J Head Trauma Rehabil

Vol. 24, No. 5, pp. 384–391

Copyright c 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Feasibility of Instrumental Swallowing

Assessments in Patients With
Prolonged Disordered Consciousness
While Undergoing Inpatient
Rehabilitation
Susan L. Brady, MS, CCC-SLP, BRS-S; Theresa L.-B. Pape, DrPH, MA, CCC-SLP/L;
Meghan Darragh, MS, CCC-SLP; Nelson G. Escobar, MD; Noel Rao, MD

Objective: To evaluate the feasibility, safety, and potential benefit of instrumental swallowing assessments for pa-
tients with prolonged disordered consciousness participating in rehabilitation. Design: Case-control, retrospective.
Participants: Thirty-five participants divided into 2 cohorts according to cognitive level at the time of baseline
instrumental swallowing assessment. Group 1 (n = 17) participants were at Rancho Los Amigo (RLA) level II/III
or RLA level III, while Group 2 (n = 18) participants were rated better than RLA level III. Results: Aspiration
and laryngeal penetration rates for both groups were similar (aspiration rate Group 1 = 41%, Group 2 = 39%;
laryngeal penetration rate Group 1 = 59%, Group 2 = 61%). Overall, 76% (13/17) of Group 1 and 72% (13/18)
of Group 2 were able to receive some type of oral feedings following baseline video fluoroscopic swallow study
(VFSS) or endoscopic exam of the swallow (FEES). Conclusion: The majority of participants who underwent an
instrumental swallowing examination while still functioning at RLA level II/III or RLA level III were able to return
to some form of oral feedings immediately following their baseline examination. Swallowing as a treatment modality
can be considered a part of the overall plan to facilitate neurobehavioral recovery for patients with prolonged disor-
dered consciousness participating in rehabilitation. Keywords: brain injury, coma, deglutition, disordered consciousness,
dysphagia, rehabilitation

R EHABILITATION TEAMS have traditionally

struggled to provide meaningful treatment for
individuals with prolonged disordered consciousness.
lowing examinations, are possible and safe and do not
increase cost for patients with prolonged disordered
consciousness during inpatient (IP) rehabilitation.1 This
Swallowing therapy may be overlooked as a plausible article presents complementary evidence regarding the
intervention because of risk for aspiration. Previously feasibility, safety, and potential benefit of conducting
reported evidence indicates that safe therapeutic oral an instrumental assessment of the swallow during IP
feedings, based on findings from instrumental swal- rehabilitation for patients with prolonged disordered
consciousness.
Author Affiliations: Voice & Swallowing Center, Department of Dysphagia following a severe brain injury is attributed
Speech-Language Pathology (Dr Brady), Brain Injury Program (Ms to physiological impairments affecting the swallowing
Darragh and Dr Escobar), Marianjoy Rehabilitation Hospital (Drs Pape mechanism and impaired cognition.2–4 Persons who re-
and Rao), Wheaton, Illinois; Department of Veterans Affairs, Office of
Research and Development, Rehabilitation Research and Development cover consciousness within 4 weeks of a severe brain
Service, Hines, Illinois (Dr Pape); and Department of Physical Medicine injury have been shown to demonstrate improved swal-
and Rehabilitation and Institute for Health Care Studies, Northwestern lowing function during the recovery trajectory,5,6 but
University Feinberg School of Medicine (Dr Pape).
limited information is available regarding swallowing
The Dr Ralph and Marian Falk Medical Research Foundation supported this function and recovery for those persons who remain in
work. This article was accepted for a poster presentation at the American Speech-
Language-Hearing Association Annual Convention, Boston, Massachusetts, a prolonged state of disordered consciousness.1,7 Dis-
November 2007. orders of consciousness have been characterized in the
Corresponding Author: Susan L. Brady, MS, CCC-SLP, BRS-S, 26 W literature as coma, vegetative, and minimally conscious
171 Roosevelt Rd, Wheaton, IL 60187 (sbrady@[Link]). states.8
384
 Swallowing Rehabilitation 385

Research with animal models has shown that the Instruments

lower brain stem-mediated crossed adductor reflex is
The RLA Levels of Cognitive Functioning11 scale cat-
eliminated by modifying the central facilitation via
egorizes language and cognitive functioning following
progressively deeper loss of consciousness. The elimi-
traumatic brain injury. The RLA levels I through III
nation of this reflex predisposes the subjects to a weak-
describe behavioral recovery from coma, and levels IV
ened glottic closure response.9 Findings from this animal
through VIII encompass the various stages of recovery
model study suggest that people with disordered con-
following recovery of consciousness. For those patients
sciousness for 4 or more weeks (prolonged) may have a
who could not reliably be classified as functioning either
weakened glottic closure response which, in human, is
at RLA level II or at RLA level III (ie, differentiation
associated with elevated risk for aspiration and/or silent
between the levels was not clearly obvious), a coding
aspiration.10
of RLA level II/III was used. Although no formal def-
Given the limited information currently available re-
inition of RLA level II/III is present in the literature,
garding treatment and recovery of swallow function in
for the purpose of this investigation, the classification
individuals with prolonged disorders of consciousness,
of “RLA level II/III” included individuals who demon-
the purpose of this case-control, retrospective study was
strated characteristics of both RLA level II and RLA
to evaluate the feasibility and potential benefits of con-
level III.
ducting an instrumental assessment of the swallow for
The FIM, developed by the American Academy of
patients with disordered consciousness admitted to a
Physical Medicine & Rehabilitation and the Ameri-
freestanding rehabilitation hospital. For the purpose of
can Congress of Rehabilitation Medicine,12 includes 18
this investigation, “disordered consciousness” was de-
items (13 motor and 5 cognitive) relating to various func-
fined as patients functioning at a Rancho Los Amigo
tional skills. Each item is rated on a scale ranging from 1
(RLA) level II or III and who received the lowest possi-
(complete dependence) to 7 (complete independence).
ble Functional Independence Measure (FIM) cognitive
Medical chart reviews for RLA levels and FIM scores
score of 5 upon IP rehabilitation admission.
and all other inclusion criteria were completed inde-
The specific aims of this feasibility study were to iden-
pendently by 2 investigators; a third investigator iden-
tify the number of individuals who successfully com-
tified discrepancies between the 2 reviewers that were
pleted an instrumental assessment of the swallow during
discussed until a consensus was reached.
IP rehabilitation, while still in a prolonged disordered
consciousness state, and to evaluate the safety and poten-
Data abstraction procedures
tial benefits (ie, returning to oral feedings) of conducting
the examination. For the purpose of this study, the term The primary purpose of the study was to determine the
“feasibility” was defined as the practical ability to com- feasibility of conducting an instrumental assessment of
plete an instrumental assessment of the swallow. We in- the swallow in patients with prolonged disorders of con-
vestigated the feasibility of conducting an instrumental sciousness during IP rehabilitation by assessing whether
assessment of the swallow during IP rehabilitation for pa- and how prescribed oral diets changed following their
tients with prolonged disordered consciousness because examination. The type of instrumental swallowing exam-
the rehabilitation team might try to use swallowing as ination was either the video fluoroscopic swallow study
a treatment modality as one tactic of the overall strat- (VFSS) or the fiberoptic endoscopic examination of the
egy to facilitate neurobehavioral recovery. The Human swallow (FEES). Aspiration, laryngeal penetration rates,
Subject’s Institutional Review Board for the hospital ap- and prescribed diet recommendations following either
proved this study. the VFSS or the FEES were abstracted from the medi-
cal chart. The level of cognitive functioning at baseline
instrumental swallowing assessment was also recorded.
METHODS
The appropriate timing for the baseline instrumental
The data in this article are derived from a retrospec- swallowing assessment was determined by several fac-
tive, case-control study, with participants identified us- tors including, but not limited to, (1) overall medical
ing medical records from a 4-year period (July 1, 2002, condition/stability of the patient, (2) pulmonary status,
through June 30, 2006). Study sample inclusion was de- and (3) the basic ability to accept food and/or spoon
termined according to admission rehabilitation impair- presentation to the mouth.
ment codes (RIC) for severe brain injury (RIC 2, 3, and Diet levels prescribed after the swallow examination
18). Inclusion criteria included all patients between 18 were coded as regular, modified, therapeutic feeding, or
and 89 years of age who were functioning at a RLA II, nil per os (NPO). The definitions for these diet lev-
RLA II/III, or RLA III level and who received the low- els have been previously described in the literature1
est possible FIM cognition score of 5 at the time of IP and are as follows: Regular diet was defined as 3 meals
rehabilitation admission. daily with no restrictions for solids or liquids; modified
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386 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2009

TABLE 1 Chart review Of the 1057 patients screened, 42 met the previously de-
scribed inclusion criteria, and 35 of these 42 participants
received a baseline instrumental swallowing assessment.
Age Time from injury onset to Seven participants who did not receive a baseline
admit to IP
rehabilitation FEES or VFSS were functioning at RLA level II (5/7)
Gender Medical complications or at RLA level II/III (2/7). Over the course of their IP
(acute) rehabilitation stay, all 7 patients were assessed to deter-
Onset date Tracheotomy tube status mine if they were appropriate to undergo an instrumen-
Type of injury Admission RLA level tal assessment of the swallow. It was determined by the
(rehabilitation)
Injury circumstances Length of stay for attending rehabilitation team that these patients did not
rehabilitation meet the basic criteria to participate in an instrumental
Diet level (admit & Medical complications assessment of the swallow; either because of medical or
discharge) (rehabilitation) pulmonary instability as judged by the attending physi-
Cognitive FIM (admit & Results of instrumental cian or because of the inability to accept food or a spoon
discharge) examination
Total FIM score (admit & Expected into the mouth.
discharge) reimbursement For these 7 participants, age at the time of injury
(rehabilitation) ranged from 23 to 71 years with a mean age of 38.57
years (±7.28 years): There were 4 men and 3 women,
Abbreviations: IP, inpatient; RLA, Rancho Los Amigo; FIM, Func-
and all had a tracheotomy tube. The time of injury on-
tional Independence Measure. set to admission to IP rehabilitation averaged 76.6 days
(±86.4 days), and IP rehabilitation length of stay (LOS)
diet was defined as 3 meals daily with a change in the was 22.57 days. None of the 7 participants demonstrated
solid and/or liquid consistency (ie, pureed solids and/or any change in RLA level or cognitive FIM ratings dur-
nectar-thick liquids); and therapeutic feeding was de- ing IP rehabilitation. All 7 participants remained NPO
fined as small, controlled amounts of food and/or liq- throughout their IP rehabilitation stay. The mean cost
uid provided by a speech-language pathologist (SLP) for of care for these 7 participants averaged $31 641 with an
practice swallows only. The total amount given during expected negative net revenue of $2295 (ie, –$2295).
a therapeutic feeding ranged from a minimum of 3 to Because the primary purpose of this case-control, ret-
5 boluses to a maximum of 4 oz to 6 oz and was not rospective study was to evaluate the feasibility and the
sufficient to maintain nutritional needs. Patients receiv- potential benefits of conducting an instrumental assess-
ing only taste stimulation were coded as NPO. Data ment of the swallow (VFSS or FEES), and because they
regarding medical complications included information did not participate in either a VFSS or a FEES eval-
on nutritional status (eg, presence of dehydration) and uation, these participants were excluded from further
aspiration pneumonia. analysis.
The secondary aim of the study was to examine the
change in cognitive functioning from the time of IP re- Description of total sample
habilitation admission to that of discharge relative to The majority of the remaining 35 participants (27/35;
changes in oral diet levels. Change in cognitive function- 77%) were male patients ranging in age at time of injury
ing was measured with the FIM cognitive scores com- from 19 to 82 years with a mean of 43.3 years (±18.86
puted by therapists at time of admission and that at the years). At IP rehabilitation admission, 30 of the partici-
time of discharge. Data abstracted from medical charts pants (86%) had a tracheotomy tube, 29 (83%) injuries
appear in Table 1. were traumatic in nature, all (100%) were NPO, and
no participants (0%) were ventilator-dependent. Average
Data analyses time from onset of injury to IP rehabilitation admission
Pearson correlation coefficients and t tests were com- was 62.3 days (±71.1 days) indicating that the study sam-
puted for continuous variables. Cross-tabulations and ple represents persons with prolonged disordered con-
chi-square tests were completed for categorical variables. sciousness. The average LOS for IP rehabilitation was
Level of significance was set at an alpha of .05. Statisti- 41 days (±18.16 days).
cal calculations were completed using Minitab Statistical
Software, Release 13. Study cohorts
The total sample of 35 participants was divided into 2
RESULTS
cohorts according to the level of cognitive functioning at
Within the 48-month time frame, 1057 patients with the time of baseline instrumental swallowing assessment.
a severe brain injury were admitted to IP rehabilitation. Group 1 (n = 17) included participants who received a
 Swallowing Rehabilitation 387

TABLE 2 Subject demographicsa TABLE 3 Baseline VFSS/FEES results

and diet recommendations
Group 1 Group 2
(n = 17) (n = 18) Group 1 Group 2
(n = 17) (n = 18)
Age, y 42.5 (18.3) 44.1 (19.9)
Tracheotomy tube, 94% (16) 78% (14) Aspiration during 41% (7) 39% (7)
% (n) baseline swallow
Duration of injury 91.0 (75.9) 35.1 (55.5) examination
onset to IP Laryngeal penetration 59% (10) 61% (11)
rehabilitation, d during baseline
IP rehabilitation 40.1 (19.4) 41.8 days 17.5) swallow examination
LOS, d NPO after baseline 24% (4) 28% (5)
swallow examination
Therapeutic feeding after 76% (13) 17% (3)
Abbreviations: IP, inpatient; LOS, length of stay.
a Values are expressed as mean (SD) unless otherwise indicated. baseline swallow
examination
Modified diet—3 meals 0% (0) 55.5% (10)
daily after baseline
baseline FEES or VFSS while their cognitive function- swallow examination
ing was at an RLA level II/III or RLA level III. Eight of
the 17 participants (47%) in Group 1 were functioning Abbreviations: VFSS, video fluoroscopic swallow study; FEES,
at an RLA level II/III for the baseline VFSS or FEES, fiberoptic endoscopic exam of the swallow; NPO, nil per os.
and the other 9 participants (53%) were functioning at
an RLA level III. Group 2 (n = 18) included those par- pants who remained NPO. Overall, 76.5% (13/17) of
ticipants who received a baseline VFSS or FEES when Group 1 and 72% (13/18) of Group 2 participants were
their cognitive function was rated as better than RLA able to receive some type of oral feedings immediately af-
level III. Of the 18 participants in Group 2, 10 (55.5%) ter the baseline VFSS or FEES. The differences between
were functioning at RLA level IV, 4 (22%) at RLA level the 2 groups are not significant (χ 2 = 0.011, P = .915).
IV/V, 3 (17%) at RLA level V, and 1 (5.5%) at RLA level The second step in evaluating pre- and postbaseline
V/VI at the time of their baseline VFSS or FEES as- VFSS or FEES diet changes between groups involved
sessment. These 2 groups were chosen for comparison comparing types of oral feedings. No participant in ei-
in order to further evaluate the feasibility of conducting ther group was placed on a full regular diet (ie, 3 meals
an instrumental swallowing examination while the pa- daily with no restrictions for solids or liquids) imme-
tient was still functioning at RLA level II, II/III, or III diately (ie, within 24 hours) after baseline instrumental
versus conducting the examination after the patient had swallowing assessment. The specific types of oral feed-
advanced beyond the RLA level III. ings/diet levels prescribed for each group immediately
Table 2 summarizes demographics for each group. The following the baseline VFSS or FEES are significantly
2 groups are similar in age at injury (t = −0.25, P = .808), different (χ 2 = 16.346, P ≤ .0001). The majority of pre-
LOS for IP rehabilitation (t = −0.27, P = .785), and tra- scribed meals for Group 2 are 3 meals daily with alter-
cheotomy tube status (χ 2 = 1.906, P = .167). There is, ation of solids and/or liquids (ie, modified diet), and
however, a significant difference between groups for time the majority of prescribed meals for Group 1 are only
of injury onset until IP rehabilitation admission (t = 2.47, therapeutic feedings.
P = .019) with Group 1 participants having significantly
longer interval between injury and IP rehabilitation
Diet and FIM changes: Admission to discharge
admission.
Table 3 summarizes the baseline aspiration and laryn- Table 4 summarizes diet levels at the time of IP re-
geal penetration rates according to the VFSS or FEES habilitation discharge for each group. When classifying
examinations. Groups 1 and 2 are similar in respect to discharge diet levels by those study participants who
these rates (aspiration χ 2 = 0.019, P = .890; laryngeal were able to return to any type of oral feedings (ther-
penetration χ 2 = 0.019, P = .890). Table 3 also summa- apeutic feedings, modified diet, or regular diet) versus
rizes by group the diet level prescribed following base- those remaining NPO, both study groups are similar. In
line VFSS or FEES examinations. Pre- and postbaseline Group 1, 76.5% (13/17) of the study participants and
VFSS or FEES diet changes were examined in 2 steps. in Group 2, 83.3% (15/18) were able to resume some
First, groups 1 and 2 were compared for persons who type of oral feedings by the time of discharge from
were able to begin some type of oral feedings after base- IP rehabilitation, and the difference is nonsignificant
line instrumental VFSS or FEES versus those partici- (χ 2 = 0.029, P = .866). When classifying the discharge
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TABLE 4 Diet level and FIM scores at IP (Pearson coefficient = 0.198, P = .253), suggesting that
a person may return to some oral feedings although
rehabilitation discharge they are not demonstrating FIM cognitive gains. Of the
10 participants who remained on therapeutic feedings
Group 1 Group 2 at the time of IP rehabilitation discharge (all from
(n = 17) (n = 18) Group 1), only 2 demonstrated improvements in their
NPO 23.5% (4) 16.6% (3) cognitive FIM scores from admission to discharge.
Therapeutic feedings 58.8% (10) 0% (0)
Modified diet—3 meals 11.8% (2) 27.8% (5)
Medical complications
daily
Regular diet (no 5.8% (1) 55.6% (10) Group 1 included 13 participants who were consum-
modifications)—3
ing therapeutic feedings under the close supervision of
meals daily
an SLP while functioning at RLA level II, II/III, or III.
Of those, 2 developed pulmonary complications and
Abbreviations: FIM, Functional Independence Measure; IP, inpa- were emergently discharged from the rehabilitation hos-
tient; NPO, nil per os. pital to acute care medical units. Both participants were
discharged within 24 hours of a documented episode of
diet levels by those study participants who were receiv- aspiration of gastric tube feeding content. In Group 2, 1
ing 3 meals daily (modified and regular) versus those not participant was emergently discharged to an acute care
receiving 3 meals daily (therapeutic feedings and NPO), medical unit with a diagnosis of aspiration pneumonia.
there is a significant difference between groups; as the This participant was NPO but had several documented
majority (83%; 15/18) of Group 2 were consuming 3 episodes of medical noncompliance with prescribed diet
meals daily as compared with only 16.7% (3/18) from level (patient consuming water against prescribed diet of
Group 1 (χ 2 = 15.101, P = .0001). NPO). There were no reported cases of malnutrition or
Table 5 summarizes FIM scores at the time of IP dehydration in either group.
rehabilitation discharge for each group. There are
significant group differences according to discharge Cost of instrumental swallow examinations by groups
FIM scores. That is, FIM cognitive and total FIM scores
are significantly different, with group 2 demonstrating Table 6 summarizes the overall cost of care and the
higher mean scores (cognitive FIM t = –3.74, P = .001; expected net revenue for each group in US dollars. There
overall FIM t = –4.27, P = .0001). There is a statistically is no significant difference between groups, indicating
significant positive association between FIM cognitive that providing an instrumental assessment of the swallow
gain and returning to the diet of 3 meals daily (regular early in coma recovery did not significantly increase the
diet and modified diet) (Pearson coefficient = 0.426, cost of care nor did it reduce the expected net revenue.
P = .011). The implication is that as cognitive function
improves, so does the likelihood of returning to either DISCUSSION
regular or modified diet of 3 meals daily. However, the
The current findings must be interpreted within the
relationship between FIM cognitive gain and returning
context of the retrospective case-control study design.
to any type of oral feedings (ie, therapeutic feedings
The study sample is a convenience sample of persons
and regular/modified 3 meals daily) was not significant
admitted to a freestanding IP rehabilitation hospital
with prolonged (more than 4 weeks consecutively) dis-
TABLE 5 FIM scores at IP rehabilitation ordered consciousness defined as RLA level II or RLA
discharge level III and those with features common to both RLA
level II/III. The majority of these participants had a
tracheotomy tube; all were NPO at the time of IP re-
M (SD)
habilitation admission, and all had the lowest possible
Group 1 Group 2 FIM cognitive score of 5 at the time of IP rehabilitation
(n = 17) (n = 18) admission.
FIM cognitive 5.94 (2.08) 12.33 (6.94) To evaluate the feasibility of an instrumental swal-
discharge score lowing assessment, the primary outcome we used was
Total FIM discharge 21.6 (10.2) 48.5 (24.6) changed in prescribed oral diets after a baseline instru-
score mental assessment of the swallow during IP rehabilita-
tion hospitalization. Previous research has shown that if
Abbreviations: FIM, Functional Independence Measure; an individual demonstrates a safe swallow during a base-
IP, inpatient. line VFSS or FEES, then an upgrade in prescribed diet
 Swallowing Rehabilitation 389

TABLE 6 Financial results

M (SD)
Group 1 (n = 17) Group 2 (n = 18) Significance

Cost of care, $ 47 296 46 933 t = 0.05

(±21 864) (±18 453) P = .958
Expected net revenue, $ 2152 3165 t = −0.12
(±26 853) (±21 591) P = .903

early in coma recovery (ie, still functioning at an RLA the VFSS or FEES may demonstrate that a safe swallow
level II, II/III, or III) may be of benefit to person with is present.
disorders of consciousness receiving IP rehabilitation.1 While the initiation of therapeutic feedings early in
Group 1 (RLA level II/III or RLA level III) received base- coma recovery is not sufficient for meeting nutritional
line VFSS or FEES earlier in coma recovery relative to needs and was not related to higher diet outcomes at
Group 2 (RLA level III or higher at the time of baseline the time of IP rehabilitation discharge, the influence
VFSS or FEES). of therapeutic feedings early in coma recovery on long-
As compared with Group 2 participants, those in term outcomes and the quality of life is unknown. It is
Group 1 had a longer length of time from injury onset also important because therapeutic feedings may provide
to IP rehabilitation admission and a lower swallowing quality of life/enjoyment for patients and/or their fami-
and FIM gains at the time of IP rehabilitation discharge. lies. Previous research, for example, has shown improved
Previously published findings indicate that longer dura- family adjustment with achievement of some tangible
tion between injury onset and IP rehabilitation admis- goals/meaningful activities; and swallowing is a very im-
sion is a negative predictor of overall outcomes.13 Thus, portant functional activity of daily living.14–16 Provision
Group 1 would not be expected to make major gains of some type of oral diet in accordance with baseline
during IP rehabilitation, but results indicate that the ma- VFSS or FEES is supported further by our findings that
jority of Group 1 participants were prescribed some type instrumental assessment early in coma recovery is cost-
of oral feedings subsequent to baseline VFSS or FEES. neutral, and no participants had medical complications
The maximum prescribed diet level for Group 1 follow- related to changes in prescribed diets.
ing the baseline swallow examination was therapeutic The second finding of interest was the similarities be-
feedings under the skilled invention with an SLP. Ad- tween the 2 groups for aspiration and laryngeal penetra-
vancement to therapeutic feedings may be considered a tion rates during their baseline instrumental swallowing
reasonable functional outcome as it may enhance qual- assessment. Although they had similar rates, participants
ity of life by providing pleasure for the patients and their in Group 2 were more likely to receive a prescribed ini-
families. tial diet recommendation of 3 meals daily versus that
The finding that Group 1 participants were able to of therapeutic feedings following their baseline VFSS or
safely tolerate therapeutic feedings after a baseline VFSS FEES. This finding further supports previous research re-
or FEES conflicts with the finding reported earlier by porting that swallowing dysfunction following a severe
Mackay and colleagues2 that an RLA level IV was re- brain injury is a multifaceted phenomenon and is related
quired for the initiation of oral feedings. Mackay and to both the underlying physiological deficits affecting
colleagues,2 however, excluded individuals below an the swallowing mechanism and impaired cognition and
RLA level IV from participating in a VFSS or FEES. that these factors together may influence return to oral
Their study design, therefore, did not allow for a direct feedings.3,4
investigation of whether or not the initiation of oral The safety of providing oral feedings with individuals
feedings is safe and feasible below RLA level IV. functioning between RLA level II and RLA level III is
The results of this study further suggest that patients obviously the main concern for any rehabilitation team.
who do not demonstrate FIM cognitive gains during IP Additional challenges such as a strong bite response or
rehabilitation may still demonstrate functional progress periods of increased lethargy may limit the ability to
with their swallowing. Therefore, by providing a VFSS conduct an instrumental assessment of the swallow with
or FEES early in coma recovery, individuals who may this patient population. In spite of these challenges, the
not otherwise improve during IP rehabilitation (as mea- results of this research provide additional support regard-
sured with the FIM) may show progress to the level that ing safety, as both groups demonstrated similar aspira-
they are able to safely tolerate therapeutic feedings as tion rates regardless of cognitive level when the VFSS
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390 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2009

or FEES was conducted. This research also revealed that The current findings provide further evidence that in-
approximately 85% (11/13) of the individuals in Group dividuals with disordered consciousness can participate
1 who were receiving therapeutic feedings while still in an instrumental assessment of the swallow and can
functioning at RLA level II, II/III, or III did not develop safely tolerate therapeutic feedings if indicated by the
any pulmonary complications as a result of the therapeu- instrumental swallow assessment, when provided under
tic feedings. Furthermore, the 2 instances of pulmonary the auspices of a skilled therapeutic intervention.1 Fur-
complications resulted from witnessed large-volume as- thermore, when deciding to initiate oral feedings early in
piration of gastric contents from the tube feedings. As- coma recovery, both safety and quality-of-life indicators
piration of the gastric tube feeding content is one of should be taken into consideration. Given that conduct-
the most serious and common complications of tube ing a VFSS or FEES early in recovery is, at worst, cost-
feedings.17 neutral and may lead to the recommendation of thera-
For prescribed diet levels at time of discharge from IP peutic oral feedings, it should be considered an option
rehabilitation, this study found that regardless of group for overall sensory stimulation and swallowing retraining
assignment; individuals with improved cognition during for patients with disordered consciousness.
the course of their IP rehabilitation (as measured by the
cognitive FIM scores) were also more likely to receive a
CONCLUSION
less restrictive diet and return to a diet of 3 meals daily by
time of discharge. This finding provides further support In summary, a convenience sample of patients with
of the positive relationship between improved cognitive prolonged disordered consciousness was able to partic-
function and swallowing ability.3,4 Individuals who ipate in swallowing assessment, and it safely tolerated
function at a higher cognitive level are more likely to therapeutic oral feedings under supervision of an SLP.
have the ability to complete various compensatory swal- Overall, our findings provide additional support regard-
low safety strategies that may reduce or eliminate the risk ing the potential benefits of conducting an instrumen-
of aspiration and, in turn, result in a less restrictive diet. tal swallowing assessment while the patient is still func-
A recognized limitation of this study is that it was tioning at RLA level II/III or RLA level III. Providing
a retrospective study of a convenience sample with a rehabilitation patients who are early in coma recovery
small number of subjects. Additionally, long-term out- (RLA level II/III) with an instrumental assessment may
comes after discharge from IP rehabilitation were not be beneficial, as the majority of patients who underwent
collected. Indications for future research may include VFSS or FEES while functioning at either RLA level
a randomized clinical trial where all participants with I/III or RLA level III were able to start some type of
disordered consciousness who successfully complete a therapeutic feedings. Rehabilitation teams might aim to
VFSS or FEES are placed into 1 of 2 groups, early oral use swallowing as a treatment modality as one part of the
feeding or deferred oral feedings, until their cognitive overall plan to facilitate neurobehavioral recovery after
status improves beyond RLA level III with long-term successful completion of an instrumental assessment of
outcomes being evaluated. the swallow.

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