CE Courses / Swallowing Disorders

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A Preventative Approach to Radiation-Associated Dysphagia (On Demand Webinar)
Format(s): On Demand Webinar
SLPs are increasingly involved in the care of patients with head and neck cancer. While preventative dysphagia services are accepted as standard of care, many clinicians don't have the background in this population to determine how to best evaluate and treat patients prior to radiation. This on demand webinar (available beginning December 16, 2022) covers what clinicians need to know to provide prehabilitative care-from justification to assessment to treatment to working within the multidisciplinary cancer care team.
New!
A Preventative Approach to Radiation-Associated Dysphagia (Live Webinar)
Format(s): Live Webinar
SLPs are increasingly involved in the care of patients with head and neck cancer. While preventative dysphagia services are accepted as standard of care, many clinicians don't have the background in this population to determine how to best evaluate and treat patients prior to radiation. This live webinar (December 14, 2022, 2-4 p.m. ET) covers what clinicians need to know to provide prehabilitative care-from justification to assessment to treatment to working within the multidisciplinary cancer care team.
New!
Special Populations in Dysphagia Management: COVID-19, Feeding Disorders, Drug Use, and Burn Care
Format(s): SIG Perspectives
These four SIG 13 articles provide information for dysphagia practice. They address a unique array of special populations and challenges in patient care involving swallowing and feeding difficulties.
New!
Addressing Feeding Needs for Children With Cerebral Palsy in the School Setting (On Demand Webinar)
Format(s): On Demand Webinar
This on demand webinar is designed for school-based SLPs who support children with complex oral feeding and swallowing needs. The speaker discusses the components of a robust feeding and dysphagia assessment, and how that assessment informs treatment decisions surrounding a student's feeding needs. The course examines effective and realistic goal development to address feeding needs within the IEP.
New!
Managing Dysphagia in Individuals With Dementia (On Demand Webinar)
Format(s): On Demand Webinar
This on demand webinar focuses on identification and management of dysphagia in people with dementia, with discussion of current research on dysphagia assessment, intervention, and caregiver burden. The webinar presents preferred practices for maximizing quality of life for this patient population.
Dysphagia in Practice: Thickening Practices, Family-Centered Care, & Early Intervention
Format(s): SIG Perspectives
This collection of SIG 13 articles addresses popular topics in dysphagia care throughout the life span regarding thickening practices, family-centered care, and early intervention. Jane Mertz Garcia, Edgar Chambers IV, and Anna Boyer utilized a survey to re-examine practice patterns for thickened liquids and provided a comparison of past practices with current to provide insight into contemporary themes that have previously not been considered. Doreen Benson and George Barnes explore the utility of a mathematical prediction model (Bayes theorem) in dysphagia management. Samantha E. Shune, Deanna Linville, and Ashwini Namasivayam-MacDonald address maximizing treatment effectiveness by using an approach with family resiliency and adaptation. Drawing from the principles of family systems theory and the biopsychosocial-spiritual framework, they use a case study as a tutorial to explore the application of family-centered care models to dysphagia management. Stephanie C. Cohen and Karen Dilfer focus on the definition of pediatric feeding disorder (PFD) and the multifaceted needs of families and children in early intervention, support for use of responsive feeding in treatment of PFD, alignment of responsive feeding strategies with early intervention principles, and barriers limiting access to consistent, high-quality early intervention services for children with PFD.
Feeding and Swallowing in School-Age Children: Anatomy and Physiology (On Demand Webinar)
Format(s): On Demand Webinar
This on-demand webinar (available beginning August 3, 2022) describes anatomical and physiological structures and functions related to feeding and swallowing to assist clinicians in interpreting evaluation findings and selecting appropriate treatment strategies for students on their caseload. The presenter discusses sensorimotor function of the trunk, shoulders, head, and neck, as well as of the upper aerodigestive tract, and reviews oral, pharyngeal, and esophageal structures and functions. The webinar includes case studies that address the impact of impaired anatomy and physiology in students with feeding and swallowing disorders.
Considerations for Dysphagia Intervention in the Hospital: Adult and Pediatric
Format(s): SIG Perspectives
This SIG 13 collection of astute articles provides information regarding managing and treating dysphagia in the hospital for both adult and pediatric patients. Nalia GurgelJuarez and colleagues explore the frequency of oral care based on staff adherence to oral care policies. Rebecca Smith et al. investigate the quality-of-life impacts of dysphagia and its interventions on mealtimes using the Swallowing Quality of Life Questionnaire and the Eating Assessment Tool. Jessica L. Rice and Maureen A. LeftonGreif review high-flow nasal cannula mechanisms of action, its use in specific populations and settings, and what is known about initiation of feeding during this therapy. Finally, Donna Edwards and colleagues explore the impact of COVID-19 on modifications in clinical practice related to pediatric feeding disorders and dysphagia via telehealth.
Adult Dysphagia Management: Diet, Sleep Apnea, Intensive Care Unit, and Dementia
Format(s): SIG Perspectives
This quartet of SIG 13 articles provides information regarding managing and treating dysphagia in the adult population. Caileen Harvey, Rachel Flemming, Julia Davis, and Victoria Reynolds investigate International Dysphagia Diet Standardisation Initiative implementation issues by surveying health care professionals in health care facilities in rural Upstate New York. Ankita M. Bhutada, William A. Broughton, Brenda L. Beverly, Dahye Choi, Sandip Barui, and Kendrea L. (Focht) Garand aim to identify the prevalence of dysphagia and reflux reported symptoms in patients with obstructive sleep apnea syndrome and determine associations between symptoms and demographic and clinical variables. Stevie Marvin summarizes published research on screening, evaluating, and treating post-extubation dysphagia in the intensive care unit. Rebekah Guastella, Stefania Oppedisano, Luis F. Riquelme, and Ashwini M. Namasivayam-MacDonald study bolus location at swallow onset, stage transition, pharyngeal transition duration, pharyngeal response duration, and pharyngeal phase duration between cued and uncued swallowing conditions in patients with dementia.
Dysphagia Revelations: What We Know We Don’t Know and What Is Normal for Swallowing
Format(s): SIG Perspectives
This trio of SIG 13 articles provides information regarding unique factions of dysphagia intervention. Sophia Werden Abrams, Harmonie S. J. Chan, Jasmeet Sikand, Heather Wilkie, and Kim Smith raise awareness for the importance of neurodegenerative disorder research involving dysphagia caused by oculopharyngeal muscular dystrophy. Michela Jean Mir and Karen Wheeler Hegland aim to shed light on the subjective use of cough assessment and the importance and interest in formal clinical cough assessment training. Kendrea L. (Focht) Garand, Mary Catherine Reilly, Dahye Choi, Rajarshi Dey, Julie Estis, and Grayson Hill evaluate community dwelling adults using Modified Barium Swallow Impairment Profile components for bolus hold type to assist in defining typical swallowing behaviors.
Interesting Discoveries in Adult Dysphagia Intervention: Screening, Evaluation, and Telehealth
Format(s): SIG Perspectives
This assemblage of articles provides information on interesting topics encountered in adult dysphagia practice. Aarthi Madhavan, Nicole Shuman, Claire Snyder, and Nicole Etter provide insight on the comparative consistency of the Eating Assessment Tool and Sydney Swallow Questionnaire scores for self-reported swallowing difficulties in a group of community-dwelling older adults completing both questionnaires. Georgina Papadopoulos-Nydam, Jana Maureen Rieger, and Gabriela Constantinescu evaluate the usability of a mobile health (mHealth) system designed for dysphagia exercise in persons with a history of stroke. Renata Mancopes, Fernanda Borowsky da Rosa, Lidia Lis Tomasi, Adriane S. Pasqualoto, and Catriona M. Steele demonstrate concern for people with chronic obstructive pulmonary disease (COPD) and share information regarding dysphagia in people with COPD, synthesizing knowledge both from the literature and from studies performed in the context of a multidisciplinary clinical pulmonary rehabilitation program abroad. Additionally, Talia H. Schwartz brings to light the importance and utility of the clinical swallow evaluation while caring for patients with COVID-19.
A Myriad of Dysphagia Interventions: NICU, Cultural Humility, Instrumentation, Nursing, Tracheostomy Tubes, and Technology
Format(s): SIG Perspectives
This collection of articles presents clinicians with evidence on a variety of topics in dysphagia that can be utilized in practice immediately. Alaina Martens and Emily Zimmerman offer insight regarding changes to feeding patterns in infants diagnosed with bronchopulmonary dysplasia after prolonged oxygen therapy in the newborn intensive care unit. Paula Leslie and colleagues provide a framework of health and illness and how food and drink are much more. They stress the importance of clinician appreciation as a cultural guest in our patients’ lives. Bonnie Martin-Harris and colleagues stress the importance of instrumentation with a thorough review of available practice guidelines and appropriateness criteria issued to date, revealing a deficit of up-to-date, comprehensive, evidence-based information on the diagnosis and evaluation of oropharyngeal dysphagia. Specifically, a lack of quality guidance on the ordering, performance, and reporting of the modified barium swallow study has hindered efforts to improve standardization and ensure quality continuity of care. Naomi Gurevich and colleagues stress the need to clarify guidelines and increase interprofessional education between both professions to improve patient care. George Barnes and Nancy Toms highlight speech-language pathologists’ need for a solid foundation of knowledge when it comes to patients with highly complex disease processes and care plans. Deirdre Muldoon and colleagues conduct a review of published literature regarding management of feeding difficulties at the oral phase of feeding in children with autism spectrum disorder and/or developmental disability. Finally, Paul M. Evitts and colleagues reveal a potential way to track aspiration in healthy adults using an app.
Pediatric Feeding: Small Steps, Big Changes (On Demand Webinar)
Format(s): On Demand Webinar
SLPs who work with children with feeding disorders often face challenges when managing oral hypersensitivities or advancing a child’s diet due to refusal behaviors. This on demand webinar explores the question, “What can I do when oral-sensory-motor deficits and difficult behaviors intersect?” The speaker discusses factors to consider when evaluating children with behavioral feeding disorders as well as uses video examples to illustrate and discuss various treatment strategies.
Respiratory Muscle Strength Training: Evidence and Protocols (On Demand Webinar)
Format(s): On Demand Webinar
Behavioral interventions that provide a calibrated mode for strengthening inspiratory and expiratory muscles are limited and often non-evidence-based. This on demand webinar discusses the evidence base for respiratory muscle strength training (RMST) devices and shares the assessment and treatment protocols necessary for valid implementation of respiratory muscle strength training protocols. The course will be useful for SLPs working in health care settings treating acute and chronic conditions that impact the functions of breathing, coughing, swallowing, and vocalizing that result from skeletal muscle weakness.
Preferred Practices for Clinical Swallowing Exams (On Demand Webinar)
Format(s): On Demand Webinar
This on demand webinar addresses the clinical utility of a clinical swallow examination (CSE) for individuals with suspected swallowing impairment. The speaker discusses the power of the CSE, which comes from employing a systematic assessment to enhance clinical decision-making. The webinar dives into the critical components for a multidimensional CSE applicable across patient populations and settings.
Innovations and Updates to Best Practices for Dysphagia Assessment and Treatment
Format(s): Journal (Online)
This journal self-study course explores best practices for dysphasia assessment and recent innovations in dysphagia treatment. The articles – from an American Journal of Speech-Language Pathology special issue “Select Papers From the 2018 Charleston Swallowing Conference at Northwestern University” – will help SLPs develop a deeper understanding of how to select appropriate treatment techniques, as well as why those techniques can be impactful in improving swallowing function. The articles delve deeply into past, current, and future treatment approaches for dysphagia and will be helpful for established clinicians as well as those who are new to the field of dysphagia assessment and treatment.
Dysphagia Management for Medically Complex Patients in Acute Care
Format(s): eWorkshop
Dysphagia may be caused by many underlying medical etiologies, and the hospital-based SLP must navigate a comprehensive world of medical diagnoses and be prepared to accurately evaluate and plan dysphagia treatment. This session presents a model for using medical chart review, online resources, swallow mechanism knowledge, and cultivated diagnostic and treatment skills to approach dysphagia in patients with any medical diagnosis.
Managing Dysphagia in Patients With COVID-19 in Acute Care and Beyond
Format(s): eWorkshop
The COVID-19 pandemic has impacted our patients in unusual ways. Patients with COVID-19 can present with a variety of symptoms: from loss of taste and smell, to fatigue, shortness of breath, and coughing. This session reviews current available evidence regarding best practices for dysphagia management for patients with COVID-19 in acute care and during their rehabilitation, including working through a case study.
Supporting People With Chronic Dysphagia
Format(s): eWorkshop
SLPs’ work with patients with complex medical conditions and their families, and the focus is often on the initial or acute stages of conditions that affect eating, drinking, and swallowing. This session addresses how SLPs can ensure best practice in the longer-term. The speaker addresses the importance of understanding how a patient’s dysphagia fits into the bigger medical and quality-of-life picture, backed by bioethical considerations and evidence. The session discusses how SLPs are not just one cog in a complex, interprofessional machine, but often the linchpin for optimal care of the patient and their family.
Evaluating Dysphagia Across the Life Span
Format(s): SIG Perspectives
The assemblage of articles presents clinicians with information on a variety of topics in dysphagia that can be utilized in practice. Laura L. Madhoun, Laura C. Merrell, Amanda Smith, Emily Snow, and Kristen M. Cherosky stress the importance of individualized and comprehensive feeding management for craniofacial anomalies through interdisciplinary collaboration. Lena G. Caesar and Meretu Kitila study clinicians’ perceptions and confidence with dysphagia service delivery. Aliaa Sabry, Amanda S. Mahoney, Shitong Mao, Yassin Khalifa, Ervin Sejdic, and James L. Coyle point out an objective way to assess laryngeal vestibule closure and opening at beside. Marie Jardine, Anna Miles, Jacqui Allen, and Rebecca Leonard give an interesting take of assessment of the aging swallow. Kelsey L. Thompson and Wanqing Zhang provide description and examples of mixed method research to comprehensively and holistically report of pediatric feeding disorders.
Practice Guidance for SLPs During the COVID-19 Pandemic
Format(s): Journal (Online)
Clinical practice for SLPs in health care settings has changed dramatically – and continues to evolve – due to the COVID-19 pandemic. This journal self-study highlights evidence-based best practices and considerations for clinicians providing care to patients with voice and upper airway disorders, tracheostomy, and head and neck cancer during the COVID-19 pandemic to maximize patient and clinician safety while ensuring efficacious care.
Guidelines for Dysphagia Management Using Telepractice (On Demand Webinar)
Format(s): On Demand Webinar
The use of telepractice for dysphagia management has increased dramatically due to the challenges of in-person practice during the COVID-19 pandemic. In this on demand webinar, the presenter will share step-by-step, evidence-based guidelines for the safe and reliable use of telehealth for dysphagia management in both pediatric and adult patients. The speaker will discuss legal safeguards, privacy and confidentiality considerations, technology infrastructure, clinician training and skills, facilitator training, and patient candidacy considerations. The webinar will include video case examples, problem-solving activities, and demonstrations of telepractice adaptations for clinical (bedside) swallowing evaluations and treatment sessions. During the webinar, the speaker will guide participants in the creation of a practical roadmap to implement telepractice with their patients with dysphagia.
Treatment Planning Following Instrumental Swallow Assessment
Format(s): On Demand Webinar
This course illustrates how SLPs can develop appropriate, evidence-based, and practical treatment plans for patients with dysphagia based on the results of instrumental swallow assessments. The speaker discusses case studies involving the use of various assessments, including videofluoroscopy, endoscopy, and high-resolution manometry.
Dysphagia & Auditory Matters in Geriatric Speech-Language Pathology
Format(s): SIG Perspectives
These articles explore thickened liquids for oropharyngeal dysphagia, importance of patient selection, & balancing physical welfare/quality of life (QOL); QOL in patients/caregivers in recovery for swallowing disorders; audiologist knowledge of cognitive impairment/screening in outcomes/communication; and hearing screening for individuals who are diagnosed with dementia.
Value-Based Health Care Relating to Management of Dysphagia
Format(s): SIG Perspectives
This collection of articles presents information currently relevant to caring for patients. Firstly, Cara Donohue and James L. Coyle, and Christina Kang and David Lott, share service delivery focusing on the diagnoses of amyotrophic lateral sclerosis and muscle tension dysphagia, respectively. Samantha Shune and Ashwini Namasivayam provide systematic strategies to better support patients’ informal caregivers. Rinki Varindani Desai and Ashwini Namasivayam-MacDonald describe the practice patterns of speech-language pathologists managing dysphagia in persons with dementia. Lastly, Nancy Swigert and Ashley Wright describe effectiveness and efficiency as the key components of a value-based health-care system.
Dysphagia Management in Schools: Addressing Evolving Challenges (SIG 13)
Format(s): On Demand Webinar
This course provides a framework to guide school-based SLPs who support child and adolescent feeding and swallowing needs during the COVID-19 pandemic. The presenters provide a foundation of best practices for school-based dysphagia management, review regulatory requirements and processes, discuss approaches to challenging service delivery scenarios, and share resources for continued professional development to strengthen this necessary, yet often less supported, area of practice. This course – part of the SIGnature Series – was developed by SIG 13: Swallowing and Swallowing Disorders (Dysphagia).
Updates in Advocacy & Billing for Dysphagia Management (SIG 13) (On Demand Webinar)
Format(s): On Demand Webinar
Due to the rapidly changing climate in dysphagia management, adhering to recent changes in billing and documentation standards and procedures can be challenging for SLPs. In this on demand webinar, speakers will identify common pitfalls and discuss strategies to meet expectations, so clinicians can avoid unethical decisions, prevent dings, and maximize local coverage for dysphagia reimbursement. The speakers will also illustrate how advocating for accurate representation in SLP billing and documentation supports clinician competency and patient outcomes. This webinar – part of the SIGnature Series – was developed by SIG 13: Swallowing and Swallowing Disorders (Dysphagia).
Unique Current Issues in Dysphagia Management
Format(s): SIG Perspectives
This collection of articles presents clinicians with information on some of the most timesensitive topics in dysphagia care of utmost relevance, particularly in the current COVID- 19 pandemic. Firstly, Liza Blumenfeld, Lisa Evangelista, Maggie Kuhn, Kristen Linnemeyer, Nogah Nativ-Zeltzer, and Heather Starmer provide best practice recommendations on the management of patients with head and neck cancers from the speech-language pathology perspective amid COVID-19. Authors Hema Desia and Jennifer Raminick then provide recommendations for safer feeding of infants on high flow oxygen therapy due to acute respiratory failure. Lastly, authors Grainne Brady and Justin Roe, Kellyn Hall and Leslie Johnson, and Annette Askren and Marnie Kershner discuss different aspects of clinician–patient collaborated dysphagia care delivery models and their impact on successful outcomes.
Cancer Management in Acute Care Settings
Format(s): eWorkshop
This session—a recorded session from ASHA’s 2020 Health Care Connect online conference—discusses cancer basics, treatment options, and their functional impacts as they relate to swallowing and cognitive-communication. The speakers discuss common referrals in acute care oncology settings and describe an algorithm for clinical decision-making.
Differentiating Typical Aging From Swallowing Dysfunction
Format(s): eWorkshop
This session—a recorded session from ASHA’s 2020 Health Care Connect online conference—explores typical variations in the adult swallow, with a specific focus on changes observed in older adults. The speaker discusses the influence of additional factors (e.g., medications, lab values) on swallowing function as well as shares MBSS videos/images.
Genetic Disorders and Swallowing: A Showcase of Pediatric Disorders
Format(s): eWorkshop
This session—a recorded session from ASHA’s 2020 Health Care Connect online conference—provides an overview of prevalent genetic disorders with an emphasis on pediatric feeding and swallowing complications. The speakers highlight currently available research and review best practices in assessment and intervention, including the use of videofluoroscopic swallow studies to underscore common swallowing deficits.
Harnessing the Power of the Cranial Nerve Exam During Your Swallow Assessment
Format(s): eWorkshop
This session—a recorded session from ASHA’s 2020 Health Care Connect online conference—explores the power of a comprehensive cranial nerve assessment as part of a swallow examination. The speaker discusses neuroanatomy and neurophysiology of the cranial nerves and shares a step-by-step procedure for performing a cranial nerve assessment, including identification of common abnormalities and how to document findings.
Role of the SLP in the ICU: Influencing Outcomes Across the Continuum of Care
Format(s): eWorkshop
This session—a recorded session from ASHA’s 2020 Health Care Connect online conference—examines the SLP’s role on patient-centered care teams in the ICU setting. The speaker discusses the SLP’s vital role in facilitating communication for patients who are intubated, and participants will have the opportunity to practice communicating with various techniques in different roles. The speaker also explores when to screen/assess swallowing post-extubation and how to reduce post-intensive care syndrome (PICS). The session also addresses the importance of communication regarding patient status and goals across the continuum of care, and how to provide bundled patient-centered care using a team approach.
Management of Pediatric Aerodigestive Disorders (On Demand Webinar)
Format(s): On Demand Webinar
This webinar explores various aspects of working with pediatric patients with complex aerodigestive disorders. Speaker Kara Fletcher Larson discusses the developmental progression to oral feeding, implementing safe feeding plans, weaning from gastrostomy tube feedings, and working within a multidisciplinary team.
Aspiration Pneumonia Prevention: The Importance of Oral Care
Format(s): eWorkshop
This course focuses on emerging research and changing practices in the management of dysphagia as it relates to aspiration pneumonia prevention and oral care. The presenters review the contribution of oral biofilms to bacterial aspiration pneumonia and systemic health, and discuss the genesis and treatments for aspiration pneumonia. The course describes the national VA deployment of a pneumonia prevention initiative and provides practical instruction in the development of an oral care program participants can use to implement a program in their own facility.
Physiologic Changes and Interactions with Disease in Older Adults
Format(s): eWorkshop
Aging produces predictable and specific changes to the human respiratory and digestive systems and predisposes older people to more severe effects of—and more protracted limitations secondary to—diseases and surgical procedures. This session provides much-needed, clinically translatable information about aging-related respiratory and digestive system changes and how they affect swallowing diagnosis and treatment. The session also reviews the systemic inflammatory response syndrome (sepsis) as a model of an atypical dysphagia-producing illness. This course is a recorded session from the 2017 online conference “Dysphagia in Older Adults.”
Swallowing, Cognition, and Dignity: A Clinical Pathway for Dysphagia Management in Persons With Dementia
Format(s): eWorkshop
This session identifies challenges associated with assessing patients with the dual diagnosis of dysphagia and dementia and describes how clinicians can be empowered to use a comprehensive, systematic clinical pathway to create an intervention plan that preserves safety, nutrition, hydration, and quality of life. This course is a recorded session from the 2017 online conference “Dysphagia in Older Adults.”
Palliative Care Perspective on Dysphagia Management
Format(s): SIG Perspectives
These Perspectives (SIG 13) presents clinicians with information across many aspects of feeding and swallowing. Firstly Kendrea Garand, Taylor Thomas, and Rajarshi Dey discuss the physiology of laterality in the clearance of boluses from the pharynx. Next, Jennifer Wilson, Amanda Simmons, and Jillian McCarthy then take us through an interesting description of speech-language pathologists’ experiences and education in pediatric dysphagia and encourage the incorporation of intensive education in this high-risk topic, via various avenues. In the final three articles, Pamela Smith, Jinxu Bridget Xia, and Claire Radford et al., present an in-depth and elaborate perspective on managing patients with dysphagia through a palliative care lens, across the lifespan.
Dysphagia and Continuum of Care
Format(s): SIG Perspectives
These Perspectives (SIG 13) include a variety of topics in dysphagia across the age continuum and across the many settings that speech-language pathologists (SLPs) address dysphagia. Parker Huston, Robert Dempster, and Lauren Garbacz provide readers with an overview of common evidence-based psychological techniques used in the treatment of adolescents with feeding disorders, including motivational interviewing and cognitive behavioral techniques. The goal of this paper is to provide a high-level overview of these concepts so that providers outside of psychology may utilize some of these techniques in therapy, when referral to a behavioral specialist or psychologist is not feasible. Next, authors Lauren Madhoun and Robert Dempster discuss the psychosocial aspects of feeding in the neonatal intensive care unit NICU and immediately following NICU discharge. Joanne Patterson extends the discussion to the adult population by describing a biopsychosocial intervention that combines cognitive behavioral with dysphagia therapy, termed Cognitive-Behavioral Enhanced Swallowing Therapy (CB-EST) and its application in managing head and neck cancer patients with dysphagia. Finally, authors Kortney Eng, Maria Jose Flores, Elisabeth Gerrity, Nupur Sinha, Katherine Imbeau, Laddie Erbele, and Cary Yeh share details from their study investigating the effect of high-flow nasal cannula (HFNC) on swallow physiology in healthy adults. We hope these articles will be of significant value to practicing clinicians and to students learning about dysphagia.
Assessment and Treatment Approaches for Dysphagia Management Across the Lifespan
Format(s): SIG Perspectives
These Perspectives (SIG 13) articles present clinicians with useful information to help assess and treat feeding and swallowing disorders in a variety of patient populations across the lifespan. Daniel Croake and Vrushali Angadi provide an overview of evidence regarding prophylactic and reactive gastrostomy tubes in individuals with head and neck cancer, to better facilitate joint decision-making of percutaneous gastrostomy (PEG) tube timing with the patient and care team. Hema Desai and Audrey Lim extend the discussion to pediatric dysphagia by summarizing the application of neurobehavioral interventions as part of feeding treatment for infants with congenital heart defects.
Feeding and Speech Interventions for Young Children With Cleft Lip and Palate
Format(s): eWorkshop
Cleft lip and/or palate is the most common birth anomaly, affecting 1 in 700 live births, but SLPs who work in early intervention often report limited training and comfort with this population. This session provides an overview of cleft conditions from birth to 3 years. The speaker discusses feeding challenges and interventions, surgical timeline, and speech and language development and interventions for infants and toddlers with cleft lip and/or palate. This course is a recorded session from the 2019 online conference “Birth to Three: Working Together to Serve Children and Their Families.”
Feeding and Swallowing Disorders in Toddlers
Format(s): eWorkshop
Feeding and swallowing skills evolve during the first 3 years of life. This session explores the resources needed for effective identification and management of feeding and swallowing disorders in toddlers. This course is a recorded session from the 2019 online conference “Birth to Three: Working Together to Serve Children and Their Families.”
Feeding, Swallowing, and Food Selectivity in Preschoolers
Format(s): eWorkshop
Feeding and swallowing difficulties have a significant impact on children’s health, well-being, development, and educational potential. These disorders affect a child’s ability to engage in mealtimes, limiting socialization opportunities, nutritional intake, hydration, and growth patterns. This session discusses typical and atypical development of feeding patterns as well as how to differentiate between feeding and swallowing difficulties and how to identify any overlap in the two. The speaker also describes behavior management techniques to help address feeding challenges. Finally, the session explores how to determine appropriate goals and supports to optimize functional outcomes to benefit the preschooler and his/her family. This course is a recorded session from the 2019/2020 online conference “Innovative Methods for Preschool Assessment, Collaboration, and Treatment.”
Understanding Picky Eating: Getting Past the "Ick, I Don't Want That" (On Demand Webinar)
Format(s): On Demand Webinar
This on demand webinar examines the continuum of picky eating and explores reasons why children become “picky” across several developmental domains. The speaker focuses on the oral motor and sensory skills necessary for transitioning from liquids to puree, meltable, and eventually textured table foods within the first year of life. The webinar presents strategies to enable SLPs to identify and treat skill deficits and ultimately decrease the likelihood of a child being labelled as having a “behavioral feeding disorder.”
Identification and Rehabilitation of Post-Chemotherapy Cognitive Impairments
Format(s): eWorkshop
This session identifies cognitive deficits that frequently result from chemotherapy and discusses how to evaluate and treat patients suffering from these deficits. This course is a recorded session from the 2019 online conference “Cancer Care: Enhancing Communication, Swallowing, and Quality of Life.”
Pediatric Brain Tumors: Types, Treatments, and Neurocognitive Outcomes
Format(s): eWorkshop
This session discusses what SLPs need to know about pediatric brain tumors – including the most common types of tumors, treatments, and neurocognitive outcomes – to best serve children with this diagnosis. This course is a recorded session from the 2019 online conference “Cancer Care: Enhancing Communication, Swallowing, and Quality of Life.”
Esophageal Cancer: Implications for Communication/Swallowing
Format(s): eWorkshop
Esophageal cancer and its treatments may result in functional impairments related to speech, swallowing, and other areas of concern to speech-language pathologists. This session discusses the esophageal cancer diagnosis and issues the SLP needs to consider while caring for patients with this specific type of cancer. This course is a recorded session from the 2019 online conference “Cancer Care: Enhancing Communication, Swallowing, and Quality of Life.”
Head and Neck Lymphedema: Evaluation and Treatment
Format(s): eWorkshop
Head and neck lymphedema is too often under-recognized and inadequately managed. This session discusses the anatomy and physiology of the lymphatic system; examines the etiologies behind head and neck lymphedema following head and neck cancer treatment; and explains strategies for identifying, evaluating, and treating patients with head and neck lymphedema. This course is a recorded session from the 2019 online conference “Cancer Care: Enhancing Communication, Swallowing, and Quality of Life.”
Nutritional Considerations for the Oncology Patient
Format(s): eWorkshop
No two oncology patients have identical nutritional needs. This session addresses how a dietician makes recommendations, taking into consideration patient/family preferences, cancer type, form of treatment the patient is receiving, and what nutrition impact symptoms the patient is experiencing. This course is a recorded session from the 2019 online conference “Cancer Care: Enhancing Communication, Swallowing, and Quality of Life.”
Pediatric Oncology and SLP Services: Assessment
Format(s): eWorkshop
This session addresses the challenges and opportunities for speech-language pathologists who evaluate cognitive-communication, speech, language, and feeding-swallowing disorders in children and adolescents with cancer. This course is a recorded session from the 2019 online conference “Cancer Care: Enhancing Communication, Swallowing, and Quality of Life.”
Pediatric Oncology and SLP Services: Treatment and Return to School
Format(s): eWorkshop
This session addresses issues that children and adolescents with cancer face as they transition between medical treatment and school. The speaker discusses the roles of the SLP and other team members in helping children make these adjustments. This course is a recorded session from the 2019 online conference “Cancer Care: Enhancing Communication, Swallowing, and Quality of Life.”
Rehabilitation for Patients With Head and Neck Cancer
Format(s): eWorkshop
Patients with head and neck cancer can experience pain and disability from cancer treatment that can affect their quality of life. This session discusses the current standard treatment for head and neck cancer, as well as common complications – including dysphagia, lymphedema, radiation fibrosis, and trismus – to inform the SLP’s assessment, diagnosis, and treatment planning and implementation. This course is a recorded session from the 2019 online conference “Cancer Care: Enhancing Communication, Swallowing, and Quality of Life.”
Using Clinical Pathways to Care for Patients With Cancer
Format(s): eWorkshop
This session explores how SLPs can use clinical pathway frameworks to collaborate with other professionals and develop unique rehab plans that deliver optimal, personalized care to patients with cancer across a variety of settings. This course is a recorded session from the 2019 online conference “Cancer Care: Enhancing Communication, Swallowing, and Quality of Life.”
Anatomical Transformation of Speech & Swallowing Function Post-Total Laryngectomy
Format(s): eWorkshop
Laryngectomy patients experience a variety of alterations in speech and swallowing post-surgery. This session discusses issues related to diagnosis and management of alaryngeal speech and swallowing post-laryngectomy. This course is a recorded session from the 2019 online conference “Cancer Care: Enhancing Communication, Swallowing, and Quality of Life.”
Dysphagia Treatment in Individuals With Head and Neck Cancer
Format(s): eWorkshop
Dysphagia is multifactorial in head and neck cancer survivors, with tumor type, comorbid conditions, and specific treatment (e.g., surgery, radiotherapy, systemic treatments) contributing to the dysphagia presentation. This session reviews common issues – including soft tissue fibrosis, lymphedema, and neuropathy – as they relate to cancer treatments and swallowing function. The session proposes an algorithm to provide standard yet personalized management of dysphagia considering diverse treatment scenarios along the continuum of survivorship, from proactive models of pre-habilitation to management of late effects in long-term survivors. This course is a recorded session from the 2019 online conference “Cancer Care: Enhancing Communication, Swallowing, and Quality of Life.”
Head and Neck Cancer Diagnosis
Format(s): eWorkshop
Head and neck cancer diagnosis is a complex, multifaceted, interdisciplinary, and time-sensitive process in which SLPs are very involved from beginning to end. This session explores clinical pathways to guide the SLP and other members of the multidisciplinary team – including, most importantly, the patient – through the diagnosis and evaluation process. The session discusses the SLP’s roles in evaluating, managing, educating, and counseling patients on speech, voice, and swallowing difficulties that may arise from the tumor and from cancer treatment toxicities. This course is a recorded session from the 2019 online conference “Cancer Care: Enhancing Communication, Swallowing, and Quality of Life.”
Head and Neck Cancer Management: Treatment Toxicities
Format(s): eWorkshop
Head and neck cancer treatments affect functional speech and swallowing outcomes. This session explores treatment strategies, compensatory strategies, and roadmaps to improve speech and swallow function for patients who have received treatment for head and neck cancer. This course is a recorded session from the 2019 online conference “Cancer Care: Enhancing Communication, Swallowing, and Quality of Life.”
Navigating Hard Conversations in Palliative Care
Format(s): eWorkshop
Conversations about difficult topics are usually laden with emotions for both patients and clinicians. This session provides communication tools to help you navigate difficult conversations. This course is a recorded session from the 2019 online conference “Cancer Care: Enhancing Communication, Swallowing, and Quality of Life.”
Speech, Language, Cognitive, and Swallowing Rehabilitation in Patients With Brain Tumors
Format(s): eWorkshop
Neurocognitive and communication rehabilitation in patients with brain tumors is different than recovery after stroke or traumatic brain injury. This session describes basic characteristics of various types of brain tumors, current treatment options, associated sequale, and expected prognosis. Diagnostic and rehabilitation considerations are reviewed as they relate to speech, language, cognition, and swallowing to help inform the most effective SLP treatment plan. This course is a recorded session from the 2019 online conference “Cancer Care: Enhancing Communication, Swallowing, and Quality of Life.”
Current Issues in Dysphagia Management
Format(s): Journal (Online)
This journal self-study emphasizes clinical decision-making in swallowing and dysphagia management. The articles focus on using data to make clinical decisions, finding noninvasive ways to screen healthy adults, and patient-reported side effects and tolerability of a specific assessment technique.
Cancer and Its Impact on Communication and Swallowing
Format(s): eWorkshop
This session provides an overview of oncology as it relates to speech-language pathology. The speaker discusses the types of cancer commonly associated with communication and/or swallowing difficulties as well as the treatments used to manage each type, emphasizing how treatment toxicities may affect communication and/or swallowing. The session also discusses the roles and responsibilities of the SLP as part of a multidisciplinary cancer care team. This course is a recorded session from the 2019 online conference “Cancer Care: Enhancing Communication, Swallowing, and Quality of Life.”
Impact of Impaired Anatomy and Physiology on Treatment of Dysphagia in Adults
Format(s): eWorkshop
This course examines the impacts of impaired anatomy and physiology on swallowing safety and efficiency in adults. The course is designed to aid clinicians in managing the evaluation and treatment of adults with oropharyngeal dysphagia. The speaker discusses the functions of specific structures, spaces, and muscles related to swallowing as well as the relationship between esophageal and oropharyngeal signs and symptoms. The course features clearly labeled animations and videos of instrumental studies – e.g., videofluoroscopic swallowing studies (VFSS) and fiberoptic endoscopic evaluations of swallowing (FEES) – at different speeds to guide clinicians’ ability to interpret the imagery. The course also includes interactive “quizzes” throughout, which provide feedback on application of concepts.
Diet Texture Modifications for Adults With Dysphagia: Improving Swallow Safety and Quality of Life (On Demand Webinar)
Format(s): On Demand Webinar
This webinar explores texture modifications for foods and liquids and their effects on swallow biomechanics and quality of life for adults with dysphagia. Using clinical scenarios and case studies, presenter Luis Riquelme discusses working with patients to achieve the optimal diet texture modifications to maximize outcomes, including patient compliance and satisfaction.
Introduction to Anatomy & Physiology of the Adult Swallow
Format(s): eWorkshop
This video course introduces the components of the normal adult swallow across all phases. The course features clearly labeled animations and videos of instrumental studies – e.g., videofluoroscopic swallowing studies (VFSS) and fiberoptic endoscopic evaluations of swallowing (FEES) – at different speeds to guide clinicians’ ability to interpret the imagery. The course also includes interactive “quizzes” throughout, which provide feedback on application of concepts. The course is designed to give clinicians the confidence to discuss normal anatomy and physiology of all phases of adult swallowing with patients, caregivers, and medical professionals, and to use their knowledge to accurately assess swallow function.
Using Exercise-Based Treatments in Dysphagia Intervention
Format(s): Streaming Video
This video course will focus on using evidence-based exercise practices in swallowing rehabilitation. The speaker will discuss the theoretical background and evidence for exercise science and then present exercise-based techniques that SLPs can implement with patients. Specific topics will include motor learning, skill vs. strength training, and muscle structure and function. Specific exercises will be discussed, including isometric lingual strength training, expiratory muscle strength training, chin tuck against resistance, Lee Silverman Voice Treatment, and more.
Dysphagia Management: Ethics and Evidence (On Demand Webinar)
Format(s): On Demand Webinar
This webinar addresses the roles and responsibilities of the SLP – especially when it comes to ethical considerations – in interprofessional management of swallowing and feeding difficulties. The SLP is one cog in a complex machine of stakeholders (including patients, their families, and other professionals) and can be the linchpin in ensuring optimal care.
Getting Started With FEES for Swallowing Evaluations (On Demand Webinar)
Format(s): On Demand Webinar
This webinar will walk SLPs through the procedures used in flexible endoscopic evaluation of swallowing (FEES; also known as fiberoptic endoscopic evaluation of swallowing) to evaluate patients with dysphagia. The course will provide a thorough explanation of the laryngeal and pharyngeal anatomy that can be viewed using FEES and guide attendees through exam interpretation.
Fundamentals of Dysphagia: A Six-Part Set
Format(s): eWorkshop
Designed for clinicians who are new to the area of swallowing disorders – as well as experienced clinicians who want a refresher – this six-course set provides a comprehensive overview of dysphagia assessment and treatment.
Special Considerations for Children With Feeding and Swallowing Disorders
Format(s): Journal (Online)
Feeding and swallowing problems in children take many forms and are often intertwined with other aspects of a child’s development. This journal self-study explores some of these interactions, including the relationship between feeding and swallowing disorders and language impairment, as well as connections between hearing and feeding/ swallowing. The self-study also includes information on how mealtime duration relates to severity of feeding and swallowing problems in children with cerebral palsy, as well as how a family-centered intervention can address mealtime behaviors in children with autism spectrum disorder. Clinicians will be able to immediately apply the information in these articles to improve management of pediatric feeding and swallowing disorders.
Best Seller
Evaluating Product Characteristics for Infant Feeding and Non-Nutritive Sucking
Format(s): Journal (Online)
Clinical decisions regarding infant feeding not only affect nutritional status but also respiratory function in medically fragile populations. The articles in this journal self-study examine products designed to promote safe infant feeding and sucking patterns. Importantly, they compare and contrast products so that clinicians are equipped to make informed decisions that do not rely on marketing claims. The first two articles focus on bottle nipple characteristics that promote safe milk ingestion and respiratory effects and the third examines a range of pacifiers to determine which characteristics promote the most productive non-nutritive sucking pattern.
Best Seller
Effects of Lingual Strengthening on Swallowing
Format(s): Journal (Online)
Research into programmed isometric lingual exercise in order to improve swallow function has yielded promising results. This journal self-study examines evidence related to this relatively new therapeutic approach. The first article in this self-study offers a review of the recent literature on isometric lingual tasks across a variety of populations and includes clinical implications based on the findings. The second and third articles are normative studies about adults without diagnosed dysphagia. One explores how tongue strengthening affects mealtime functioning in older, long-term care residents, while the other examines relationships between performance variability, isometric strength, swallowing pressure, age, and gender.
Best Seller
Evaluating Feeding and Swallowing Disorders in Infants and Children
Format(s): Streaming Video
This video course presents systematic, evidence-based strategies for carrying out a comprehensive evaluation of infants and children who demonstrate signs of dysphagia and/or broader feeding problems. The course includes detailed discussion and strategies for collecting a child’s relevant history and conducting a physical examination and feeding observation. With a focus on function, the course offers guidance on interpreting evaluation findings and making optimal recommendations for next steps that promote functional outcomes. Video clips of professionals and caregivers working with infants and children, as well as discussion of case studies, enhance the learning experience.
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Management of Swallowing in Patients With Head and Neck Cancer: Fine-Tuning Your Decision-Making
Format(s): On Demand Webinar
Clinicians often conduct instrumental evaluations of swallowing for patients who have been treated for head and neck cancer, and making decisions regarding oral vs. non-oral nutrition and specific diet type can be challenging. This webinar will discuss how to make judicious decisions concerning eating and diet, and what variables to incorporate into the decision-making process with this population.
Demystifying Swallowing and Feeding in the School Setting
Format(s): On Demand Webinar
Many school-based SLPs recognize a need to identify and treat swallowing and feeding disorders in their school’s student body but are uncertain about how to do this. In some cases, SLPs are unsure exactly how to start and proceed, and in other cases, their supervisors and/or districts are not supportive of these efforts. In this webinar, the presenter will discuss common apprehensions/fears about swallowing and feeding programs in schools and how to alleviate these concerns. She will provide ideas for implementing these programs in schools as well as strategies for gaining support from administrators and others. The webinar will also include suggestions for working as part of a school-based team to identify and treat students who have swallowing and feeding disorders.
Supporting Early Infant Feeding in the NICU
Format(s): On Demand Webinar
To support infants in the NICU setting and maximize oral feeding outcomes for these babies, SLPs need to consider the maturational status of premature infants, medical conditions of ill newborns, and positive and negative experiences in the NICU. This webinar will address the maturation of the oral, pharyngeal, and esophageal phases of swallowing, which directly affect safety and efficiency, as well as medical conditions that increase an infant’s risk of feeding disorders. We will explore evidence-based interventions designed to improve feeding experiences, taking into account maturational and medical status, and discuss the concept of homeostasis and its importance in the NICU.
Possible Effects of Medication on Communication and Swallowing: What SLPs Need to Know
Format(s): On Demand Webinar
Medication can have a significant impact on a client’s swallowing or communication deficit, and this webinar will give SLPs much-needed information to ensure they are considering medication effects when evaluating and treating their clients. The webinar will explore the latest evidence-based research to help SLPs recognize drug interactions and know how and when to report them to a health care team member. The presenter will discuss examples of medication interactions and recommend actions SLPs can take during assessment and treatment to ensure the best outcomes for their clients.
An Expanded Approach to Clinical Practice in Dysphagia
Format(s): On Demand Webinar
This webinar will explore an expanded approach to dysphagia assessment and treatment designed to maximize an individual’s eating and swallowing safety, efficiency, and pleasure. Traditional management approaches typically view dysphagia as a mechanical and/or physiologic problem. By contrast, the expanded approach explained in the webinar strives to give the clinician a more holistic portrait of the patient’s lived experience with dysphagia. The expanded approach to evaluation incorporates a wider array of measurement tools from across health care domains while maximizing efficiency so the broader assessment does not require additional time. The expanded approach to treatment includes recommendations for diet changes as well as tips for facilitating the use of evidence-based practices.
Assessment and Treatment of Dysphagia in Older Adults
Format(s): eWorkshop
This course includes five recorded sessions from the 2017 online conference “Dysphagia in Older Adults.” These sessions focus on assessment and treatment strategies to optimize outcomes for older adults with dysphagia. The conference included a total of 13 sessions, with the broad goal of giving clinicians new, evidence-based strategies for improving overall quality of life for older adults.
Nutrition and Counseling Considerations for Older Adults With Dysphagia
Format(s): eWorkshop
This course includes four recorded sessions from the 2017 online conference “Dysphagia in Older Adults.” These sessions include points to keep in mind when counseling older adults with dysphagia and their families or caregivers about nutrition, diet, and other topics. The conference included a total of 13 sessions, with the broad goal of giving clinicians new, evidence-based strategies for improving overall quality of life for older adults.
Oral Hygiene in Older Adults: Assessment, Care, and Complications
Format(s): eWorkshop
Inadequate oral hygiene practices can contribute to or result in severe localized and systemic illnesses, significantly altering the health status and well-being of older adults. Care providers must recognize symptoms, conditions, and their potential consequences and elevate routine oral hygiene care to oral infection control programs. This session from the 2017 online conference “Dysphagia in Older Adults” identifies possible oral hygiene complications—from oral pain to pneumonia—and discusses how to recognize and assess them. Speaker John Ashford also addresses the importance of standardized intervention.
Considerations in Dysphagia Management
Format(s): Journal (Online)
This journal self-study course explores some considerations that SLPs who work with specialized patient populations in various health care settings face in dysphagia management. Articles discuss instituting dysphagia exercise programs for patients with amyotrophic lateral sclerosis; the injury process and acute care management of individuals with dysphagia due to chemical ingestion; and preliminary evidence concerning new speaking valve technology for patients living with tracheostomy. The final article evaluates from a legal perspective the common practice of encouraging patients who decline dietary restrictions to sign waivers of liability.
Dysphagia Intervention: Planning and Implementation
Format(s): eWorkshop
This course provides an overview of the essential elements of planning and implementing successful dysphagia intervention. The speaker reviews how to select and utilize appropriate treatment strategies and techniques by summarizing specific compensatory, bolus modification, postural, and rehabilitation strategies for oral and pharyngeal dysphagia and discussing the evidence underlying these strategies. The course also reviews what variations in dysphagia management might be needed depending on particular disease stages and processes.
Dysphagia Management: Documentation and Goal Writing
Format(s): eWorkshop
This course provides an overview of the documentation requirements for Medicare reimbursement for dysphagia-related services, including evaluation, treatment plans, treatment notes, progress notes, discharge summaries, and common diagnostic and procedure codes. The speaker discusses frameworks – including the SMART and International Classification of Functioning, Disability, and Health (ICF) frameworks – to help focus treatment plans on meaningful, measureable, and functional goals, giving examples of long- and short-term goals. The course also includes tips for streamlining documentation and suggestions for documenting progress to show skilled service.
Theoretical Basis of Exercise and Treatment of Dysphagia
Format(s): eWorkshop
In order to select the appropriate treatment techniques for oral and pharyngeal dysphagia in adults, clinicians need to understand the physiology of swallowing. This introductory course discusses the strengths and weaknesses of the evidence base for dysphagia treatment and reviews the principles of neuroplasticity and motor learning as they relate to the effects of injury to the central nervous system and the potential results of swallowing intervention. The presenter discusses examples of neuromuscular treatment for pharyngeal dysphagia and gives tips on analyzing evidence and applying a theory-driven approach.
Best Seller
Pediatric Feeding Assessments and Interventions
Format(s): On Demand Webinar
This course focuses on managing feeding difficulties in young children ages 1-6 years. The presenter discusses and demonstrates assessment tools as well as intervention approaches, highlighting evidence-based techniques.
Best Seller
Reading and Interpreting Videofluoroscopic Studies: A Tutorial
Format(s): Streaming Video
An information-rich videofluoroscopic assessment can help clinicians determine which components of the complex oropharyngeal swallow need to be targeted for intervention. Visualizing all of the elements that contribute to a well-integrated or disordered swallow mechanism requires an ordered and disciplined review. This video course demonstrates methods to enhance clinicians' ability to perform a videofluoroscopic assessment and discern the discrete elements of the oropharyngeal swallow. Participants can practice determining the integrity or disorder of the swallow mechanism by viewing and interpreting case study video.
Best Seller
Management of Communication and Swallowing Impairments Related to Artificial Airways
Format(s): Streaming Video
Endotracheal tubes, tracheostomy tubes, and ventilator dependency can have adverse effects on communication and swallowing. SLPs who take the lead role in remediating these impairments need to have the knowledge and skills to provide appropriate, safe, and evidence-based interventions. This streaming video course is designed for the SLP who has an interest in post-extubation dysphagia and in communication and swallowing challenges associated with tracheostomy tubes and ventilator dependency. The course reviews the literature and presents a “how-to” guide for managing these medically complex patients. Medical SLPs will walk away with strategies to best manage their patients who are experiencing complications due to artificial airways.
Elements of a Comprehensive Clinical Dysphagia Evaluation
Format(s): Streaming Video
This course describes the elements of a complete clinical dysphagia evaluation – from consultation to instrumental exam – so clinicians can determine the appropriate evaluation tools for the individual patient. The course covers the key points to address in a consultation, how to discern the salient parts of a medical record, how to conduct an informative interview with the patient or caregiver, how to determine what tests and tools to employ in the clinical examination – and how to conduct it – and when to employ instrumentation.
Feeding Tubes in Adults With Advanced Illness: Use, Overuse, and the SLP’s Role
Format(s): On Demand Webinar
Studies on feeding tubes in individuals with advanced illness have raised doubts about the long-term benefit and potential overuse of feeding tubes. SLPs are often asked to offer recommendations about a person’s ability to eat and drink by mouth but may be concerned that restrictions on oral intake could lead to the use of feeding tubes. The boundaries of professional roles are often blurred, further complicating the issue. This course addresses the clinical research surrounding the use of feeding tubes, offers evidence-based practice guidelines, and provides solutions to the challenges facing SLPs with regards to feeding tube overuse.

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