(110) Demystifying Research in a Clinical Setting: How Working Clinicians Completed a Research Study in a Clinical Setting in Order to Understand the Influence of Verbal Instructions and Delivery Method on Bolus Size with Healthy Adults
Sophia Bjerga, M.A., CCC-SLP: No financial or non-financial relationships to disclose
Katherine Cipriano, M.A., CCC-SLP: No financial or non-financial relationships to disclose
Michael Pietrantoni, M.A., CCC-SLP: No financial or non-financial relationships to disclose
Susan Brady, DHEd, M.S., CCC-SLP, BCS-S: No financial or non-financial relationships to disclose
Abstract: Clinical speech-language pathologists (SLPs) have experiences that provide them a unique perspective when approaching the world of research. As a full-time clinician, it can seem daunting to begin a research project in the clinical setting. This session will provide an overview of the steps involved with clinical research and practical tips on how clinical SLPs can get involved with research. Additionally, this session will discuss the research findings investigating the effects, if any, that various conditions (i.e., verbal instructions and delivery method) may have on thin liquid bolus amounts in healthy adults. Clinical implications for swallow safety and indications for future research studies will be discussed.
Summary of Presentation : This presentation will identify the key components required to initiate a research study and outline how working clinicians can conduct research in a clinical setting. Challenges encountered, support required, and lessons learned will be reviewed. The first part of this presentation will break down the barriers that may seem intimidating to a clinical SLP who is interested in research. To begin research in a clinical setting, an SLP must first consider a research question of interest. Understanding key research elements, such as research designs, statistics, rules, and regulations, is essential to creating a well thought out and successful research study. SLPs should consider their target audience, how to disseminate research findings, and how to expand their research findings to new areas of investigation in the future. The presentation will provide an example of an application of these lessons learned in a research project conducted at an inpatient rehabilitation hospital. The second part of the presentation will describe the specific components of a dysphagia research study conducted by the presenter who is a clinical SLP. The purpose of this study was to evaluate the effects, if any, that verbal instructions and delivery method may have on bolus size. Bolus modification, such as reducing the bolus size, is a frequently used intervention for treating individuals who present with volume dependent aspiration (Brady & Leder 2019; Brady & Donzelli, 2016). Clinically, different instructions or delivery methods may be employed to assist the patient with successfully reducing the bolus size to increase swallow safety. One strategy commonly used in clinical practice is to restrict the use of straws for individuals with dysphagia in an attempt to reduce bolus size and increase swallow safety. Another common clinical strategy is to use specific instructions in an attempt to facilitate a smaller bolus size. This may include something as simple as “take a small sip” or the clinician may include a pragmatic cueing strategy to facilitate a small sip such as “take a small sip like it's hot coffee”. Further, the carryover of these bolus reducing strategies are also used during meals for ongoing swallow safety. While these strategies are commonly used in clinical practice, it is unknown if there are actual differences in how an individual may respond to the delivery method or to various verbal instruction. To date, the effects of the verbal instruction on bolus size has not been previously investigated. This research study employed a prospective, randomized, repeated measure design using a convenience sample of healthy adults. Inclusion criteria included health volunteers from the community between the ages of 18-89 years with no previous history of head / neck cancer, stroke or neurologic disease, or history of swallowing difficulties. The subjects had adequate hearing and cognitive skills to follow one-step commands, and the physical ability to self-administer a bolus from a cup or straw. Subjects were initially randomized into either the cup group or the straw group. Each subject consumed eight boluses of water under the following four instructions: 1) Take a drink; 2) Take a comfortable sip; 3) Take a small sip; 4) Take a small sip like it is hot coffee. The order of instruction was randomized and each subject had eight cups prepared (4 cups with 60-ml of water in a 120-ml cup; 4 cups were prepared with 120-ml of water in a 240-ml cup). Each cup and its content (water) were weighed after each administration to extrapolate the volume consumed under each condition. The pilot data from this project included an analysis of 80 boluses across 10 subjects. The final research study will include data from up to 100 participants. The pilot results revealed statistically significant differences between the different instructions (Take a drink = 21.78ml; Take a comfortable Sip= 16.15ml; Take a small sip = 5.8 ml; and Take a small sip like it is hot coffee = 3.45ml; F=12.625, p≥.0001). No statistically significant differences observed between the mean volume bolus size consumed between the delivery methods for cup vs. straw (cup = 12.46 ml; straw=10.22ml; t=0.904, p=.369) or for cup size (4-ounce cup=10.43ml; 8-ounce cup = 11.8ml; t=.0554, p=.581). Results from the pilot data provide evidence to support that verbal instructions influences bolus size with healthy adults. The use of a simile in the verbal instruction (i.e., “like it is hot coffee”) resulted in the lowest volume consumed by the study participants. The mean bolus size for a “comfortable sip” instruction (12.56ml) was comparable to previous research by Steel et al., (2019) of 12.12ml. Further, the preliminary data suggest that what we do clinically when providing verbal instructions to facilitate a safe swallow can have implications. Implications for the dysphagia rehabilitation team will be discussed to further highlight the importance of clinical SLPs getting involved with research.
SELECTED References: Brady, S.L., & Leder, S. (2019). Endoscopic Evaluations. In D. Suiter & M. Gosa (Eds). Dysphagia: Diagnosis and Treatment in Children and Adults. New York, NY: Thieme Publishers Fager, S., Hakel, M., Brady, S., Nordness, A., Delgado, A.,Barlow, S. , Palmer, J. B. (2015). Speech and Swallowing Disorders. In D. Cifu & K. Kowalski (Eds). Braddom's Physical Medicine and Rehabilitation (5th Ed). Elsevier Inc Brady, S., & Donzelli, J. (2013). The modified barium swallow and the functional endoscopic evaluation of swallowing. Otolaryngology Clinics of North America, 46(6):1009-22. doi: 10.1016/j.otc.2013.08.001. Brady, S., Pape, T., Darragh, M., Escobar, N., & Rao, N. (2009). Feasibility of instrumental swallowing assessment in patients with prolonged disordered consciousness while undergoing inpatient rehabilitation. Journal of Head Trauma, Sept-Oct, 384-391. . Brady, S., Darragh, M., Escobar, N., O’Neil, K., Pape, T., & Rao, N. (2006). Persons with disorders of consciousness: Are oral feedings safe/effective?” Brain Injury, December, 20 (13-14): 1329-1334. Gaeckle M, Domahs F, Kartmann A, Tomandl B, & Frank U. Predictors of Penetration-Aspiration in Parkinson's Disease Patients With Dysphagia: A Retrospective Analysis.Ann Otol Rhinol Laryngol. 2019 Apr 2:3489419841398. doi: 10.1177/0003489419841398. [Epub ahead of print] Leder SB, Suiter DM, Green BG. Silent aspiration risk is volume-dependent. Dysphagia. 2011 Sep;26(3):304-9. doi: 10.1007/s00455-010-9312-2. Epub 2010 Nov 10. Clark HM, Anderson CC, Hietpas F. Volumes of discrete sips from straws of varying internal diameters. Am J Speech Lang Pathol. 2014 Feb;23(1):84-9. doi: 10.1044/1058-0360(2013/13-0032). Lawless HT, Bender S, Oman C, & Pelletier C. (2003). Gender, Age Vessel Size, Cup vs. Straw Sipping, and Sequence Effects on Sip Volume. Dysphagia, 18, 196-2003. doi: 10.1007/s00455-002-0105-0 Bennett JW, Pascal HW, Van Lieshout, Pelletier C, & Steele CM. (2009). Sip-Sizing Behaviors in Natural Drinking Conditions Compared to Instructed Experimental Conditions. Dyspahgia, 24, 152-158. doi: 10.1007/s00455-008-9183-y Steele CM, Peladeau-Pigeon M, Barbon CAE, Guida BT, et al., (2019). Reference Values for Healthy Swallowing Across the Range from Thin to Extremely Thick Liquids. Journal of Speech Language Hearing Research, 21 (62), 1338-1363. doi: 10.1044/2019_JS:HR-S-18-0448
Learning Objectives:
At the completion of this activity, participants should be able to:
Describe the key elements required to initiate a research study in a clinical setting.
Describe an example of a research project completed in a clinical setting
Explain the effects, if any, that various conditions (i.e., verbal instructions and delivery method) may have on bolus amounts with self-administration of thin liquids.