A Pilot Study of the Rehabilitation Services Provided for Patients with Dysphagia in Medical Settings in Jordan

Services provided for dysphaiga conditions are poorly investigated in Jordan. The aim of this study was to explore the rehabilitation services provided to patients with dysphagia in medical settings in Jordan. Data were collected from public and private hospitals, hearing and speech centres, and rehabilitation centres located in Amman province. Thirty-eight participants (16 patients and 22 professionals from various disciplines) were interviewed. There was limited knowledge about dysphagia among healthcare professionals. The provision of rehabilitation services was minimal and secondary to the provision of medical services. Clinical pathways and guidelines need to be devised to organize the work of professionals involved in the management of dysphagia.

their study, Ho, Liu and Huang (2014) found that over half of the rehabilitation unit stroke patients had dysphagia.
The significance of investigating dysphagia stems from the fact that it is associated with several complications such as aspiration pneumonia, malnutrition, and increased length of hospitalization (Ho et al., 2014;ASHA, n.d.c). Dysphagia can cause choking, bronchospasm, an increased infection rate, dehydration and weight loss (ASHA, n.d.d). In head and neck cancer patients, dysphagia can also lead to poor wound healing and reduced tolerance to medical treatments (Gaziano, 2002). Furthermore, dysphagia is known to have various debilitating side-effects on the health and quality of life of patients (Swan, Speyer, Heijnen, Wagg, & Cordier, 2015). Dysphagia has negative psychological side effects such as depression and anxiety (Zhang, Huang, Wu, Chen, & Huang, 2014). This, in part, is due to the fact that oral food intake is one of the pleasures human beings experience (Kringelbach, 2015).
Signs used for the identification, evaluation and treatment of dysphagia are variable as their representation varies from a patient to another (Kruger, 2014). This in turn, adds the complexity of the rehabilitation of dysphagia due to the variation in the application of the procedures of assessment and intervention especially in Jordanian medical institutions. In fact, and as an example of this variability, Crary and Carnaby (2014) report that the frequency of coughing/dysphagia incidences increase following a clinician's decision concerning the timing of introduction of oral intake, and the texture material and the size of bolus, which varies from clinician to clinician. Langmore and Pisegna (2015) report that the rehabilitation of dysphagia is challenging due to lack of consensus concerning the criteria that constitutes a healthy swallow, and the criteria used to measure its improvement (Langmore & Pisegna, 2015). Such criteria could be related to minimized complications such as decreased recurrences of aspiration, patient's satisfaction, the pressure generated on the pharyngeal walls while swallowing, the strength of the swallow by measuring the strength of the tongue during the process, the endurance of the patient over various textures, and/or the speed of the onset of the swallow (Langmore & Pisegna, 2015).

Dysphagia Rehabilitation: Common Approaches/Manoeuvres
Methods used for the assessment and evaluation of dysphagia are multiple. There are clinical non-instrumental assessment approaches such as cervical auscultation, meal observation, orofacial examination and the instrumental assessment approaches that rely on the use of instruments assessment tools such as Fibreoptic Endoscopic Evaluation of Swallowing (FEES) and modified barium swallow www.scholink.org/ojs/index.php/rhs Research in Health Science Vol. 5, No. 2, 2020 88 Published by SCHOLINK INC. tests (ASHA, n.d.d). However, in their study, Kjaersgaard, Nielsen and Sjölund (2014) found that both instrumental and non-instrumental approaches of evaluation are equally effective in making a decision concerning the initiation of oral intake, and reducing the risk of aspiration pneumonia for the initiation oral intake (Kjaersgaard et al., 2014;Kjaersgaard, Nielsen, & Sjölund, 2015).
One of the most common rehabilitation methods for the management of dysphagia is Exercise-based therapies (Crary & Carnaby, 2014). Also, Transcutaneous Electrical Stimulation (TES) contributes to exercise-based dysphagia rehabilitation in adults (Crary & Carnaby, 2014). Also, one of the c compensatory techniques is the intraoral stimulation using the tactile, temperature and variation in size and texture of food. For example, Hä gg and Tibbling (2015) found in their study of 31 stroke patients a significant improvement in the activity of the four facial quadrants, in the swallowing capacity, and in lip force following the application of the intraoral stimulation even in cases of long-standing post-stroke dysfunction.
For the effects of the swallowing training to be effective, Zhang et al. (2014) found that the earlier the identification and the initiation of the management starts, the better it is in counteracting the negative effects of anxiety and depression. In addition, in their study Murray Miller, Doeltgen and Scholten (2014) found that the management of dysphagia and its side effects should be directed at counteracting the dehydration by the incorporation of protocols for the provision and monitoring of consumption of liquids, by offering more fluid via thickened-food or free water protocols or by routine use of non-oral supplementary routes.

Recent Investigations
Crary and Carnaby (2014), in their review, report the presence of a rising acknowledgement of the complexity of dysphagia and which resulted into a shift in its common rehabilitation practices (Crary & Carnaby, 2014). Recently, there is a growing awareness for the need for designing integrative and comprehensive rehabilitative programmes for dysphagia management instead of relying on techniques centred on a single practice, e.g. oral-motor exercises (Crary & Carnaby, 2014). There is a shift in the trend of managing dysphagia from solely relying on exercise therapy to the use of adjunctive methods, particularly the Transcutaneous Electrical Stimulation (TES) (Crary & Carnaby, 2014). Also, the current practices focus on the incorporation of documentation of physiological changes as a method of evaluation of dysphagia and monitoring the progress brought forth by exercise therapy (Crary & Carnaby, 2014).
There are multiple exercise based rehabilitative techniques/manoeuvres employed for the management of dysphagia such as the effortful swallow, the masako, the super-supraglottic exercise, and the McNeill dysphagia treatment protocol (Langmore & Pisegna, 2015). However, such procedures lack the sufficient evidence that supports their utility due to scarcity of research studies (Crary & Carnaby, 2014;Langmore & Pisegna, 2015) (Table 1 summarizes examples of some studies and their limitations).
Even when the effects of such techniques are researched, generally their effects are limited to short term outcomes (Langmore & Pisegna, 2015). The rehabilitative approaches for intervention of dysphagia need to be further evaluated and researched due to methodological limitations associated with the sample size, research design, and inclusion criteria of participants (Crary & Carnaby, 2014). Such methodological limitations may limit the generalization of the results of studies that yield the evidence concerning the utility of common techniques for the management of dysphagia (Langmore & Pisegna, 2015).
In Jordan, research regarding dysphagia in general and the efficacy of the rehabilitative techniques in particular is scarce. As such, professional practices in dysphagia assessment and rehabilitation is generally are generally not well support by research investigations other than those conducted in the Western countries. In the number of patients with pneumonia before or after oral initiation.
No significant difference in the effectiveness of both approaches for: -Evaluation for eligibility for oral intake -Reducing the risk of aspiration pneumonia

Research Aim and Objectives
This paper represents the findings of pilot study that aims to explore the nature of rehabilitation services provided to patients with dysphagia in medical settings in Jordan. This paper reports the findings which incorporated qualitative research methodologies.

Design
Information regarding the current practices in dysphagia assessment and rehabilitation is far from sufficient on. That is, the knowledge about rehabilitation services provided in medical institutions in Jordan is scarce and this gathering information through specifically designed exploratory questionnaires and personal interviews a suitable design to underpin this research study, and as an approach for data analysis.

Sample and Recruitment
The sample constituted 38 participants (22 males, 16 females). They are 16 patients (9 males, 7 females) with dysphagia and 22 professionals (13 males, 9 females) (i.e., 2 physicians, 16 nurses, and 4 speech pathologists in terms of discipline). The average experience of professionals was 11.4 years (range 1-36 years). Table 2 demonstrates the demographics of both the patients and the professionals, while Table 3 presents the experience and the specialization of the professionals. Note. n= number, yrs= years Note. n= number, yrs= years, SLPs= Speech Language Pathologists Data were collected from various medical institutions: 3 public hospitals, two private hospitals, one private hearing and speech centre, one public centre, and one public rehabilitation and reform centre, all of which were located in Amman province. Amman is the capital of Jordan where most health-related services are concentrated.
Professionals who had a certificate of experience in dysphagia or self-reported exposure to dysphagia conditions were included in the current study. It should be noted here that dysphagia practice in Jordan is still in its developing stage. Additionally, none of the medical institutions contain a specialized department or a unit to evaluate or manage dysphagia. Thus, departments where dysphagia patients were located such as the ICU, the Internal medicine Unit, and the Otorhinolaryngology (ENT) Unit were targeted.

Data Collection
The semi-structured interview was selected as the method of data collection to allow for in-depth data to be gathered (Ritchie & Lewis, 2007). A crude interview guide was used and included questions that served as pointers only, and were typically followed by prompts, such as Can you elaborate on that?
Or give an example from your own experience? Table 4 demonstrates the main topic that was explored: "Rehabilitative services provided", and some examples of questions pertinent to each topic.

Ethical Issues
Ethical approval to pursue this study was granted from the Institutional Review Board at the [concealed for blinded review].

Data Analysis
After data collection, data was organized under a set of codes where data scripts that share the same topic or keywords were aligned under each code. After that, the codes were grouped into themes where the coded data that share the same meaning were grouped together under the same theme. MAXQDA11 software was used to assist the tabulation of data under a set of codes and themes. Finally, from the constructed themes which are the basis for the creation of interrelations and explanations.

Findings
The data analysis revealed five main themes: The subjects understanding of the primary conditions where dysphagia presents as secondary symptom, the symptoms of concern used to identify dysphagia, the professionals involved in the management in dysphagia, the rehabilitative services provided, and level of knowledge about dysphagia. Those are presented in Figure 1 and will be further discussed in the subsequent subsections.

Dysphagia: The Primary Conditions
Based on the findings of this study, dysphagia presented as an associated symptom with other primary conditions which are presented in Table 5. Cerebrovascular Accident (CVA) was the most neuromuscular conditions reported by participants to result in dysphagia. For the GI tract disorders, the Gastroesophageal Reflux Disease (GERD) was the most common disorder resulting in dysphagia as reported by participants. Table 5 summarizes the main findings concerning the main conditions that caused dysphagia and their percentages.
Another interesting finding was that about (22.7%) of professionals reported that the examination of the gag reflex is an important procedure for the identification of dysphagia. However, several research studies are raising doubts regarding the clinical relevancy of this for the identification of dysphagia such as the study conducted by Leder (1996). This finding will be further discussed in subsequent sections.

Note. *= Highest percentage, SLPs= speech pathologists, OTs= Occupational therapists, PTs=
Physiotherapist Participants reported that professional involved in the management of dysphagia conditions were not working as a team but rather their efforts were dispersed and disorganized. There were referrals between departments and between various disciplines, however several professionals did not know the role of other professionals. Some participants even thought that the management of dysphagia is exclusive to speech pathologists:  Table 9 summarizes the services provided for patients with dysphagia, the most common provided service as reported by professionals was the application of feeding tubes as reported by 71.7% of participants. This supports the assumption that the management of dysphagia does not take into account possible rehabilitation, but a medical procedure.

Services Provided for Patients with Dysphagia
Though education of the patients and the family about dysphagia and how to manage it was the main service reported (56.3%), only 18.2% of the professionals reported that they provide such a service.
This maybe attributed, in part, to the misconception that medical intervention is the sole appropriate intervention for dysphagia clients, or that professionals may not have viewed that education was part of their role but rather as an extra task that is not within their scope of practice.
The evaluative services included instrumental and non-instrumental methods. The most instrumental methods used for the evaluation of dysphagia were reported to be fluoroscopy (42.1%), followed by endoscopy (28.9%), then modified barium swallow (MBS) (7.9%), and finally the esophageal manometry (5.3%). None of the patients or their family members reported to receive any of these services. This could be due to their lack of knowledge about those methods; thus, patients may have been subjected to those procedures without knowing their purpose.
The rehabilitative services for the treatment of dysphagia were mainly focused on positioning (34.2%), swallowing manoeuvres, oral motor exercises, and TTOS (13.2%). Electrical stimulation was not reported by any of the participants to be used in dysphagia the management. This could be attributed to the lack of the knowledge of professionals about other non-conventional methods used in the management of dysphagia.  There is a need to equip the professionals with the necessary knowledge and training required to manage dysphagia cases.

Services Provided
Some professionals and patients and their care givers stated that feeding tubes are sought as the first and preferred form of intervention for dysphagia as it is easy to administer and requires less time in terms of management follow up. Mitchell, Kiely and Lipsitz (1998) stated that feeding tubes may contribute to patients' death by complications related to infections that it may contribute to; therefore, this should be taken in consideration that it does not help all patients with dysphagia. There is a need to invest in the provision of rehabilitative integrative services to guarantee that services provided for the management of dysphagia are comprehensive and carefully chosen.
The assessment of dysphagia condition was based on the use of instrumental and non-instrumental methods. Videofluoroscopy was one of the most common methods used by professionals for the evaluation of dysphagia. However, several methods for evaluation and intervention were not used by professionals. One example is the use of the TES although several investigations show that it possesses potential benefits if used as part of the exercise-based dysphagia rehabilitation (Crary & Carnaby, 2014). Other methods of intervention such as the use of adaptive equipment such as adaptive cups and spoons and esophageal manometry were not common. This could be partly attributed to the unavailability of dysphagia evaluation and training tools. Those are available internationally but are either unavailable in the Jordanian market and/or expensive. Examples of resources needed for swallowing and therapy include chewy tubes, oral and facial massagers, brushes, modified cups and spoons, food thickeners, expiratory pressure threshold devices, and electrical stimulator massagers.

Members of the Team Involved in Dysphagia Management
The licensing speech pathology practice). Also, the Canadian Occupational therapists collaborate with stakeholders at national and regional levels to promote and engage in research to further best practices in all areas of feeding, eating and swallowing including dysphagia assessment and management (ASHA, n.d.b;Clark, Avery-Smith, Wold, Anthony, & Holm, 2007).
According to the ASHA (n.d.a) the management of dysphagia requires a team of professionals consisting of physicians, nurses, nutritionists, psychiatrists, occupational therapists and physiotherapist, and this team is led by speech pathologists. The role of a speech pathologist is to evaluate and treat patients with dysphagia by performing the necessary modifications of physiologic responses and diet modification. Occupational therapists evaluate and treat sensory and motor impairments and assess the need for prosthesis or equipment that can facilitate self-feeding and swallowing. Physiotherapists are required to evaluate and treat body positioning, sensory function and motor movements necessary for safe and efficient swallowing ASHA (n.d.a). Also, they recommend seating equipment to support proper feeding. The physicians' role is mainly directed at evaluating and treating the main medical condition causing dysphagia, while nurses are responsible of working closely with the patient and his/her family members in implementing safe swallowing techniques and compensatory or facilitation strategies for swallowing.
In this study, none of the participants were occupational therapists as the researchers could not identify This study showed that Jordanian professionals involved in the management of dysphagia do not work collaboratively. Such matter would cause replication of some services and potential contradicting form of consultations or procedures. As such, the care delivered to clients with dysphagia lacks the holistic and comprehensive approach. There is a need for the various professionals to be involved in the management of patients with dysphagia where their roles as team members are defined. Both the medical services and the rehabilitative services need to be provided side by side for a comprehensive and effective management of dysphagia conditions. For example, some dysphagia cases are of a behavioural cause which may require the evaluation of a speech pathologist and the intervention of an occupational therapists and/or a psychiatrist (ASHA, n.d.a).
The healthcare system in most medical institution in Jordan lacks clear guidelines for the management of dysphagia. The Legislations governing the speech-pathology licensing in Jordan issued by the MOH (1999; Amended, 2014) do not contain a detailed description of the scope of practice of speech language pathologists. However, Speech-language pathologists certified by the Jordanian Ministry of Health and guided by international regulations consider dysphagia as common practice. In fact, a number of speech language pathologists are also certified by international organization such as ASHA.
There is not a clear delineation between the roles of various specialists who are involved in the management of dysphagia conditions.

Knowledge about Dysphagia
In Jordan, there are no clear guidelines that govern the evaluation or the detection of dysphagia. Several dysphagia conditions are not detected by professionals, and the client and/or his caregivers were the ones to initiate the process by reporting a complaint related to quality of swallowing or its complications such as aspiration pneumonia. Physician and nurses in particular, are not well trained to detect dysphagia, especially if it was of the "silent" type. Some professionals, i.e., nurses, lacked either interest and/or knowledge about dysphagia. This is marked by the fact that several possible dysphagia conditions were identified by the research team as possible candidates for formal assessment. Those potential patients have been admitted to the ward for weeksmonths while nurses were not aware that those clients may have dysphagia. This might call for administering both theoretical and hands-on training courses on dysphagia screening and nursing management.
Several professionals involved in the management of dysphagia used procedures unsupported by evidence-based research to screen for dysphagia. 22.7% of the professionals who participated (in this study reported that the absence of a gag reflex is an important indicator of dysphagia. However, depending on the integrity of the gag reflex upon a complaint made by the client or his caregiver concerning the presence of difficulty in swallowing is not sufficient to confirm or refute the presence of swallowing disorders (Leder, 1996). In his study, Leder (1996) found that although all subjects were referred for bedside dysphagia evaluations specifically because they had no gag reflex, 86% (12/14) were nevertheless able to eat at least a puree diet. The gag reflex, traditionally considered part of the bedside dysphagia evaluation, was absent in 13% (9/69) of non-dysphagic subjects, raising further doubts regarding its clinical relevancy.
Several professionals involved in the management of dysphagia reported to acquire the knowledge and skills required to manage conditions of dysphagia from their own resources. Thus, there is a need to provide the necessary knowledge, training, and skills for the assessment and management of dysphagia to professionals in order to enhance patients' safety, and the effectiveness of services provided (Ho et al., 2014).
Professionals did not assume the required role in teaching the clients and their caregivers about dysphagia and its management as they themselves, did not have sufficient knowledge. The ASHA (n.d.b) deems the patients and their caregiver as part of the team required for an effective management of dysphagia. A large proportion in dysphagia management depends on the clients' education. For example, GERD management requires teaching the client about the effects of smoking and alcohol on this condition. Clients had limited knowledge about the role of rehabilitation professionals in dysphagia and though they may need rehabilitation services, there was not enough education provided to them.
This was expected because of the scarcity of dysphagia specialists and research projects directed towards dysphagia in Jordan. Public awareness and community service activities directed towards raising awareness about dysphagia are very limited in number and quality. Consequently, some patients and caregivers had to seek answers through unprofessional means such as asking a former patient and/or caregiver who had the same problem or seeking internet resources that are not always based on documented research. Additionally, dysphagia is relatively a newly promoted subspecialty of the rehabilitation professions in Jordan, and in the speech-language pathology profession in particular.
Organized initiatives directed at raising public awareness about dysphagia are strongly recommended.
For example, there are days designated for promoting awareness regarding different disorders/diseases.
An example is the "National Dysphagia Awareness Month" that is mentioned by the National Foundation of Swallowing Disorders, USA (2016). Such public awareness events may be of vital importance to raise awareness about dysphagia among professionals working in the field, patients and their caregivers.

Conclusion
This study targeted the dysphagia and the rehabilitative services offered for dysphagia patients in Jordan. The study and consequent studies may l pave the way for future investigations regarding the rehabilitative services for Jordanian patients with dysphagia and develop ways to improve the quality of such services.

Key Points
 Rehabilitation services need to be integrated the current model of management of dysphagia in medical institutions in Jordan.

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There is a need for professionals to acquire more knowledge, skills and experience required for the management of dysphagia.

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Patients with dysphagia and their families are part of the dysphagia team and educating them is the responsibility of the professionals.

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Clinical guidelines need to be developed to better organize the work of professionals involved in the management of dysphagia.