techniques: Postural techniques
-Pharyngeal Posturing -> HEAD TILT
* Tilt head to stronger side
* MUST CHECK ON VFSS
* Tilting head to the stronger side allows the bolus to move down that way.
- difficult to maintain during a meal – lots of practice with clinician support
47
Compensatory techniques: Postural techniques
-Pharyngeal Posturing -> SIDE LYING
*Difficult to do VFSS – feeding at risk?
*to compensate reduced pharyngeal contraction resulting in diffuse pharyngeal residue
* Assess well before use – not suitable for many people. Issues of acceptance, compliance, self-ability to feed and socialise throughout means.
* *LOTS of caution
48
Compensatory techniques: Postural techniques
-Pharyngeal Posturing -> NECK EXTENSION
* CONTRAINDICATED for neuro-population. Use with head and neck cancer population.
* MUST CHECK ON VFSS
*Bypasses need for anterior-posterior bolus movement, using gravity to move the bolus.
* CONTRAINDICTED in people with delayed swallow response
* *LOTS of caution
49
Compensatory techniques: BOLUS CONTROL TECHNIQUES
| How do they work?
* Aim to redirect the bolus through functional (rather than structural) techniques.
* Some can be facilitated by the caregiver, but most depend on cognitive abilities (or environmental cues)
50
Compensatory techniques: BOLUS CONTROL TECHNIQUES
List some:
**Mostly used in conjunction with other strategies ie modified diet.
* 3 second prep
* Lingual sweep
* Cyclic ingestion
* Dry swallows
* Thermal gustatory stimulation
* Bolus placement
* Modification of bolus size
* Modification of intake rate
* Slurp and Swallow
51
Compensatory techniques: Bolus control techniques -> 3 SECOND PREP
*Successful with people with PD and also people with ataxia
* Developed to manage delayed pharyngeal swallow or tachyphagia (eating too quickly)
* 1, 2, 3 swallow – self or other
* Makes the usually automatic task of the swallow into a volitional task by inserting a conscious pause prior to the bolus transfer to allow organisation of bolus transfer and elicitation of the swallow
52
Compensatory techniques: Bolus control techniques -> LINGUAL SWEEP
* To clear oral residue, particularly useful for areas of weakness
* Can use tongue to purposively clear oral cavity, or use finger if tongue is too weak.
* also about teaching the client to be aware of the residue left in the buccal cavity.
53
Compensatory techniques: Bolus control techniques -> CYCLIC INGESTION
*Trial this and ensure it works for that person and really does clear the solids, to make sure they are safe.
* Alternate solids and liquids
* For pharyngeal weakness and dyscoordination, or hypertonicity of UES.
* Useful for oral residue
54
Compensatory techniques: Bolus control techniques -> DRY SWALLOWS
* MUST CHECK ON VFSS. Watch to see effect of fatigue – this technique can be fatiguing
* Some people can feel the food in their throat – will use this. Others can’t and need to be taught a ratio.
* for post-swallow residue
* Instruct client to have a swallow between boluses, or every second/third bolus, as per VFSS results.
* twice the work -> fatigue effect on muscles
* Don’t use for people with muscle fatigue issues??
55
Compensatory techniques: Bolus control techniques -> THERMAL GUSTATORY STIMULATION
* Chilled laryngeal mirror to stroke anterior faucial arches (5-6 times) prior to and during meals.
* Frozen lemon-glycerine swabs or lemon ice (not as well researched)
* Developed to treat delayed swallow response
* **Wears off really quickly – maybe works for first 2 swallows… Michelle has used to elicit swallow response where there has been none.
56
Compensatory techniques: Bolus control techniques -> BOLUS PLACEMENT
* Developed for difficulties in manipulation/sensation of bolus (e.g. place on stronger side)
* Position bolus at a point of strength within oral cavity
*practice. Play around with placement
57
Compensatory techniques: BOLUS CONTROL TECHNIQUES (Modification of bolus size and rate of intake)
How do they work?
* Developed for oral phase difficulties
* Some people: smaller bolus allows better motor control and manipulation [CHECK: can they judge to reduce their own bolus size? Smaller spoon?]
* Other people: Larger bolus gives better sensory feedback
* *MAKE SURE CLIENTS ARE ABLE TO BE RELIABLE AT ACTUALLY DOING THIS
58
Compensatory techniques: Bolus Control Techniques -> SLURP AND SWALLOW
* Good for partial glossectomy
* DO NOT USE in neuro population due to airway protection issues
*Developed for poor anterior-posterior bolus transfer -> allows transfer straight to the back of the pharynx
59
Compensatory techniques: VOLITIONAL AIRWAY PROTECTION STRATEGIES
How do they work?
Aim to place specific aspects of the swallow under voluntary control.
* The patient must be cognitively and linguistically capable to follow the directions
* These manoeuvres require significant effort! -> requires sustained motivation on part of patient.
60
* Supraglottic Swallow
* Super-supraglottic swallow
* Effortful swallow
* Mendelsohn Manoeuvre
* Pharyngeal expectoration
* Vocal quality checks
- > these are all…?
Compensatory techniques: VOLITIONAL AIRWAY PROTECTION STRATEGIES
61
Compensatory techniques: Volitional Airway Protection Strategies -> SUPRAGLOTTIC SWALLOW
* Closes VF before and during the swallow
* Good for people who are aspirating before the swallow
1. Take a deep breath. Hold it.
2. Keep holding your breath as you swallow.
3. Cough immediately post-swallow
* *Difficult to learn, and to maintain over the course of a meal.
62
Compensatory techniques: Volitional Airway Protection Strategies -> SUPER-SUPRAGLOTTIC SWALLOW
**CONTRAINDICATED for people with heart or blood pressure issues
* Effortful breath hold closes airway entrance before and during the swallow by tilting arytenoids forwards and closing the false vocal folds.
1. Inhale and hold your breath tightly, bearing down.
2. Keep holding your beath and bearing down as you swallow.
3. Cough when breathing out
* *Hard to do. Very tiring.
63
These two manoeuvres can be both rehabilitation techniques and compensatory techniques (short term effect, can strengthen muscles for long-term benefit)
* Mendelsohn Manoeuvre
| * Effortful Swallow (modified Valsalva)
64
Compensatory techniques: Volitional Airway Protection Strategies -> PHARYNGEAL EXPECTORATION
*Clearing throat after meal (or more often?)
65
Compensatory techniques: Volitional Airway Protection Strategies -> VOCAL QUALITY CHECKS
Training the client in what to listen to re: vocal quality, and practice this a lot.
*If they have signs of gurgliness or poor voice quality they implement one of the other strategies (ie pharyngeal expectoration).
66
Compensatory techniques: PROSTHETIC DEVICES
| Some examples:
* Palatal lifts
* Trache valves (valves put on the front of a tracheostomy tube to help people swallow a little bit easier)
**Not broadly used for the neuro population
67
Compensatory techniques: MODIFYING DIET CONSISTENCIES
AVOID:
* Mixed consistencies
* Crumbly foods
* Foods that don’t form a cohesive bolus
IDDSI – 8 levels (0-7)
Drinks: 0-4
Foods: 3-7
**3 and 4 overlap: Liquidised food = moderately thick fluid (3), and
Pureed food = Extremely thick fluid (4)
68
Measurement of outcomes in dysphagia. Ask…
* What are we trying to measure?
* What are our goals?
* Why might we collect outcome data?
69
Some outcome measures to use for dysphagia:
* Royal Brisbane Hospital Outcome Measure for Swallowing (“Impairment” and “activity”)
* SWAL-QOL – QoL measure
* AUSTOMS – all areas of ICF
* FOIS (Functional Oral Intake Scale)
70
SWAL-QOL and SWAL-CARE
*Measures QoL in people with dysphagia (44 items)
*Validated and reliable
*Range of populations
Qs (Eating, Food selection, Symptom frequency/bother, Mental health)
71
Australian Therapy Outcome Measures (AusTOMs) (Perry & Skeat, 2004)
*Use at beginning and end of therapy
6 AusTOM scales for Speech Pathology
* Speech
* Language
* Voice
* Fluency
* Swallowing
* Cognitive Communication
- > each 5 point rating scale relates to ICF domains of impairment, activity limitation, Participation restriction and distress/wellbeing
72
Functional Oral Intake Scale (FOIS)
(Crary, Carnaby-Mann & Grher, 2008)
* Tested for validity and reliability
* take at beginning and end of intervention, for everyone.
7 point scale
* Level 1: NBM
* Level 2: Tube dependant w/minimal attempts at food/liquid
* Level 3: Tube dependant with consistent oral intake of food/liquid
* Level 4: total oral diet of single consistency
* Level 5: total oral diet with multiple consistencies, but requiring special preparation or compensations
* Level 6: total oral diet with multiple consistencies without special preparation, but with specific food limitations
* Level 7: total oral diet with no restrictions
73
EAT-10 (Belafsky et al, 2008)
* Quick, do at admission and discharge (more frequently for longer clients) for all clients
* provides patient’s perception of their swallow and how it affects them.
* 10 Q measure using 5 point rating scale
* Score >3 means likely dysphagia
* Good reliability/validity
74
Mann Assessment of Swallowing Ability (MASA) (Carnaby-Mann, 2002)
* tested for reliability and validity on stroke population
* Dysphagia clinical assessment that can also be used as an outcome measure
* 24 clinical items for evaluation of oropharyngeal dysphagia following stroke
* Each score weighted on a 10 point scale
* Gives an overall numerical score as well as a risk rating.
75
Clinical data and VFSS are also a good form of…
Outcome measurement
