Swallow the Gap
A pivotal podcast on a mission to improve medical intervention for patients with swallowing disorders (dysphagia). Primarily intended for medical speech-language pathologists (SLP) and also relevant for professionals and students involved in pulmonology, otolaryngology, gerontology, nutrition, rehabilitation sciences, and various other areas of healthcare. Join us as a force for change by inspiring critical thinking, facilitating discussion, and stimulating professional development for those involved in the evaluation and treatment of patients with aerodigestive disorders.
https://www.swallowthegap.com (Gap Education, LLC)
Swallow the Gap
Elevating Research Standards in Dysphagia
Dr. Catriona Steele, president of the Dysphagia Research Society, discusses her journey in dysphagia research, including motivation from her pre-PhD days, and focuses on systematic reviews. She highlights the need for rigorous and transparent methodologies in evaluating research quality, introduces the FRONTIERS framework, and underscores the importance of continual learning and questioning in the field.
Episode Resources from Dr. Steele:
PRISMA guideline: Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & Group, P. (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Annals of Internal Medicine, 151(4), 264-269, W264. https://doi.org/10.7326/0003-4819-151-4-200908180-00135
Prospero: https://www.crd.york.ac.uk/PROSPERO/
Open Science Framework: https://osf.io/
Cochrane Collaboration: https://www.cochrane.org/
EQUATOR Network: https://www.equator-network.org
Covidence: https://www.covidence.org/
Rayyan: https://www.rayyan.ai/
Clinical Trials dot gov: https://clinicaltrials.gov
Frontiers Framework: https://www.frontiersframework.com
Episode Sponsorship:
The TIMS Medical team is excited to announce that ASPEKT-C will be included in upcoming releases of TIMS MVP in 2025, following close collaboration with The Swallowing Rehabilitation Research Laboratory.
The team at TIMS (www.tims.com) is honored to support the implementation of ASPEKT-C which assists clinicians in identifying the underlying mechanisms of impaired swallowing safety and efficiency. Additionally, the ASPEKT-C Method also enables clinicians to compare swallowing parameters to reference values in healthy individuals, offering valuable insights for improved care.
To learn more about ASPEKT-C, visit The Swallowing Rehabilitation Research Lab website. For updates on upcoming TIMS MVP releases, follow TIMS Medical on social media or sign up for email notifications at www.tims.com.
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Today's episode of Swallow the Gap is sponsored by Tim's Medical. The Tim's Medical team is excited to announce that Aspect C will be included in upcoming releases of Tim's MVP in 2025, following close collaboration with the Swallowing Rehabilitation Research Laboratory, which was actually founded by today's guest. Hey everybody, Today I have Dr Katrina Steele from the Kite Research Institute and the current president of the Dysphagia Research Society. Welcome, Thank you for joining me.
Speaker 2:Thank you, tim, it's a pleasure.
Speaker 1:Yeah, absolutely. Is there anything, before we get into this topic of interest, that you wanted to tell people about yourselves right now?
Speaker 2:Sure, well, I can start with just a little bit of background. So I trained as a speech pathologist in the early nineties and worked clinically for about 10 years. I don't think I knew we did dysphagia before I went to do my degree. I thought I would be an aphasia clinician and then my final clinical placement was in dysphagia and I fell in love with it. And then my first clinical position was in a home for the aged, where the most common reason for referral was dysphagia.
Speaker 2:And I've ever since, and about after seven or eight years of clinical practice, I was frustrated, mainly because I loved all of the work we would do about diagnosis and I loved fluoroscopy and we would put so much effort into it. And I felt that after all of that, we had one generic intervention we were offering, which was pureed foods and thickened liquids, and I was frustrated by that and inspired by people at the time, like Maggie Lee Huckabee, who were doing rehabilitative work, and so that was really what drove me back to do my PhD me back to do my PhD and I was fortunate to get a grant just at the end of my PhD, and I've been now doing this research for 20 years and love doing it, yeah, and you put out some very helpful stuff.
Speaker 1:I don't know how many times and I should probably update what I'm referencing how many times I referenced mole thinner and steel. As far as the variability of swallowing, you know, highway movement, of timing measures and those types of things. I think that's fantastic because it is my opinion that we over-diagnose dysphagia and we over-restrict, and so I think that's really helpful to have that anchoring point to be like well, you know, actually it's okay that it initiated in the pure form sinuses, because if you, you know, frame by frame and time it, there was no, you know, there are no adverse outcomes and that's within a typical range that that sort of thing too.
Speaker 2:So I think, yeah, I appreciate it. So the you know, this theme of what's normal or what is typical has really become a focus of our work over the last decade, starting with Sonia's dissertation really, and we're, as you may know, we're trying to characterize reference values across the IDSEE levels up to extremely thick, primarily in healthy people on video fluoroscopy. It's a big job and then also to look in patient populations and one of the big questions there will be are there characteristic profiles or people use the word phenotype? I'm not a lover of that term, but I will say, so far the different groups we've looked at, there are certain things that do jump out as unusual in certain populations. So that's really interesting. And then it also will ultimately help us decide whether an intervention is working if we can move numbers from outside the healthy range back into the healthy range.
Speaker 1:Yeah.
Speaker 2:Yeah.
Speaker 1:Makes a lot of sense to have an anchoring point, something that we can reference, versus just the kind of system one like.
Speaker 2:I don't feel good about that, you know, like I saw that and it doesn't because there's so much variability within that there is a lot of variability and trying to tease apart the variability that is due to measurement choices that we make, as opposed to variability. That's really there is one of our current questions. So there's so much to ask. I always say there's no shortage of PhD questions for people to pursue.
Speaker 1:Yeah.
Speaker 2:So inclined.
Speaker 1:Yeah, no, and I love that you've got your your your hands in this like elbows deep, really going after so many different things in a very clinically practical way. To me, that's one of the things that I appreciate about the research that you do is I think it has a very good translation to clinicians. You're not necessarily just looking at some, some slight nuance, but it's something that we can use to make patient outcomes better and as a clinical degree, I mean, that's what matters.
Speaker 2:That's yeah, I hope so. We really want it to be clinically relevant.
Speaker 1:Yeah, no, I think it's great. I really appreciate what you're putting out there. It sounds like so. As a researcher, you've done a lot of research, you've studied methodology, you've looked at threats to validity internally and externally, and you've read a lot of research too, right, and so it sounds like one of the things that you're interested in is looking at systematic reviews and trying to establish the rigor of those right or the let's say I need a fancier word for this I guess the validity. Can I still use that term?
Speaker 2:Validity, trustworthiness there you go we trust it.
Speaker 1:Yeah, let's just.
Speaker 2:Yeah, yeah, I chose this topic to talk about today because systematic reviews are ubiquitous, right? You probably know that any new doctoral student it's really one of the first tasks that we suggest is to help you define your question, go and do a systematic review and figure out what the gap is that you want to study, review and figure out what the gap is that you want to study and then, at the same time, they have this position of prominence on all of those pyramid diagrams that you see, just Google the pyramid.
Speaker 2:Yeah, I mean, they're right at the top systematic reviews and meta analyses, as if there's some you know holy grail, and I don't think it's that simple. I think there are good systematic reviews or bad systematic reviews, and for clinicians who are reading the literature, it's important to know how to read them, to figure out if this review is one that you are going to take away as something that should influence your practice.
Speaker 1:Okay, yeah, I think you answered the question I was just going to ask. I was going to ask you know the clinical relevance. But you know that makes total sense If a study I mean if you have one study that's purporting to make not a correlation but a causal relationship between your two variables, and then you have a systematic review that's trying to find all the studies that meet their criteria and are supposedly rigorous and good, but they're not doing a good job at that. But then this is being upheld as a gold standard or just a good practice. That becomes a problem.
Speaker 2:It does, and there are so many systematic reviews out there now, and I think I became sort of more interested in what makes a review good versus not good when I started stumbling across reviews that come out around the same time, that are essentially looking at the same question and come up with different answers, or look at different selections of articles, and so you start to ask why did that group choose to include this one and exclude that one? You know which one is correct and I'll tell you. I'm doing a systematic review right now. We published a review in 2015 or 2016 for IDSEE looking at the effects of texture modification on physiological measures of chewing and swallowing, and it's now 10 years old and so we decided it would be good to update it.
Speaker 2:And when we cast our search net, we decided to include systematic reviews as one source of evidence, and there are 150 systematic reviews that made it into our pile for us to weed through, and a lot of them are dancing around very similar questions. You can ask does texture modification work for reducing pneumonia? And then you can ask does giving people free water impact pneumonia? And you're just asking two sides of the same. So I think it's a minefield of publications out there, it becomes really difficult to figure out your way through and figure out which ones to trust and to put energy into Sure.
Speaker 1:So yeah, so if clinicians, you know, we typically in our master's programs will have some sort of a research class, but I would argue the regardless of the depth that's provided, that it's not something that most of us walk away from feeling that confident in. So, as clinicians who aren't primarily trained in research, what do you think are some of the most important things for us to be aware of when looking at the methods to see? Is this something I can trust?
Speaker 2:Yeah, well, maybe I'll talk through sort of what I've learned over my time dabbling with systematic reviews, because I'm not trained as an epidemiologist, I'm not trained in systematic review methodology specifically, but certainly along the way I've picked it up.
Speaker 1:Yeah.
Speaker 2:And hopefully now I'm doing better reviews than I did, you know, originally.
Speaker 2:So the first thing is that there has been methodology developed and that's now considered standard best practice.
Speaker 2:In systematic reviews we also now distinguish between systematic reviews and scoping reviews, which are less focused on a really precise question and meant to characterize a topic, and for both of those there's something called the PRISMA statement and PRISMA checklist, which is a best practice guideline that's widely accepted as the way to go.
Speaker 2:So that is very helpful and certainly if you're thinking about doing a review or if you're reading a review, you should see whether they followed the PRISMA guidance. There's also registries now of reviews so you can go and see whether somebody's currently working on a review and whether they've registered that. So there's a registry called Prospero, which is for systematic reviews, and so if you're going to do a review and you want to register at a Prospero, you go in and they ask you it's like submitting an ethics proposal they ask you to outline all of the plans and steps of your review and they'll ask you follow-up questions if you aren't clear enough. So it's an attempt to sort of make sure everybody's on the right path. It's also a place if you're thinking of doing a review to make sure that nobody else is working on the same question at exactly the same time?
Speaker 1:Oh nice, even before it's published.
Speaker 2:Right, not everybody does register Some people keep it secret, but I can tell you, because it's happened to us, that it's really frustrating to have a review and to submit it for publication, and then the reviewers come back and say, yeah huh, you know, um, somebody else published a review on this exact question a month ago. How is yours different? Um, and it becomes much harder to publish your work yeah and on the scoping review side, um, prospero won't accept scoping reviews, but Open Science Framework will, so that's another place to look.
Speaker 1:Open Science Framework, Prospero P-R-O-S-P-E-R-O. It looks like their website is wwwcrdyorkacuk. Yes, wwwcrdyorkacuk. Slash prospero P-R-O-S-P-E-R-O. Just for anyone who wants to check that out.
Speaker 2:It's at the University of York in England and they may, so they review your protocol before you do it and then, if they accept it, it gets posted on their registry there are also now tools that are available for doing systematic reviews.
Speaker 2:When we did the IDDSI one more than a decade ago, we had this crazy Excel file that I tried to manage with all of the ratings yeah, all of the ratings and now there are softwares that anybody who has an academic affiliation can probably use through their university. There's one called Covidence, which I find really good, and there's a newer one called Ryan, which I think is R-A-Y-Y-A-N and I haven't used it, y-y-a-n and I haven't used it. I have colleagues who have, and it uses some sort of automated algorithm to try to weigh the relevance of the articles that you're looking at, to try to streamline the task. So there are choices there, and certainly the one we're doing right now in Covidence. It's enormously helpful to have a platform organizing the work so you can have lots of reviewers involved, and this makes sure that every article is reviewed by two people and it flags differences of opinion so that you can then discuss them, differences of opinion, so that you can discuss them. So those are sort of infrastructure pieces behind the review I didn't mention.
Speaker 2:In addition to Prisma, of course, there are guidelines on how to do systematic reviews that come from organizations that specialize in this. Probably the most famous organization is the Cochrane Review, cochrane Collaboration, and the Cochrane Collaboration was designed and born to do evidence-based reviews in medicine, and they have courses that people can take. They have a very strict methodology and I think one of the things that's important to know is that in a Cochrane review, you only look at randomized control trials. That's the only source of evidence that makes it into the set, and so that sort of leads to. One of the things that I think is important to ask as a reader is what limits did the authors put on their search strategy, and do you think those are good limits? Because I this exercise is like casting a net on the literature to find all of the articles that might be relevant, and there's a real balance between wanting to make sure you don't miss something.
Speaker 1:Sure.
Speaker 2:And not overwhelming yourself with irrelevant references, and I think that's the most challenging piece. It's a bit soul-destroying because now we run our searches in multiple search engines. We put the search terms in and then you specify limits. So for the IDSI search that we're doing right now, we're trying to be really comprehensive and we cast the net across three or four search engines and we came up over a 10 year timeframe with 66,000 articles.
Speaker 1:It's quite a few to filter through green.
Speaker 2:Yeah, it's crazy. And of those 66,000, about 2,200 look like they might be in the ballpark. So we had to eliminate 64,000 odd articles, which is kind of tedious work to do. Oh, absolutely, and certainly not fun for graduate students who are starting this, so you can understand why people put limits on, like saying, okay, this is too big. We're only going to look for articles that are randomized control trials.
Speaker 1:Yeah.
Speaker 2:Or we're only going to look at articles, or we're only going to look at articles, and so that 66,000 was for articles from 2012 forward rather than from the dawn of publication, and so you'll see choices being made. There's two systematic reviews that I found interesting to compare a few years ago that were both around the efficacy of behavioral interventions for dysphagia.
Speaker 2:That were both around the efficacy of behavioral interventions for dysphagia and one of them had put like a five-year limit and the other had put an 18-month limit. And so interesting to stop and say do I think an 18-month limit is enough to answer my question? Is there likely to be enough material published in the last 18 months? I would say no, but just interesting?
Speaker 1:I wouldn't think so. I mean as much as I feel we struggle to find good studies in the literature that actually substantiate how effective an exercise is for a specific pathophysiology or whatever other outcome for swallowing you had to limit it to a year and a half. I mean like if you limit it to 20 years you might get some stuff, but and I know that, I know that recency is is important, but at the same time that just does seem really over over.
Speaker 2:Yeah, that seems overly restrictive to me. Other limits, you'll see, is, you know, only in English. Or a very common one that I think is worth really thinking carefully about is do you only look for peer reviewed publications or do you also dig beyond that into what we call the gray literature? So the gray literature is things that actually haven't made it to publication. So it might include conference abstracts, for example, or trials that you know are underway but not yet published. And it's a bit of a slippery slope, because then you have to ask why hasn't it made it to publication? Is that just timing, or is there a reason why it hasn it made it to publication? Is that just timing, or is there a reason why it hasn't made it into publication?
Speaker 2:So, personally, I tend to stick to peer-reviewed publications only. Sure, but those are choices that authors make to manage the job of the search. To manage the job of the search, then you should look at how many people were rating and how were. Was this done just by one person, for example, and or was it done by more than one person? And was there a process for comparing decisions and resolving any discrepancies? Because, like it or not, we're all prone to bias, and so deciding whether to include or not include an article sometimes can pull on those biases. So it's really important, I think, to have a second reader and to have them have an opportunity to challenge the decisions of one person.
Speaker 1:Okay. Especially when you're working through a huge number, you get tired too Earlier in the day you might be a little more stringent than you are later. It's like oh, it looks good. I can see that there would be a lot of different things that would influence that process. So it sounds like, from what you're saying, you've got this idea and coming into a systematic review.
Speaker 2:how broadly you're going to cast your net.
Speaker 1:So like how, yeah, are you just going to do a title search? You can do an abstract, abstract search too. Are you going to look in one journal or all of these different journals or search areas, and then? So you have that, and then you have the filtering process. So within the filtering process, some things that are important are make sure they're peer reviewed, I mean, that's at least. That is not perfect, but it of course establishes, hopefully some integrity of the particular one you're looking at. But then also having a checks and balances system for inter-rater reliability between two judges to minimize bias, is that?
Speaker 2:my thought following so far. Yeah, and then one other comment to make is often people will update systematic reviews at a given frequency and I think it's important to stop and say how likely is it there's new information in the timeframe since the last review was done, and here your filters come into question as well. So there's an example I like to use here is there's a series of systematic reviews and best practice guidelines that fall out of those that were done by a group in Denmark looking at the effectiveness of thickened liquids for managing, you know, pneumonia and other downstream consequences, and they made a decision to only look at randomized, controlled trials. So the set is pretty small. And in their first iteration they found the big study, the Logum and Robbins Protocol 201 studies that were published in 2008. And that was really one big grant with a couple of publications. And we probably all know the story that in direct comparison, within the video fluoroscopy there was less aspiration on the thicker consistencies, but with use over time there wasn't a clear answer and, if anything, randomization of people who are aspirating to thickened liquids turned out to be unadvisable because there were some nasty downstream outcomes irreplaceable because there were some nasty downstream outcomes. So that was their first paper and they concluded it wasn't strong evidence.
Speaker 2:And then three or four years later they said let's do this again. And I guess the first thing I would say is I don't think there are secret randomized control trials of big questions hiding in the literature to find we would all know if there was a big study happening. We could look at something like clinicaltrialsgov to see if it was happening. But they don't appear to have done that. So they did the whole exercise over again and they found the same two studies and then they found one more which was a tiny study in like 12 or 20 people with a particular etiology that wasn't strong enough to shift the needle at all on the finding.
Speaker 2:And so they published that again and then three or four years later they cast the net again and exactly the same thing happened. They found the Logerman and Robbins papers and one or two more tiny papers and so evidence on that question hasn't been moving because nobody is doing a big study that's randomized and properly controlled and the exercise of going hunting for it is a bit futile. So I think you need to have a good question and to warrant the effort that goes into it. I think, make sure nobody else is already doing it and make sure that you have something to pull, because I've also seen people presenting really beautiful systematic reviews on a lovely, clear, focused question and they cast their net and they do all their screening and at the end of the day they get zero studies that are relevant to synthesize and that's just a waste of everybody's time. It's entirely predictable that a systematic review conclusion statement will say there's insufficient evidence to answer this question, but to find nothing is a waste of time.
Speaker 1:Yeah, yeah, it's almost. I mean, we have a lot of value for systematic reviews supposedly being at the top of this, this pyramid we look at as far as levels of evidence go, and I'm trying to think of an analogy, an analogy to compare it to, because if I mean, if you don't have the pieces that are necessary in order to get a good systematic review, then maybe you should be working on designing a good randomized control trial for the question rather than pursuing a systematic review. It almost is like you know, learning to run before you can walk.
Speaker 2:Yeah, and I do think in dysphagia we struggle because we know that there's this evidence-based framework in medicine, we know that there's incredible value on randomized control trials. But they are so hard to do and in order to get large numbers for a randomized control trial you have to decide that a large number of people are similar and equally likely to benefit or not benefit from the intervention you're studying. And I struggle with that as a clinician because it's in direct tension with the idea that we want to do personalized mechanism-specific therapy for dysphagia. And so you'll see these big studies that say we recruited, I don't know, 100 people with dysphagia post-stroke. That is not to me a remotely homogeneous population.
Speaker 1:Stroke could be anywhere.
Speaker 2:It could be anywhere, the dysphagia could look different. I just really reject the idea that all of those people are equally likely to benefit from a prescribed uniform therapy. X.
Speaker 1:No, I totally. I mean, if you think of the brain as the controlled system, you haven't been very specific at all in describing dysphagia. It's just you know the etiology, so from a neurological cause, so maybe so you got that. But it's kind of like lumping all the dysarthria together. You could have a flaccid and you could have a spastic and it's like, well, you know, the treatment's gonna work differently from from flaccid yeah, so, yeah.
Speaker 2:So one of the consequences of this is when you actually go to places like the cochran collaboration and see what they've managed to say about evidence in our field, they don't find much, and what they do find isn't about behavioral interventions which are customized to the patient. They're about things like acupuncture or magnetic, trans-cranial magnetic stimulation. Actually, I would say I'm surprised, in the review that we're doing right now, about the proportion of studies that are in the pile that have to do with something like transcranial or rapid TMS. There's a lot, and the outcomes might not be measured in ways that we would like, but it's just interesting that there's such a large body of literature, because I don't think that doesn't fit with my understanding of the kind of work we're doing.
Speaker 1:Yeah, you said something a second ago and I'm going to paraphrase. I'm going to butcher, but the questions might not be the ones that we would like. I believe you said something to that effect. That makes me think of, just overall, if we're asking the right questions as far as research goes, or if we're looking at the right parameters. So, in one of the studies you mentioned, as far as the influence of thickened liquids on different bolus flow parameters, penetration, aspiration, et cetera, well, I mean I hate to throw the term common sense out there, but if somebody because I mean what is common sense? Right, but get away from system two a little bit, or system one a little bit, but with thickened liquids, okay, right, I mean it might reduce that. But is that the right question to ask? It might reduce airway invasion. It probably will. Probably will Someone's aspirating liquids.
Speaker 1:You give them nectar, thick liquids, they're probably less likely to aspirate, unless maybe it's if it's after the swallow. That's a different story, but typically, yeah, but I don't know if that's the right question. Why do we care about aspiration? We care about it because we don't want anyone to asphyxiate and they can't ventilate and get air in and out and we don't want it to affect external respiration gas exchange between the alveoli and the capillaries in some way. And so there's our you know, our pneumonia or whatever else we're looking at. So those, to me, are they're asking the right questions and that's so important because you can substantiate a relationship and you might get a really good relationship and say, yeah, thicken liquids reduce aspiration. That's great, but it's like, is that where our focus should be? It's a good study, but it moves our focus, I think, away from the big picture outcomes and potentially doing something that has potential to be detrimental in the right patient populations. I don't know, that's a soapbox for me.
Speaker 2:Yeah, it is a soapbox topic and it's a really controversial one right now. I've seen arguments in both ways. I'm actually more on the side of understanding the physiological effect of texture and consistency on swallowing, and I'm very interested, of course, in the long-term outcomes of addressing somebody's dysphagia appropriately. But to me there are so many other things that need to be controlled. I don't think that texture modification in and of itself is enough to mitigate the different mechanisms that contribute to respiratory outcomes or, for that matter, nutritional and hydrational outcomes. So I think we need to be careful and there's a lot of papers that ignore those confounding relationships. So I've always said that I don't think it's fair to evaluate a speech pathology intervention using an outcome like pneumonia, because I don't think we're that powerful. But, yeah, I do think that we need to understand that the pros and cons of thickening and and it's not, it's not always a beneficial intervention and and definitely it's over prescribed, and we we need to fight for better assessment before we recommend it. In my opinion, yeah, that yeah, that makes.
Speaker 1:No, that makes a lot of sense to me. One question that I guess what comes out of that is I. So it's, it's, it's multi-variate, right, and even if you, if you simplify it to the three pillars which there's, of course, more to it than the three pillars, you know immune system status, laryngeal valve integrity or presence of aspiration whatever, and oral hygiene even if you just look at those three things, it shows that it's multivariate and that aspiration is probably the least important one. So the idea that, like, yeah, we're not really that powerful to control this with, just with thickening liquids or whatever it is that would help to reduce the bolus and, wow, help to reduce the bolus and wow, I'm having a moment.
Speaker 2:I like to turn the question on its head and so, rather than saying, do I think thickened liquids are the right thing for this patient and why? I think the place where I find myself most challenged is in asking am I comfortable not considering an intervention to reduce the opportunity for aspirating? Am I okay with what people call the risk element? Here and for some people you might arrive at a point in discussion with the patient and the family and consideration of all of those elements, that some degree of informed risk is something that people are comfortable with. But there are certainly in my patient's caseload history people where I could not bring myself to sort of cavalierly say, go ahead and aspirate, and so I think it's that dynamic and there, if I know that a change in diet texture limits that opportunity for transporting things into the airway, then I feel I need to explain that and probably recommend it, Keeping in mind that of course, people aspirate outside the context of eating and drinking and I think mouth care is a really important part of this equation as well.
Speaker 1:Yeah, no, absolutely. I think I don't mean to discredit the importance of understanding the relationship of diet textures on bolus flow parameters. I think it's important. I just I also think there's so many other questions within that to ask too. Why do we care about this? But it's kind of like it's building, they're building blocks.
Speaker 2:You're building one thing upon the other, upon the other, and I think you have to know the answer to these questions yeah mentioning before yeah, it has to be a thorough, careful consideration, and I think I always, I sure hope that the people who are listening have themselves drunk thickened liquids.
Speaker 1:Oh yeah.
Speaker 2:And you know, spend a day on texture modification and thickened liquids and think about the impact that that has. It's huge, and so we should use it wisely and cautiously. And the other thing you know if you want a soapbox is we should revisit it regularly. We should give patients the opportunity to return to more normal eating and drinking at the earliest possible opportunity if we can. So I joke here about in Canada.
Speaker 2:we don't have mobile video fluoroscopy vans or mobile endoscopy vans, but in my lab it's kind of a joke. But it's not really a joke. We dream of, you know driving one of these around and finding all the people who are stuck out there on enteral feeding or on texture-modified diets that they no longer need, who simply haven't had an opportunity to be re -evaluated.
Speaker 1:Yeah, yeah, not as assuming that they're going to stay the same.
Speaker 2:Exactly Giving them the opportunity for change.
Speaker 1:No, that makes a whole lot of sense With this idea of looking at the integrity of systematic reviews, because it helps, you know, if we're thinking of the idea of showing a relationship between a treatment and an outcome within a controlled setting to see if, well, maybe it will apply to to our patients, like, obviously, it's going to be incredibly important that we have faith in that A lot. It does sound like. There are a lot of areas, though, where there can be, oh, where they can not go wrong, but where they may not be as trustworthy as we would like them to be, and I know you've discussed some of that, and what I would love to do is, after this, we can chat, and I want to make sure I write down some of these resources to be able to point people to. On the other side, I want to, I would love to hear what you think is really promising, or what you're you're excited about, like, how are we moving in a in a good direction?
Speaker 1:Cause, in my mind, like there is a lot to be critical of as far as, like these are things we can do better and these are things we need to be wary of. At the same time like I'm trying to be really mindful of that because I can go really far that direction. So I try to still infuse hope into things. So, like what do you see, how are we moving in like the right direction in this regard? I mean, I think just this the awareness that people are getting is moving in the right direction, because then they can be better filters and as clinicians in applying this. But maybe from the back end, the research side what are you? What are you excited?
Speaker 2:Well, I do.
Speaker 2:I do think the emergence of guidelines about how to do this and tools with which to do it is is moving us in the right direction. One of the steps we haven't discussed yet is that once you get your set of articles that you think are relevant and meet your criteria, there's a really important step in terms of evaluating the quality of those articles. And at the beginning of the pandemic, I was part of a journal club that formed really just to stay connected. So there were six labs, so myself and Sonia Malfenter, who you mentioned, and Ashwini Namasivam McDonald, who both of those are my previous doctoral students.
Speaker 2:And then we pulled in some of our collaborators, so Rebecca Afu at Dalhousie University here in Canada and Nicole Rogaspuglia at Madison Wisconsin and Emily Plowman, and so we had this journal club and we thought we would get all our students together and have regular meetings, and we found ourselves inevitably, I think, reviewing systematic reviews in Swallowing, and very quickly the trainees started to say, yeah, but there's no common method for evaluating the quality of these articles from a dysphagia perspective. There are tools for evaluating quality broadly, like the Cochrane risk of bias tool, and there are tools that look at single subject design, but we were finding that very commonly and this is still true somebody would say something like we did a video fluoroscopy and then they wouldn't tell you anything about how they did that video fluoroscopy things that matter to the transparency of their methods yeah, the rigor and the transparency just wasn't reported.
Speaker 2:So, how many boluses, what textures were they? What volumes were they? Um, what was the barium that was used? What was the frame rate used? Those kinds of methodological considerations. And that video fluoroscopy was lacking. This Endoscopy was also lacking.
Speaker 2:This and so the things that our trainees and I should say that trainees who are doing doctoral degrees have really sharp critical teeth, you know, they're trained to go in and find all the things that are wrong. And so these methodological shortcomings in terms of reporting, but maybe also in terms of how the studies were actually done, were coming out, and the need for a framework to critically appraise the quality of the dysphagia methods came out of this journal club, and so we built a critical appraisal tool and it's public domain. It's called the Frontiers Framework. It's https wwwfrontiersframeworkcom. I think I'll check that for you and in a beta version it will be refined over time.
Speaker 2:But this group of trainees designed the questions that they felt we needed to be asking and checking. So the vision is that it can work in this exercise of reviewing the quality of things you're reading, so you can go check, check, check. They did or they didn't report this, but it's also the vision is. It's a tool that you could use if you're designing a study. You could look at this and think about all of the things you need to plan for or, when you're writing your own article, all of the things to check that you've included. And it's quite a humbling exercise to take one of your own historical articles and run it through this critical appraisal tool and realize all the things you could have reported better the tool and realize all the things you could have reported better.
Speaker 1:Well, I mean, what I like about it is it seems to have stemmed from a need that was made very clear during, like when you're trying to discuss these articles, that it was kind of in the forefront of your mind. We have these general tools to look at systematic reviews, but nothing to evaluate from the perspective of dysphagia.
Speaker 2:So I don't know, and what we found was I think we looked at three systematic reviews early in the pandemic in that first few weeks and we found that all three of these sets of authors had come up with their own tools to address this short, but they were limited to a particular focus, so we wanted something a bit broader. Yeah, so I'm quite excited about it. We will have a series of articles coming out in a special forum in AJSLP later this year introducing the tool and the different themes in the tool, because there are different sections and when you there's also a web-based interface. So when you go into it it asks some basic questions and then it limits the set. So if you've only done video fluoroscopy, it'll bring up that section, but it won't bring up another section. That's not relevant.
Speaker 2:So what we're hoping is that people will start using it and give us feedback on it and over time that will evolve. I think in a couple of years we think it'll be time to pull a consensus panel together to look at feedback and refine the tool, but then that it will become something that's a resource that's useful. So I've had some fun using it in some workshops with clinicians just to explore some selected articles, and it's fascinating. Actually, the most recent time I did this, we were looking at thick and liquids as a topic and so we pulled in Protocol 201 articles as two of the articles to appraise and so not to say that the methods weren't done well, but there are gaps in the reporting of how those video fluoroscopies were done. That I think would surprise people today and that if we were doing it again, we would want to report better.
Speaker 1:Yeah, there are a couple of things that I believe are really beneficial that have come from this. So one you've provided you all together have collaborated and provided this method to evaluate so that we have a better idea that we're not comparing apples to oranges. We have a better idea that we're we're really measuring what we think we're measuring.
Speaker 2:Yeah.
Speaker 1:So that's going to help, but also, I think that this has potential to help in the production of research too, because you had mentioned that other individuals are making their own, so they're taking all this time and all this energy to make their own. So, but if you have this, then that's one less thing they have to worry about. They can really focus on their study in other ways and make it perhaps a little easier to get things done, which that's fantastic too.
Speaker 2:Yeah, we hope so. One of the questions the reviewers asked us is are you reinventing the wheel Right? So that people may know? There's something called the equator network, which is a place where guidelines live, and so, in order to address the reviewers' concerns, we also did a scoping review of all of the guidelines that are housed at the Equator Network to find out which of them, if any of them, addressed issues of quality and rigor and transparency relevant for dysphagia research. Want to guess how many we found?
Speaker 1:want to guess how many we found, uh oh, and do the ones that were just used?
Speaker 2:in those articles count, if not?
Speaker 2:I'm going to say zero, zero, zero, zero essentially, we found that all of these guidelines are worthwhile, um, but they're not specific enough to the kinds of things that matter to us as dysphagia clinicians, and so you need both, really. And, yeah, so that that article will be coming out as part of this series, and and that might be useful for people too, because what we did was we mapped the five I think it was 542 guidelines that are were warehoused at the equator network as of the date that we did it, that were warehoused at the Equator Network as of the date that we did it, and we profiled them to say which ones address topics that might be interesting to speech, language pathologists and dysphagia researchers. So that's there, too, to point people to things. So we don't reinvent the wheel.
Speaker 1:Moving forward, Sure Well, that sounds great, it sounds very practical. It complements something that is already there, but it provides a deeper level of specificity for a very specific topic.
Speaker 2:Yeah, yeah, I hope so.
Speaker 1:Yeah.
Speaker 2:And I just I want to say again that a huge amount of the work that's been done around the Frontiers framework and that Equator Network review was done by trainees, and so they get the authorships and deserve the credit.
Speaker 1:That's excellent. That is great. Well, there is always so much to talk about. I appreciate everything that you've brought up and you mentioned a number of resources that I want to double check to make sure I write for the description, because I mean, this is I.
Speaker 1:We were, before we started recording, talking about some of the different purposes of the podcast, and it's one, you know, to get conversation going, to get people talking about things that are important, and another one is to reduce some of the power distance between, or perceived power distance, maybe between clinicians and and those who are doing research and tenure track positions or are tenured at their university, because sometimes it can be intimidating. But what I get from this is I mean, everyone has just been so open to conversation and welcoming. I mean you're so people are passionate about what they do and they just seem to welcome discussion. So I think this kind of showcases that. There was a third thing, oh yeah, the resources too. Right, so we're not going to get everything on here, but it's a starting point for conversation If people want to continue the conversation.
Speaker 1:They can check out these resources or, you know, reach out any number of things, but it's a beginning.
Speaker 2:Yeah, and if I could plant a bit of an ad here. I think, you know, once upon a time I was a clinician who was thinking about research and I probably did that. You know. Should I do a PhD question four or five times before the stars aligned for me?
Speaker 1:I do it about once a week.
Speaker 2:But I had a habit at the time, and I don't know how open people would be to this habit, but whenever I went somewhere, to a professional development meeting, I would see if the local dysphagia guru would have me for a visit.
Speaker 2:And, as the story goes, susan Langmore was one of those people and she very graciously had me come and spend a day at her clinic, and in the course of that conversation she said you should go to dysphagia research society meeting, which I had never done. And so I decided sure that sounds like fun, I'll go. And so I went along as a clinician and it changed my life. I immediately was hooked, and the opportunity to speak to established researchers in a fairly intimate conference is extraordinary and to network with other people in the field, and so I'd really love to encourage people to come next year. We're going to be in Philadelphia March 25th to 28th. I think the networking that happens at those meetings is extraordinary and profound. And so come, we'd love to have you, and it is a place where you can go up to the big names and say hi and hopefully we'll be welcoming and interested to meet people.
Speaker 1:Yeah, no, I echo that 100%. Actually, this was the year when it was in San Francisco and it was DRS and the World Dysphagia Summit. Due to some different parameters, I just attended the World Dysphagia Summit part of it and it was very sad to miss DRS, and this year I was very sad to miss it. But there is the networking and the conversation. Those things are so important because it helps to calibrate us. So we're talking about the right things. That exposes us to different perspectives and different questions that we didn't even know were out there. And just within the idea of learning, okay, you can listen to a lecture, you can read a textbook, but you really get into it when you start applying it in conversation and you get excited about it and you want to learn about it. So you remember it. There's so much of those things that go on behind the scenes and I think things like DRS are fantastic in that regard because it helps to infuse passion within everybody and really get the conversation going. So, yeah, thank you for.
Speaker 2:And you can also see the battles being fought. You know, but the debates like and and think about how people are pushing the envelope and and expanding what we know, and I love that. I mean you can watch people like me getting up and asking challenging questions and see how that goes. So I think it's really a special thing. It's totally different than going to a more clinically focused meeting, but it does have clinical implications and relevance. So, yeah, hopefully some of your audience will think about coming.
Speaker 1:Well, I'm hoping to be there. So, yeah, if you all do end up coming and are influenced or were influenced by this episode, come and tap our shoulders, let us know. That'd be really cool. But anyway, thank you so much for everything. Is there anything else that you'd like to leave people with before we wrap up?
Speaker 2:just like to encourage people to keep asking questions, and the thing I think I love most about this field is the opportunity to keep learning for sure and challenging what we know for the benefit Ultimately, we hope of our patients.
Speaker 1:Yeah, yeah, I still feel like we're kind of in the pioneer stage of of.
Speaker 2:We are. It's an early stage of our field.
Speaker 1:So yeah, it's exciting to to at the opportunity to have an influence on that. It's super cool, so yeah absolutely. Asking questions. All right, well, thank you so much, dr Katrina Steele. We will include some of the resources that were mentioned today within the description for this podcast episode. That can be found at swallowthegapcom slash podcast or any of the descriptions on Apple podcasts and whatnot. But thank you so much for joining and we hope to see you at VRS. I hope to be there.
Speaker 2:My pleasure.
Speaker 1:Have a great week. That brings to close another episode of Swallow the Gap. A huge thanks to Dr Katrina Steele for joining us today. Please see the episode description for some resources that are pertinent to today's content, and also see the episode description for more information from Tim's Medical, who graciously sponsored this episode and will be featuring Aspect C and upcoming releases of Tim's MVP in 2025, following close collaboration with the Swallowing Rehabilitation Research Laboratory. For updates on Tim's MVP releases, follow Tim's Medical on social media or sign up for email notifications at wwwtimscom. That's T-I-M-S dot com. I just recorded a fun episode with Dr Janina Vilmskota from the Medical University of South Carolina. That's very neuro-focused and it'll be coming out soon, so keep an eye open for that. There are several events coming up in the new year. Hope to see you around for some of those and, either way, thank you so much for being.
