Use of the ICF in Dysphagia Management

Travis T. Threats, Ph.D.1

ABSTRACT

The evaluation and intervention of persons with dysphagia repre-sents a significant percentage of speech-language pathologists’ caseloadsin medical settings. Because of its overtly medical nature, there has beenconsiderable focus dealing with the direct physical health aspects ofdysphagia management. This article argues that the use of the WorldHealth Organization’s International Classification of Functioning, Disabil-ity and Health (ICF) by clinicians can expand and greatly enhance theoutcomes for persons with dysphagia. The different components of the ICFare discussed in relation to dysphagia assessment and management. Thearticle concludes by noting that speech-language pathologists can usethe ICF framework beneficially to justify and strengthen their role in themanagement of dysphagia.

KEYWORDS: ICF, dysphagia, outcomes

Learning Outcomes: As a result of this activity, the reader will be able to (1) demonstrate an understanding of

dysphagia as a potential social disability, (2) demonstrate an understanding of how dysphagia can be assessed and

treated via the components of the ICF, and (3) demonstrate an understanding of how viewing dysphagia through

the ICF framework can enhance dysphagia management.

The exact prevalence and incidence ofdysphagia is not known but it is estimated thatprevalence may be as high as 22% in those olderthan 50 years of age; �10 million individuals inthe United States are evaluated each year forswallowing difficulties.1 Dysphagia assessmentand intervention accounts for a significant per-

centage, in some cases the majority, of thecaseload for speech-language pathologists whowork in medical settings. Speech-languagepathologists work with persons with difficultiesin the oral and pharyngeal stage of the swallow,which includes from entry of food into themouth until the time food enters the esophagus.

1Associate Professor and Chair, Department of Commu-nication Sciences and Disorders, Saint Louis University,St. Louis, Missouri.

Address for correspondence and reprint requests: TravisT. Threats, Ph.D., Department of Communication Sciencesand Disorders, Saint Louis University, 3750 Lindell Blvd.,St. Louis, MO 63108 (e-mail: threatst@slu. edu).

The International Classification of Functioning,

Disability and Health (ICF) in Clinical Practice; GuestEditors, Estella P.-M. Ma, Ph.D., Linda Worrall, Ph.D.,and Travis T. Threats, Ph.D.

Semin Speech Lang 2007;28:323–333. Copyright #

2007 by Thieme Medical Publishers, Inc., 333 SeventhAvenue,NewYork,NY10001,USA.Tel:+1(212) 584–4662.DOI 10.1055/s-2007-986529. ISSN 0734-0478.

323

Of all the disorders speech-language path-ologists evaluate and treat, dysphagia is themost medical in a traditional sense of a medicaldisorder being one that could potentially resultin death. Dysphagia can result in aspirationpneumonia, malnutrition, dehydration, de-creased functioning of the pulmonary system,and inability to take medications orally. De-creased saliva production can also increase thelikelihood of oral bacteria developing in the oralcavity and spreading to the rest of the body.

The World Health Organization (WHO)defines health as ‘‘the complete physical, men-tal, and social well-being and not merely theabsence of disease or infirmity.’’2 In the case ofdysphagia, which can cause disease or infirmity,it might appear that this expanded definition ofhealth is not necessary. However, when dys-phagia is examined broadly, it is clearly not onlya chronic disability but also one that has po-tential activity/participation limitations andpsychosocial consequences, some of which aresimilar to having a communication disorder.Viewing dysphagia through the lens ofWHO’s International Classification of Func-tioning, Disability and Health (ICF)3 can thusexpand speech-language pathologists’ viewand approach to dysphagia assessment andintervention.

Unlike communication disorders such asaphasia, the literature on dysphagia rarely dis-cusses dysphagia in terms of life effects, con-centrating mainly on direct health effects.DeRenzo4 states the following:

Although there are no universal foodcustoms or dietary laws, every society, frompreliterate to technologic, develops eating anddrinking customs and attaches symbolic valueto certain foods and ways of consuming spe-cific nutrients. These customs dictate whatmay and may not be consumed, at what times,and in what places. Most often, these customshave little to do with nutritive factors but are,instead, designed to delineate and solidifysocial relationships. Religious and secular cer-emonies are replete with ritualistic eating anddrinking behaviors symbolizing life and mer-riment. The gaiety of the bacchanal continuesto symbolize life and vitality to this day. Theprovision of food and drink, whether or not

actual feasting occurs, is characteristic of mostrites of passage. . ..Often saying ‘‘We eat to-gether’’ is saying, ‘‘We trust each other, evenif we are not members of the same tribe orkin. This is as true for the Nyakyusa ofTanzania as for teenagers in a U.S. highschool cafeteria. The meanings we attach toeating and drinking, and swallowing are con-nected to our most cherished activities andremind us of the intangibles of human ex-istence—trust dependence, social worth, andlove—and, therefore, become integral to howwe see ourselves as individuals and in relationto others’’ (p. 102–103).

It is striking how the above quote alsodescribes human communication. It is alsotrue that communication and swallowing occurtogether, a characteristic rarely discussed in thedysphagia literature despite the crucial impli-cations for dysphagia management of personsin their natural environments. This quoteshould inform those in the field how limitingit is to view dysphagia in purely technical ratherthan more than humanistic terms.

Dysphagia is described in this article usingthe components of the ICF: Body Structures,Body Functions, Activities and Participation,Environmental Factors, and Personal Factors.All ICF codes have qualifiers that indicate theseverity of the limitation or restriction. Theseuniversal qualifiers attached to the ICF codesrange from 0 (no problem or within normallimits) to 4 (complete or profound problem).The relationships among these different com-ponents of the ICF are discussed, an exampleusing the ICF to describe dysphagia is de-scribed, and a rationale for why speech-lan-guage pathologists should adopt the ICFframework in their work with this populationis discussed.

ICF BODY STRUCTURE AND BODYFUNCTION COMPONENTS ANDDYSPHAGIAThe Body Structures and Body Functions codesthat directly describe aspects of swallowing arepresented in Tables 1 and 2, respectively. Inaddition, the Body Functions codes that de-scribe behaviors that may influence food and

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liquid intake are presented in Table 3. The BodyStructures items cover parts of the neurologicalsystem, and structures needed to carry out thephysical act of taking food into the mouth,appropriately handling it, and getting it intothe stomach, such as teeth, tongue, the jaw, andthe larynx. These Body Structures codes can bemodified via use of the qualifiers to specify howthe structure deviates from the norm (e.g.,deviating position, partial absence) and whetherthe abnormalities are unilateral or bilateral.

The Body Functions codes that directlydescribe the swallowing process including spe-cific movements such as Biting (b5101), as wellas more global codes such as Pharyngeal swal-lowing (b51051). The qualifier for these codes

describes the extent that the movement, speed,and efficiency of the movement deviate fromthe norm. In addition, there are several BodyFunctions codes that have a significant impacton whether a person will be a successful ineating and drinking. The oral stages of theswallow are voluntary and thus require cogni-tive input to complete successfully. The phar-yngeal stage of the swallow is initiated byspecific oral manipulations of the food by thetongue. Thus both the oral and pharyngealstages of the swallow require cognitive inputto function optimally. As a result, ICF BodyFunctions codes dealing with motivation, ap-petite, taste, attention, insight, and memoryfunctions are included in Table 3. These be-haviors need to be assessed to address compre-hensively the swallowing difficulties of thosewith dysphagia because they contribute to riskfactors for aspiration (food going into thelungs) and choking.

ACTIVITIES AND PARTICIPATIONAND DYSPHAGIAThe Activities and Participation codes dealingdirectly with the intake of food and liquid arelisted in Table 4 and Activities and Participa-tion codes related to eating and drinking be-haviors are listed in Table 5. As statedpreviously by DeRenzo,4 eating is a socialbehavior and thus the evaluation of the severityof the swallow should also include the effects ofdysphagia on these activities. In the Activities

Table 1 Body Structures Codes: Swallowing

s320 Structure of mouth s330 Structure of pharynx

Teeth s3300 Nasal pharynx

Gums s3301 Oral pharynx

s3202 Structure

of palate

s340 Structure of larynx

s3203 Tongue s3400 Vocal folds

s3204 Structure of lips s398 Structures involved

in voice and speech,

other specified

s3208 Structure of

mouth, other specified

s399 Structures involved

in voice and speech,

unspecified

s3209 Structure of

mouth, unspecified

s510 Structure of

salivary glands

s520 Structure of

esophagus

Table 2 Body Functions Codes: Swallowing

b510 Ingestion Functions b5101 Swallowing

b5100 Sucking b51050 Oral swallowing

b5101 Biting b51051 Pharyngeal

swallowing

b5102 Chewing b51052 Esophageal

swallowing

bB5103 Manipulation

of food in mouth

b51058 Swallowing,

other specified

b5104 Salivation b51059 Swallowing,

unspecified

Table 3 Body Functions Codes: Influences onEating/Drinking Behaviors

b110 Consciousness

functions

b140 Attention functions

b117 Intellectual

functions

b144 Memory functions

b1301 Motivation b147 Psychomotor

functions

b1302 Appetite b156 Perceptual

functions

b1303 Craving b1644 Insight

b1670 Reception of

language

b1646 Problem-solving

b2102 Quality of vision b 255 Smell function

b250 Taste function

USEOFTHEICFINDYSPHAGIAMANAGEMENT/THREATS 325

and Participation component, there are fourpotential qualifiers. The first and fourth quali-fiers relate to the behavior in persons’ real livesand are the performance qualifiers. The secondand third qualifiers refer to behavior directlyobserved in the clinical setting and are thecapacity qualifiers, with the former being howa person does without clinical assistance, suchas in an assessment, and the latter how a persondoes with clinical assistance, such as cueingfrom the clinician. The first performance quali-fier describes how persons function in theiractual lives and the fourth performance qualifierdescribes how persons would function if theyhad no assistance from the environment.

The four qualifiers of the Activities andParticipation component are critical areas forspeech-language pathologists to systematicallyevaluate and examine the relationships among

them. In a typical clinical noninstrumentalevaluation of the swallow, clinicians announceto the clients that they are there to observethem eat to evaluate their swallowing. Theclients are told to eat while the clinicians closelyobserve the activity and also often palpate thethroat for signs of pharyngeal dysphagia. Thisevaluation makes the act of eating very sterileand clinical as opposed to the more normalcongenial manner of eating with other individ-uals. After this evaluation, the clinicians writeup the observations in the most objective lan-guage possible. The clients know that not onlyare they being evaluated, but also that theclinical judgment will influence what types ofdiets will be recommended. There is no talkingduring the evaluation and clients often are noteating food they particularly enjoy, especially ifthey are being evaluated in a medical setting.Contrast this clinical, sterile scene with eatingat a wedding. At a wedding, there is talking(often over noise) eating and drinking, and thedrink may well contain alcohol. The persons arehappy to be there and the food and drink are ameans to celebrate. The behaviors representedby the Body Functions codes that contribute tosuccessful eating and drinking can be markedlydifferent in the person’s natural environments,especially the cognitive behaviors such as atten-tion. Considering that dysphagia has directhealth consequences, overall eating behaviorthat is different from that observed in the clinicmust be addressed in intervention.

In the evaluation of eating and drinkingcodes of the Activities and Participation com-ponent of the ICF, it is important to note howbroadly these codes are written. They includegetting the food from the plate to the successfulswallow, as well as other behaviors such asappropriately using utensils and opening bottles.This type of evaluation necessitates an interdis-ciplinary approach. No one member of a singleprofession may be able to adequately rate thesecodes on his or her own; the two principalprofessions are speech-language pathology andoccupational therapy. This interdependencemay actually be best for patients in that adequateoverall eating and drinking behavior is the goalfor all patients. Awareness and appreciationof all aspects of eating, including Body Func-tions (e.g., biting and sustained attention),

Table 4 Activities and Participation Codes:Swallowing

d550 Eating Carrying out the coordinated tasks

and actions of eating food that

has been served, bringing it to the

mouth and consuming it in a

culturally acceptable ways, cutting

or breaking foods into pieces,

opening bottles and cans, and

using eating implements, having

meals, feasting or dining

d560 Drinking Taking hold of a drink, bringing it to

the mouth, and consuming the

drink in culturally acceptable ways,

mixing, stirring, and pouring liquids

for drinking, opening bottles and

cans, drinking through a straw or

drinking running water such as

from a tap or a spring; feeding

from the breast.

Table 5 Activities and Participation Codes:Related to Eating/Drinking

d630 Preparing meals

d850 Remunerative employment

d9100 Informal associations

d9191 Ceremonies

d920 Recreation and leisure

d9300 Organized religion

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Activities and Participation (e.g., successfullyeating the food to the mouth), EnvironmentalFactors (e.g., lighting in room, pleasantness ofeating partners), and Personal Factors (e.g., foodpreferences) need to be realized by all membersof the interdisciplinary team, regardless theirdiscipline specific goals for the patient. If theindividual spills half of the food getting it fromthe plate to the mouth, or spills half of the foodfrom the mouth while chewing, the result is stillincreased chance of malnutrition. In addition, ifthe individual has trouble with one or bothactivities, the client’s ability to eat appropriatelyin social settings is severely compromised. Sucha person might avoid eating with others with theconsequence that they end up eating very little atall. In addition, important ritualistic eatingcould be affected, such as that associated withreligious ceremonies (e.g., a devout RomanCatholic person being unable to take HolyCommunion).

ENVIRONMENTAL FACTORS ANDPERSONAL FACTORS INDYSPHAGIAThe Environmental Factors component of theICF is needed to understand fully the impact ofdysphagia on persons. The Environmental Fac-tors codes most related to swallowing are listedin Table 6. Unlike the other qualifiers in theICF, environmental factors can be evaluated aseither facilitators or barriers. As seen in Table 6,environmental factors include immediate facil-itators or barriers, such as whether the appro-

priate food consistency is available, to othereffects such as the support and attitudes offamily members. For example, Attitudes ofhealth professionals is a code in the ICF andmay affect whether a given patient is evendeemed appropriate for dysphagia intervention,such as with frail elderly patients.

Attitudes and support of all persons in theclients’ environments are influenced by culture.One of the signatures of any culture is whatfoods are consumed and how they are con-sumed. The effect may be that two peoplewith technically the same severity of dysphagiamay function very differently because of theirculture. For example, in cultures that favor largeconsumption of meats, a person with difficultywith mastication of dry foods may have moretrouble eating socially than in a person with thesame dysphagia symptomatology in a culturethat eats mostly rice and soft vegetables.

Personal factors are those characteristics ofthe person that are not related or due to thehealth condition. They include demographicinformation, such as age and race, as well aspersonality traits, such as coping styles andmotivation. Given that eating and drinkingare behaviors, they are subject to wide individ-ual variations in food and liquid preferences aswell as eating styles. Some people are fast eatersand others premorbidly ate slowly; some peopleeat a lot, whereas others eat relatively little. Inliquid preferences, there are those who drinkcoffee all day and those who only drink water.In terms of personality, some people reactto challenge with despair, whereas others ap-proach all challenges pragmatically and sys-tematically. When persons have dysphagia,these preferences and personality traits influ-ence everything from their reaction to havingdysphagia to how willing they are to followdysphagia precautions.

When dysphagia recommendations goagainst a person’s personal and/or environmen-tal factors, there are ethical issues because of thedirect health aspect of swallowing. Two of thetenets of health care ethics are autonomy andbeneficence.5 Autonomy refers to persons’ rightto make their own health care decisions, even ifthey contradict those of health care professio-nals. Beneficence refers to making sure thatmaximum benefit is provided to those persons

Table 6 Environmental Factors Codes:Swallowing

e1100 Food

e115 Products and technology for personal use in

daily living

e240 Light

e250 Sound

e310 Immediate family

e320 Friends

e340 Personal care providers and personal assistants

e410 Individual attitudes of immediate family

members

e450 Individual attitudes of health professionals

e580 Health services, systems and policies

USEOFTHEICFINDYSPHAGIAMANAGEMENT/THREATS 327

given intervention. In its annex discussing theethical use of the ICF, the ICF states that theICF codes should be assigned with full knowl-edge of the persons whose behavior is beingevaluated, with the person having the right toobject. The ICF emphasizes the autonomyaspect of health care ethics. In the use of theICF, there are several ethical dilemmas thatcould occur in dysphagia management. Forexample, if a person has a cognitive-communi-cative disorder along with dysphagia, thespeech-language pathologists might be likelyto attribute his or her refusal to follow dyspha-gia recommendations to decreased insight andthus an impairment rating would be warrantedon that ICF Body Functions code. If a personhas the right to know what his or her ICFcode rating is, then there could be conflictbetween the clinician and the patient over adecreased insight code being used to justifyviolating individual autonomy regarding foodpreferences.

DYSPHAGIA ASSESSMENTThe American Speech-Language-Hearing As-sociation (ASHA) Preferred Practice Patternsfor the Professional of Speech-language Path-ology6 states that dysphagia evaluation shouldfollow the ICF framework, including ‘‘normaland abnormal parameters of structures andfunctions affecting swallowing; effects of swal-lowing impairments on the individual’s activ-ities (capacity and performance in everydaycontexts) and participation; contextual factorsthat serve as barriers to or facilitators ofsuccessful swallowing and participation forindividuals with swallowing impairments.’’

Body Structures and Body Functions

Assessment of Dysphagia

Dysphagia assessment typically involves both aclinical assessment and one or more instrumen-tal assessments. The clinical assessment in-cludes the case history and medicalbackground, which could capture key bodystructures (e.g., cranial nerve or cerebral lobedamage) and personal factors (e.g., age, occu-pation, family), as well as the specific medicaletiology of the possible dysphagia. In the clin-

ical examination itself, the Body Functionscodes dealing with the oral stage of the swallowcan be evaluated, as well as some indications ofthe pharyngeal-stage swallow. Depending uponhow the clinical assessment is done, the capacityqualifiers of the Activities and Participationitems regarding overall eating and drinkingbehavior could be evaluated. However, if theperson is fed the food by the clinician, theneating style cannot be evaluated. Another lim-itation is that in the medical setting, personsoften are not given the usual foods and drinksthey consume. More detailed background ques-tions of the person and/or their significantothers about eating and drinking behaviorscould help fill in the gaps of possible relevantActivities and Participation areas as well asimportant Personal and Environmental Factors.

The two primary instrumental evalua-tions for dysphagia are the flexible fiberopticexamination of swallowing (fiberoptic endo-scopic evaluation of swallowing [FEES]) andthe videofluoroscopic modified barium swallowevaluation. Both of these evaluations assessBody Structures and Body Functions compo-nents of the swallow. Given that they evaluatethe swallow in a decidedly artificial environmentwith a usually limited rate and amount of foodpresented, the interpretations from these twoevaluations must be tempered with informationthat evaluates other components of the ICFframework. In fact, basing dysphagia evaluationand management only on these instrumentalevaluations may lead to recommendationswith limited relevance or practicality for agiven patient.

Activities and Participation Assessment

of Dysphagia

Sonies7 defines functional eating (in parallelwith a definition used for functional commu-nication) as ‘‘the ability to eat a meal effectivelyand independently in a given environment so asto sustain adequate nutrition for a healthy lifestyle’’ (p. 263). Assessment of eating at drinkingat the Activities and Participation level isnot completed as regularly as Body Structuresand Body Functions testing because there arefewer agreed upon measures for Activities andParticipation.

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There are several measures that lookbroadly at eating proficiency. One measurethat has been used by speech-language pathol-ogists to evaluate overall eating and drinkingbehaviors is the ASHA National OutcomesMeasurement System for Swallowing.8 This isa seven-level scale that ranges from ‘‘Individualis not able to swallow anything safely bymouth. Compensatory strategies are effec-tively used when needed’’ to ‘‘The individual’sability to eat independently is not limitedby swallow function’’7 (p. 35). Other globalassessments of eating and swallowing in-clude Wisconsin Speech-Language-HearingAssociation’s Functional Outcome Assess-ment Measurement of Swallowing,9 and theAustralian Therapy Outcome Measures Swal-lowing Scale.10

Although these measures evaluate overalleating proficiency, they still link the overalleating behavior with the actual physical capa-bilities of the swallowing mechanism. For ex-ample, they do not directly consider cognitivecharacteristics of the person or the eating envi-ronment other than some measures that broadlyaddress the independence of eating. Thesemeasures are appropriate for the measurementof codes for Activities and Participation codesof Eating (d550) and Drinking (d560) but notfor the possible social limitations of havingdysphagia. Sonies7 notes that these measurestend to be developed for specific facilities ororganizations and are thus not well standar-dized.

One measure that is both well standardizedand also includes broader aspects of the Activ-ities and Participation restrictions and restric-tions secondary to dysphagia is the SWAL-QOL tool.12–13 This measure, which also looksat quality of life issues, is appropriate for lookingat the performance qualifier of the Activities andParticipation component in that it examinesreal-life functioning of persons with dysphagiavia the patients’ perspectives. As a result, it looksbeyond the specifics of the swallow to how beinglimited in swallowing effects one’s ability tofunction in society. The SWAL-QOL includesquestions regarding both Body Functions andActivities and Participation behaviors. Exam-ples of Body Functions skills on the SWAL-QOL include patient reports of coughing, food

being stuck in throat, difficulty chewing, anddrooling (b51051, b5102, b5103). Examples ofActivities and Participation behaviors on thisassessment measure include the following lim-itations or restrictions secondary to the dyspha-gia: (1) not going out to eat, (2) restrictions onsocial life, (3) changes in work or leisure, (4)avoidance of social gatherings such as holidays,(5) suspected role changes in family, (6) nolonger enjoying or desiring to eat, and (7) takinglonger to complete meals.

Environmental and Personal Factors

Assessment in Dysphagia

As with other areas of the field, the systematicassessment of environmental and personal fac-tors related to dysphagia is lacking. TheSWAL-QOL includes no direct questionsabout Environmental Factors but does have amore Personal Factors questions on it than thetypical dysphagia assessment, including ethnic-ity/race, years of schooling, and marital status.The same authors produced the SWAL-CARE,14 which looks at the one environmentalfactor of how the clinician interacts with theclient. Most of the questions are factual onesdealing with how specific information is pre-sented, but there are also questions that may tapinto the attitudes of the clinician, includingwhether the client believes that the clinicianputs the client’s needs first, and if the client hasconfidence in the clinician (e355 and e450).

The effects of the environment on patientswith dementia and dysphagia have been inves-tigated.15,16 Changes in lighting (e240) or levelof sound in room (e250) as well as the level ofsupport from family (e310 and 315), personalcare providers (e340), and health professionals(e360) can make the difference between livingsuccessfully with dysphagia and dire physicaland social consequences.

The relationship between EnvironmentalFactors and Personal Factors with dementiaand dysphagia has been described by Brushet al17 in discussion of a fictional (yet typical)woman admitted to a nursing home; a combi-nation of environmental and personal factorscontributed to poor eating and drinking behav-iors. Environmental factors discussed were thelighting and seating arrangements of the dining

USEOFTHEICFINDYSPHAGIAMANAGEMENT/THREATS 329

room, as well as mislabeled food, which reducedher ability to enjoy mealtimes. A personal factoralluded to is that the resident previously likedspicy foods and now must eat bland nursinghome food. These factors alone might contrib-ute to poor eating, but with such patients thereis often at minimum an underlying oral-stagedysphagia. The combination of having moremechanical difficulty with chewing and manip-ulation of the bolus and eating under less thandesirable circumstances may have a negativesynergistic effect on nutrition and hydration.

Even when the importance of Environ-mental and Personal Factors components isacknowledged, there are still no agreed uponstandards to assess them. This may be due tothe belief that the person with dysphagia is theidentified patient and thus all attention shouldbe on trying to ‘‘fix’’ the patient. The environ-ment does not have a possible life-threateningillness, so it is not evaluated for possibleintervention. In the traditional medical model,only the person with the disease need betreated.

Intervention Using the ICF Framework

Given the preponderance of Body Functionsand Body Structures assessments of dysphagia,it is not surprising that most dysphagia therapyfocuses on these aspects of the disorder. In fact,these aspects must be worked on to ensuredecreased risk of aspiration and adequate nu-trition and hydration. This approach, althoughit is essential, is not sufficient to interveneglobally with persons with dysphagia. As re-search with the SWAL-QOL has shown, dys-phagia has far-reaching consequences.

The development of assessment tools ex-amining Activities and Participation and En-vironmental and Personal Factors of personswith dysphagia will lead to better interventionfor this population. Sonies states ‘‘. . .it issuggested that the swallowing problem beviewed in relationship to how dysphagia af-fects the emotional stability, happiness, social-ization, and friendships, and satisfaction withlife of the person with the impairment. Oncewe have an indication of which measures aremost influential for patient functioning andwell-being, the most critical elements of an

assessment can be used to focus dysphagiatreatment’’ (p. 274).7

CASE EXAMPLEDr. D, a 67-year-old man, has a new stroke thathas caused a mild to moderate oral-stage dys-phagia secondary to an infarct in his motorcortex of his left frontal lobe. Last year, hehad two mild strokes, which affected his leftprefrontal lobe and his left temporal lobe,resulting in a mild cognitive communicativedisorder characterized by impairment of higherlevel abstract thinking and problem solving,and difficulty making new verbal memories.

The clinician evaluated Dr. D as an out-patient 2 weeks after he was discharged fromthe hospital. A clinical evaluation of him in theclinic room with food from the hospital cafe-teria demonstrated that he had some coughingduring meals, although he denied he was hav-ing any difficulty eating. He also complainedabout the modified diet he has received, tellingthe clinician that he still eats steaks despite thedifficulty and length of time it takes him, thathe still has coffee, and that before his stroke hewould drink 6 cups of coffee a day. Hiscase history indicates he has been married for30 years and is a retired biology professor whomakes a comfortable living with income from aproduct he patented and is still a top-sellingbiology textbook. His favorite activity is eatingout with his wife at different restaurants andgoing to baseball games with his two brothers. Avideofluoroscopic modified barium swallowevaluation revealed moderately decreased mas-tication skills, mild difficulty forming and ma-nipulating the bolus, and premature spillage offood and liquids into the pharynx. He had nopharyngeal residue after the swallow. In oneinstance, there was an estimated 5% aspirationof liquids before the onset of the pharyngealswallow, which was accompanied by coughing.

In this case, the relevant Body Structuresimpairment would be the damage to his cere-bral lobes, with a qualifier indicating that thisdamage occurred on the left side. These bodystructure abnormalities could be indicated us-ing the ICF without necessarily knowing thecause or etiology. The primary new BodyFunctions impairments would be impaired

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chewing (b5102), oral manipulation of foodand control of bolus (b5103). Body Functionsimpairments secondary to his previous strokeinclude higher abstract thinking (b1640),problem solving (1646), development oflong-term memories (b1441), and insightinto difficulties (b1644). A potential Activitiesand Participation limitation includes recrea-tion and leisure activity (d920). Relevant en-vironmental factors would be the support andattitudes of his spouse and relatives toward hismodification of his diet (e310, e410). Relevantpersonal factors would include his previousoccupation, high socioeconomic level status,and his family situation. The key to full assess-ment and planning for invention for Dr. D isnot just to realize all of the components of theICF, but also to look at their interaction witheach other.

Intervention should address Dr. D’s BodyFunctions impairments of chewing and controlof the bolus. The modification of his diet tomechanical soft should be maintained to com-pensate for his reduced oral-stage abilities. Forcontrol of the bolus, he could practice eatingwithhis chin tucked in and head slightly titled down-ward. He will also need to control the rate andamount of food (and especially drink) that heconsumes. Given that Dr. D has limited insightinto his swallowing disorder, the speech-language pathologist should provide instructionand guidance to his wife and brothers not onlyabout the nature of his swallowing disorder butstrategies to increase the likelihood of his suc-cessful eating.

Although he has swallowing and cognitiveBody Functions impairments, Dr. D’s Activ-ities and Participation needs still must beaddressed. This area of functioning needs tobe addressed not only to improve quality oflife; it may also increase the likelihood that hewill be compliant with his dysphagia precau-tions. For eating out, his wife could seek outrestaurants that serve items he both likes andcan eat safely. Eating steaks may prove to be sotiring that he does not consume enough of therest of his food. Any steak that he eats shouldbe moist and preferably a thin cut. Given thathis oral-stage dysphagia will slow his rate ofeating of all solids, the physician should pre-scribe that he drink nutritionally dense liquids

that will allow him to eat smaller meals with-out risking malnutrition. Eating smaller mealsmight lessen the effect of seeming to takelonger to finish meals than his eating com-panions.

Regarding coffee drinking, if Dr. D canlearn to keep his head down and take small sips,he may be able to continue this behavior. Sincehe has demonstrated that he coughs whenliquids are in the airway or being aspirated, thepatient can practice his drinking of coffee usingthe different strategies with the clinician in thetherapy room. To get across the possible neg-ative effects of aspirating liquids such as coffee,the clinician could use his personal factor ofhis biology background by showing Dr. D hismodified barium swallow, and have a discussionabout the acidity level of coffee and possibledamage to his lungs. Considering his cognitivecommunication disorder, the clinician wouldneed to structure the instruction, supplementedby support from Dr. D’s family, to decrease hisrate if he wishes to continue drinking coffee,and explain that the amount of coffee he drinksmay need to be decreased.

The ability to follow any swallowing pre-cautions will be greatly decreased by drinkingalcoholic beverages, especially in the midst ofwatching a baseball game. Given that it can behot during baseball games, the clinician couldsuggest to Dr. D and his spouse that he bringchilled water to the games and also food fromhome. It would be especially helpful if thebrothers could also drink water at the games,at least at the games they attend with him.Although it is possible for him to aspirate withwater, the negative effects would be less thanthose associated with aspiration of alcoholicbeverages.

Even with these precautions, Dr. D wouldneed to be monitored closely for signs ofaspiration pneumonia, malnutrition, and dehy-dration. Although allowances are made for himto be able to continue to participate in the socialaspects of eating, it must be remembered thatbeing ill and requiring hospitalization arethreats to Activities and Participation behaviorsthemselves. If Dr. D can maintain his healthwhile following the above-described program,then the ultimate goals of dysphagia therapywould have been realized.

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BENEFITS OF USING THE ICFFRAMEWORK FOR DYSPHAGIAMANAGEMENTAs mentioned, dysphagia is among the moreovertly medical disorders that speech-languagepathologists treat. It would also appear to be adisorder that the profession should have min-imal difficulty in justifying evaluation and treat-ment. However, it is one thing to say thatdysphagia is a potentially serious disorderthat should be treated, and quite another tosay that speech-language pathologists are anessential participant in the management team.The most important issue regarding our roleis to demonstrate via documentation the effec-tiveness and efficiency of intervention, includ-ing transdisciplinary assessment and outcomes.

There is a growing demand for health careprofessionals to provide relevant clinical out-comes for the clients. Ultimately, dysphagiaassessment and its subsequent interventionmust accomplish the four goals of (1) adequatenutrition and hydration, (2) decreased risk ofaspiration related illness, (3) decreased chokingrisk, and (4) decreased risk of psychosocialeffects such as social isolation or depression inpersons with dysphagia. The first three aresuperficially straightforward medical goals, butthey can only be achieved if clients are ableperform the Activities and Participation globalbehaviors of eating and drinking with success.There may be a greater risk of noncompliancewith dysphagia recommendations if the Activ-ities and Participation aspects of dysphagia arenot factored into the assessment and interven-tion. For example, to maintain adequate nutri-tion, one must be able to see the food, get thefood to one’s mouth, orally manipulate thefood including mastication, send the food tothe esophagus, and keep food in the stomach.Thus, the entire act of eating requires cooper-ation of several professionals: outcome meas-ures should consider how each professioncontributes toward these global goals. Forthere to be decreased risk of social isolationor psychological reactions to having dysphagia,the intake of adequate nutrition has to occurwithin the social contexts of eating and drink-ing behaviors. Decreased views of one’s eatingand overall competence, by itself, can limit theamount of food a client eats. Research is

needed to demonstrate the efficacy of dyspha-gia treatment, and clinical facilities need tokeep adequate outcome data to demonstratethat dysphagia invention produces these globaloutcomes.

Although dysphagia is a medical condition,the incidence can still be underestimated inhealth data systems because it is a symptomand not the disease etiology itself. Thus, aperson who has had a stroke would have codesfor the stroke and other conditions in his or herchart, such as hypertension and diabetes. Dys-phagia may not be under this system. In addi-tion, even if dysphagia is listed, it will not be inthe level of detail contained in the ICF, whichseparates oral and pharyngeal dysphagia asseparate codes, and even classifies specific func-tional limitations such as reduced ability to biteinto food. As a result, more fine-tuned outcomedata cannot currently be collected on the effi-cacy and effectiveness of dysphagia therapy. Forexample, does moderately impaired ability tomanipulate food in the mouth better predictrisk of poor maintenance of nutrition thanmoderately reduced ability to produce saliva-tion? What is the relationship between variouscognitive and communication impairments andsuccess in dysphagia intervention? Thus theICF can be used to guide interdisciplinaryefficacy and effectiveness studies of dysphagiamanagement. In addition, examination of dys-phagia in this complex manner may justify theargument of why a trained speech-languagepathologists needs to work with persons withdysphagia, as opposed to the creation of adysphagia therapist, who would be trainednarrowly only to look at the physical aspectsof the swallow.

CONCLUSIONWith a broader view toward dysphagia assess-ment by following the ICF framework, clientswith dysphagia can be provided with interven-tion that best honors the health care ethicaltenets of both autonomy and beneficence. Likelanguage, eating and drinking behaviors arecentral to what it means to be human and asocial animal. In addition, like communication,swallowing and eating/drinking behaviors needto be viewed as complex and not simply as a

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Body Functions impairment (e.g., the amountof delay of the onset of the pharyngeal swallow).Only by looking at the patient with dysphagiaholistically can these real-life outcomes be real-ized. Whether speech-language pathologistscontinue to work with persons with dysphagia(and get reimbursed for the activity) depends onwhether these outcomes can be achieved.

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