Each month, Informed SLP members receive a link to read, print, or listen to the Evidence You Can Use reviews:
You can also browse archives by topic:
…or search for a specific topic:
Here are some sample reviews.
They’re all editorial reviews of the research, with lots of links out to additional information and sometimes even free therapy materials (that’s our favorite— when the scientists share treatment protocols!)
True or False: Healthy people do not silently aspirate.
FALSE! Huh? According to this study by Butler et al. (2018), while most healthy participants, of course, did not have penetration or aspiration, 18% of participants aspirated at some point during the study and 75% of those aspirators did not cough or clear their throats. Let’s dig a little deeper into the details:
The participants, aged 30–90, in this study were all HEALTHY. No history of swallowing, speech, or voice problems and no known neurologic or otolaryngologic disorders. They could walk, talk, and they all considered themselves to be healthy. No remote stroke. No reported pneumonias. Anyone with a reason for an SLP referral was not included in this study.
This study used Fiberoptic Endoscopic Evaluation of Swallowing (FEES) to look at the Penetration-Aspiration Scale (PAS) ratings of swallows of different volumes of water and milk. The breakdown of these results by age, sex, volume, and more is in Tables 3 and 4 and they are definitely worth looking at yourself if you ever read or write FEES reports.
Let’s get back to healthy people silently aspirating. First, over 80% of penetration episodes and 64% of aspiration episodes did not cause a throat clear or cough. This means we need to seriously reevaluate the assumption that silent aspiration is necessarily disordered and consider if, in general, we are over-interpreting penetration or aspiration that does not cause a response.
How much aspiration are we talking about here? The author describes “the majority (but not all) of the aspiration events in this study to be trace in nature ranging from a pea-sized amount of aspirate just below the level of the vocal folds to a small thin line of aspirate coursing down the anterior trachea.” So, it’s there, but typically not a ton of liquid entering the lungs. Also, most of the participants who aspirated did so intermittently. A third of the participants in their 80s silently aspirated at least once, but this only occurred in less than 3% of the trials.
Most of the people who were aspirating, silently or not, were over 60 with an increasing chance of aspiration as the participants got older. And, overall, PAS scores were slightly higher for milk (2% or whole) when compared with water, though this effect was only significant in participants over 70 (Figure 1). While the impact wasn’t huge, if you typically use milk in your FEES studies and your patient aspirated, you could consider also testing water. Or vice versa, depending on your concerns for that particular patient.
These results also raise the question: how do we know these “healthy” people aren’t actually getting sick from what they’re aspirating? While we don’t know for sure, there were no significant differences between aspirators and non-aspirators when looking at chest CTs. These healthy aspirators appear to be, well, healthy.
There are too many interesting findings in this article to discuss all of them here. Read the article to find out more about differences in aspiration risk between men and women and if aspirators and nonaspirators stayed in those same groups over time.
Anything else? Yes. We have to keep in mind that these results only apply to FEES. These results are inconsistent with findings from normative studies done with videofluoroscopy of older people. The authors discuss some possible reasons, but for now, stick with using these results to help interpret FEES.
The main takeaway from this study is that the normal range of aspiration is likely bigger than we had previously thought, especially in people over 60. These findings are a good reminder for us to always consider the whole picture of a patient’s health, history, and risk factors for aspiration pneumonia before automatically interpreting (silent) aspiration as disordered and something to be avoided at all costs.
Butler, S.G., Stuart, A., Markley, L., Feng, X., Kritchevsky, S. (2018) Aspiration as a Function of Age, Sex, Liquid Type, Bolus Volume, and Bolus Delivery Across the Healthy Adult Life Span. Annals of Otology, Rhinology & Laryngology. doi: 10.1177/000348.
Ahhh! How intense should voice treatment be?
Treatment intensity is not a new topic for The Informed SLP (see How much treatment is enough?), but it’s worth discussing in our new adult medical section as it is a topic that spans the ages—and the research!
Two recent articles tackle this subject by exploring optimal frequency and dosage for voice treatment.
In the first study, researchers compared massed practice (“intense” training with closely timed treatment sessions) to spaced practice ("traditional" treatment with longer intervals between sessions). They found that short-term, intense voice treatment was at least equally effective as traditional treatment for individuals with dysphonia even after 1 year. In this service delivery model, participants had better compliance with appointments than in the "traditional" model. However, participants did not report significant improvement in daily living on psychosocial measures. This study supports the idea that there may be a “golden mean” between intensive and traditional therapy frequency. This may come as a relief in the face of a high caseload, limited appointment availability, insurance limitations, transportation issues, etc.
Researchers offer the following suggestions for designing your client’s voice treatment:
Start with intense frequency, reduce number of sessions gradually + periodic follow up
Start with intense frequency, switch to follow-up sessions only + return to intense practice, as needed
Or a combination: Start with intense frequency, reduce sessions gradually + follow-up program (with the option of returning more intense practice down the road, if needed)
Bottom line? Intense frequency first, then go from there.
Bonus! The second study we’re covering found that intensive group treatment may be just as effective as individual treatment, which also may help us maximize scheduling time.
Another important factor when it comes to providing intense treatment is home practice. There is no better feeling than when you can tell your client has been practicing! This study gives some insight about how prescribed homework “dosage” of vocal function exercises can impact outcomes. Researchers found that high-dosed practice showed the greatest improvement in maximum phonation time. However, the participants who were asked to perform exercises 2x a day (as opposed to 4x a day) had better compliance than their high-dose counterparts. In fact, 50% of the "high-dose" participants withdrew from the study! Participants who were asked to practice only 1x a day also had poorer compliance compared to the 2x a day folks. This suggests that asking too much—or too little— of our clients when it comes to home practice can backfire. Remember the “golden mean” idea from the previous study?
It is important to note, that this study was completed using "normal" voice participants. It is unclear if having a voice disorder might change your motivation to participate in treatment, which warrants further investigation.
Bane, M., Vrushali, A., Dressler, E., Andreatta, R. & Stemple, J. (2019). Vocal function exercises for normal voice: The effects of varying dosage. International Journal of Speech–Language Pathology. doi: 10.1080/17549507.2017.1373858.
Meerschman, I., Claeys, S., Bettens, K., Bruneel, L., D'haeseleer, E., & Van Lierde, K. (2019). Massed versus spaced practice in vocology: Effect of a short-term intensive voice therapy versus a long-term traditional voice therapy. Journal of Speech, Language, and Hearing Research. doi: 10.1044/2018_jslhr-s-18-0013.
Stuck trying to retrieve a word? Try drawing it!
Remember all those years you spent honing your drawing skills so you could beat your folks at Pictionary? Turns out that may just be handy when you or your client with aphasia are stuck trying to get a word out.
This study by Hung & Ostergren suggests that if you’re working with persons with aphasia (PWA) on naming, you may see more success if they draw the item instead of write it.
In the study, 15 PWA, ranging in age from 44 to 81 years, were given the same set of 30 black and white pictured items to name on three different days under three different conditions:
naming the picture without strategies (confrontation naming; CN)
naming the picture with a drawing strategy (DN)
naming the picture with a writing strategy (WN)
The authors found that regardless of the type of aphasia, the quality of the drawing, or one’s ability to recognize the item, a PWA was more likely to name an item when they were drawing its image versus writing its name. So even a participant with non-fluent aphasia produced target words more accurately when they were drawing it.
But there are some caveats: Not surprisingly, the authors found that the severity of aphasia affected one’s ability to name an item. Compared to persons with mild aphasia, persons with moderate or severe aphasia were more likely to benefit from this strategy of drawing as a facilitative technique for retrieving a word. For persons with mild aphasia with preserved or relatively strong writing skills, writing was as much a strength as drawing when it came to word retrieval.
Why is drawing a more effective route to word retrieval compared to writing? The authors speculate that the act of drawing promotes deeper semantic processing of the key features of the item. Drawing therefore activates the semantic network more strongly compared to writing. Unlike drawing, writing heavily relies on the left hemisphere and linguistic systems. Writing also increases the cognitive–linguistic demands for word-retrieval. There is a growing body of evidence that supports the use of drawing as a more effective solution to word retrieval compared to writing. In fact, Hung & Ostergren (2019) replicated the findings of Farias and colleagues who used fMRI data to explore the neural effects of drawing, (2006).
Another rationale proposed by the authors is that drawing activates cerebral hemispheres bilaterally, thereby stimulating the semantic network more strongly for retrieval. The authors “draw” upon previous research to support their hypothesis that drawing activates both hemispheres to facilitate recall of key visual features and mental images associated with the item.
What does this mean for clinical practice? Perhaps we need to start incorporating assessment of drawing skills as part of our evaluation routine. One such tool under study is the Drawing Assessment Protocol. In terms of intervention, consider including drawing in your semantic feature analysis routine. Looking for stimuli ideas? Hung and Ostergren (2019) used line drawings from the Reading Comprehension Battery for Aphasia– 2nd Edition.
Like what you see so far?
That was just three web-based reviews. Remember— we also have printable and audio versions for members!
Each month, we search hundreds of journals trying to find clinically-relevant research to cover, and share everything usable that we find with you!
Want more info? Here’s our team. And please don’t hesitate to email us at firstname.lastname@example.org with any questions you have!