4/28/16. Today s Objectives. Evidence Based Decision Making in the Evaluation and Treatment of Dysphagia

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Identify 3 factors to consider during decision making for clinical evaluation of dysphagia 2.

1 Evidence Based Decision Making in the Evaluation and Treatment of Dysphagia Megan Urban, MA, CCC-SLP, BCS-S Ashley Edds, MS, CCC-SLP April 29, 2016 Disclosures Financial Megan and Ashley are employed by Duke University Medical Center Non-financial None Today s Objectives 1. Identify 3 factors to consider during decision making for clinical evaluation of dysphagia 2. Identify 3 different primary deficits that could present in oropharyngeal swallow function 3. Identify 3 evidence based dysphagia interventions as they relate to a primary deficit in oropharyngeal dysphagia. 1

PART 1: The Clinical Evaluation of Swallowing (CSE) Questions to consider: 1. Do we even need to complete a CSE? 2. What components should be included in a CSE? 3. Are there any red flags? 4.

2 PART 1: The Clinical Evaluation of Swallowing (CSE) Questions to consider: 1. Do we even need to complete a CSE? 2. What components should be included in a CSE? 3. Are there any red flags? 4. Are there any rules of thumb? To CSE or not to CSE? Apparently it s a question. Do Establishes a relationship with your patient Allows you to enact the healthcare ritual Sometimes, an instrumental is not always an option Trial therapeutic or compensatory strategies Determine appropriateness for an instrumental Do they want an instrumental? Create patient centered plan of care Do Not Cannot determine laryngeal and pharyngeal anatomy Cannot determine bolus flow characteristics Cannot detect silent aspiration Poor intra- and inter-rater reliability for single signs/ symptoms of dysphagia Screen can determine presence of dysphagia and therefore, need for instrumental evaluation Cannot tell us how to treat the dysphagia Verghese, A., Brady, E., Kapur, C. C., & Horwitz, R. I. (2011). The Bedside Evaluation: Ritual and Reason. Annals of Internal Medicine Ann Intern Med, 155(8), 550. Coyle, J. L. (2015). The Clinical Evaluation: A Necessary Tool for the Dysphagia Sleuth. Perspect Swal Swal Dis (Dysph) Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 24(1), 18. Leder, S. B. (2015). Comparing Simultaneous Clinical Swallow Evaluations and Fiberoptic Endoscopic Evaluations of Swallowing: Findings and Consequences.Perspect Swal Swal Dis (Dysph) Perspectives Screen vs. Evaluation Screens are designed to predict which asymptomatic persons are at high risk of having the disease of interest. Screening cannot Diagnose Develop focused plan of intervention Pass or fail Passà diet Failà further assessment Clinical bedside evaluation allows for the assessment of multiple factorsà produces a diagnostic impression Intervention trial 2

Evaluation of dysphagia CSE Screen Instrumental Overall

Goal of successful dysphagia evaluation: Evaluate the

developing pneumonia from aspiration Ability to consume

3 Evaluation of dysphagia CSE Screen Instrumental Overall Diagnosis + Plan Purpose of clinical swallow evaluation Goal of successful dysphagia evaluation: Evaluate the patient s overall dysphagia and aspiration risk Risk of developing pneumonia from aspiration Ability to consume meals to meet nutritional goals The patient s ideals/goals about their care 3

4 Components of the Clinical Swallow Examination Test Category Ingredients What does it provide? General observations Posture Respiratory rate, rhythm Supplemental oxygen dosage, delivery method Medical/case history Review past medical history Review current situation, medications, swallow history Interview patient, informants Baseline for comparison during swallowing trials Prediction of respiratory-swallow coordination Baseline information Predisposing conditions Recent/current factors altering baseline Swallowing situation before, since illness Attitudes, expectations of informants Awareness of impairments Oral-facial sensorimotor examination Sensory function of oral cavity, oropharynx, face, head, neck Motor function of oral cavity, oropharynx, face, head, neck Dentition, denture, saliva management, oral hydration Predisposing oral disease Prediction of pharyngeal abnormalities Oral health Ability to follow commands Ability to perform compensatory postures Infection risk factors Explanations for sensorimotor impairments Coyle, J. L. (2015). The Clinical Evaluation: A Necessary Tool for the Dysphagia Sleuth. Perspect Swal Swal Dis (Dysph) Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 24(1), 18. Component of the Clinical Swallow Examination Continued Test Category Ingredients What does it provide? Speech/ Language Precision of articulation, resonance Phonation Auditory comprehension Verbal, other expression Cognition Attentions, orientation, memory Awareness of impairments Self-regulation Swallow Trials Variety of conditions of swallowing Compare eating and feeding behaviors in controlled, naturalistic environment Functional of oral, palatal structures Predict laryngeal, pharyngeal function Predict pharyngo-laryngeal secretions Training capacity Ability to express symptoms Ability to participate in testing Learning/training capacity Cognitive factors interfering with efficacy of interventions Overt signs of impaired airway protection Evidence of oral impairments Predict effects of post-swallow oral residue Form hypotheses about clearance of swallowed material, their nature Identify potential efficacy of interventions that are logical to assess with instrumentation Assess ability to participate in instrumental testing Components of a successful CSE Chart review Case history Oral mechanism exam PO trials Decision making 4

5 Chart review Past medical history Lab values Imaging Prior swallow studies History of silent aspiration Past Medical History Congenital Disease Neurologic disease Surgical Endotracheal tubeà Trauma to vocal folds Systemic and metabolic disorders Respiratory impairments Esophageal disease Lab values (and other numbers) Value What is it? How can I use it? Cautions White blood count (WBC) Elevated WBC à body reacting to an inflammatory response If elevated, may be an indication of an infectious process Could be a response to any inflammatory response (injury, stroke, cancer) Absolute neutrophil count (ANC) Albumin (Alb) and Prealbumin (PAB) Electrolytes BUN and creatinine First responders to site of microbial infection Nutritional markers Many can be associated with dysphagia Indicators of renal impairment If elevated + elevated WBC, may be indicative of bacterial infection Decreased albumin could indicate increased risk for development of infection (nutrition tied to immune system) Ammonia elevation can lead to significant cognitive and neurological changes Hypokalemia low potassium can cause weakness and fatigue Hypocalcemia low calcium can cause mental status changes If elevated, complications related to dysphagia may arise (dry mouth, loss of appetite, nausea, vomiting) Oral neutrophils will often dip in critically ill patients, increasing pathogenic bacteria in oral cavity Can be influenced by SO MANY factors (hydration, medication, renal dx, pregnancy, activity level, liver dx, etc.) 5

aspiration, others argue it can take up to 2 minutes to drop after an aspiration event has occurred Cvejic et al (2011) baseline RR >25 bpm associated with aspiration in patient s with COPD.

6 Lab values (and other numbers) Value What is it? How can I use it? Cautions SpO2 Respiratory rate (RR) Peripheral oxygen saturation how much hemoglobin in the blood is oxygenated Measure of breaths per minute Some suggest that a 2% drop in SpO2 can indicate aspiration, others argue it can take up to 2 minutes to drop after an aspiration event has occurred Cvejic et al (2011) baseline RR >25 bpm associated with aspiration in patient s with COPD. Can be a good marker for swallow/breathing coordination. Colodny (2000) no correlations between aspiration on FEES and SpO2 levels. Mills, R. H., & Ashford, J. R. (2008). A Methodology for the Inclusion of Laboratory Assessment in the Evaluation of Dysphagia. Perspect Swal Swal Dis (Dysph) Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 17(4), 128. Sheffler, K. (2015, October 9). Critical Lab Values in Dysphagia. Retrieved March 21, 2016, from Imaging Check chest x-rays CT if available Opacities Diagnosis of pneumonia= New and persistent infiltrate + one of the following Positive pleural or blood culture Radiographic evidence of necrosis or cavitation Histopathologic evidence of the pneumonia Two of the following:» Fever» Leukocytosis (elevated WBC)» Purulent tracheal secretions Aspiration is gravity dependentà be suspicious of either lower lobe James, C. (2016, February). Dysphagia in Patients with Cardiovascular Public domain and Cardiopulmonary Disease. Lecture presented at Complex Cases in Adult Dysphagia: Cardiovascular, Respiratory, and Digestive Systems. Prior test results History of silent aspiration Esophageal studies Barium swallow EGD Manometry Ambulatory ph studies 6

--face symmetric --no change in taste CN injury Stroke Functional impact --unilateral --unilateral --drooling, anterior leakage weakness of weakness of --pocketing upper and lower lower face

7 Case history current presentation Interview patient, family, caregiver Talk to your nurses! Why was the order placed? Oral mechanism exam Cranial Nerve Facial Task --observe face at rest (nasolabial fold) --lift eyebrows --smile and lip rounding --ask about taste if upper and lower facial weakness Expected finding --face symmetric --no change in taste CN injury Stroke Functional impact --unilateral --unilateral --drooling, anterior leakage weakness of weakness of --pocketing upper and lower lower face --reduced oral pressure face --denies change --reduced taste on anterior --reported lack in taste 2/3 of tongue of taste Trigeminal --observe jaw at rest --open and close mouth with and without resistance --stroke 3 branches of face and inside oral cavity --symmetric jaw opening --sensation intact to light touch --mandible deviates to one side --reduced sensation --symmetric jaw weakness --reduced sensation --open mouth positioning --drooling, oral residue or anterior leakage --reduced chewing --reduced hyoid elevation Hypoglossal --stick out tongue --lateralize tongue with and without resistance --elevate tongue --lingual protrusion at midline --no tongue weakness --unilateral tongue weakness with deviation --lingual atrophy --unilateral tongue weakness with deviation --no lingual atrophy --impaired bolus containment, manipulation, transit --reduced pressure for bolus propulsion, hyoid elevation, tongue base retraction Pharynegal branch of Vagus --Palatal elevation upon phoniation --symmetric soft palate elevation --soft palate weakness on one side --symmetric soft palate elevation --posterior leakage --nasal regurgitation --reduced pharyngeal shortening, constriction, bolus propulsion & clearance, airway closure --Reduced PES opening 7

4/28/16 Oral mechanism exam Facial nerve

Predict deficits and ask probing questions

Hypoglossal nerve Other things to check Cough

Nectar thick liquids Honey thick liquids

8 4/28/16 Oral mechanism exam Facial nerve Trigeminal nerve Why know CN function? Predict deficits and ask probing questions Develop prognosis Create tx plan Vagus nerve Hypoglossal nerve Other things to check Cough strength Palpation of dry swallow Vocal quality Secretion management PO trials Ice/water trials Do you test more on your CSE? Nectar thick liquids Honey thick liquids Puree Soft solids Dry/hard/crunchy solids Where is the threshold for cut off? 8

!! Odynophagia Complaints of globus Are there any rules of thumb? Not really.

9 Other considerations Feeding tubes Tracheostomy tubes Mental status General status Fatigue Ability to self-feed Oral care!!! Odynophagia Complaints of globus Are there any rules of thumb? Not really. Each patient is different! Poll: There aren t any rules of thumbs, but there are red flags. What are your red flags? 9

Red flags to consider Spontaneous cough 2 or more of the following 6 factors Abnormal volitional cough Abnormal gag reflex Dysphonia Dysarthria Cough after swallow Voice change after the

Clinical predictors of dysphagia and aspiration risk: Outcome measures in acute stroke patients. Archives of Physical Medicine and Rehabilitation, 81(8), 1030-1033.

10 Red flags to consider Spontaneous cough 2 or more of the following 6 factors Abnormal volitional cough Abnormal gag reflex Dysphonia Dysarthria Cough after swallow Voice change after the swallow Bronchitis History of silent aspiration?rll pneumonia Opacities History of frequent, unexplained pulmonary infections Daniels, S. K., Ballo, L. A., Mahoney, M., & Foundas, A. L. (2000). Clinical predictors of dysphagia and aspiration risk: Outcome measures in acute stroke patients. Archives of Physical Medicine and Rehabilitation, 81(8), Decision making is this enough? Why might you want an instrumental? Why might you NOT want an instrumental? When is it not appropriate? Purpose of instrumental swallow study 10

Video Fluoroscopic Swallow Study or Modified Barium Swallow Study Primary objective: obtain a video of the upper aerodigestive tract during swallowing via x-ray Uses barium of different consistencies

focal folds Different consistencies and textures assessed, usually dyed for easier identification Public domain Indications for instrumental swallowing study Indicated Inconsistent signs and symptoms

11 Video Fluoroscopic Swallow Study or Modified Barium Swallow Study Primary objective: obtain a video of the upper aerodigestive tract during swallowing via x-ray Uses barium of different consistencies Completed in radiology suite Public domain Fiberoptic Endoscopic Evaluation of Swallowing (FEES) Swallowing assessed via scope Direct visualization of the laryngeal vestibule, pharyngeal cavity, focal folds Different consistencies and textures assessed, usually dyed for easier identification Public domain Indications for instrumental swallowing study Indicated Inconsistent signs and symptoms Need to confirm a suspected diagnosis or assist with differential diagnosis Confirmation of the dysphagia Confirmation of dysphagia and potential contribution to nutritional or pulmonary compromise Safety and efficiency of swallow remain a concern To gain information is needed to guide management and treatment May be indicated The patient has a medical condition or diagnosis that is highly correlated with dysphagia (silent aspiration) The patient has previously diagnosed dysphagia and a change in swallow is suspected The patient has a chronic degenerative disease or a disease with known progression In a recovering condition for which oropharyngeal function may require further management Not indicated The patient is too medically fragile to tolerate The patient is unable to cooperate or participate The study would not change the clinical management of the patient The patient doesn t want it! 11

VFSS (MBS) vs FEES Brady, S., & Donzelli, J. (2013). The Modified Barium Swallow and the Functional Endoscopic Evaluation of Swallowing. Otolaryngologic Clinics of North America,46(6), 1009-1022.

12 VFSS (MBS) vs FEES Brady, S., & Donzelli, J. (2013). The Modified Barium Swallow and the Functional Endoscopic Evaluation of Swallowing. Otolaryngologic Clinics of North America,46(6), VFSS (MBS) vs FEES (continued) Advantages Disadvantages VFSS Can see oral, pharyngeal, & esophageal phases Evaluate hyolaryngeal excursion, penetration, and aspiration Noninvasive Radiation exposure Exam time may be limited Fluoroscopy turned off between swallows Requires transport Patient weight/size FEES Direct visualization of laryngeal & pharyngeal anatomy Secretion assessment Portability Longer exam time Real food Biofeedback Can t see oral or esophageal phase White-out at height of swallow Examiner must make inferences about aspiration and penetration Invasive (scope sensitivity) VFSS (MBS) vs FEES (continued) Contraindications Disadvantage VFSS Unable to transport to radiology Positioning for study Radiation Allergy to barium FEES Facial trauma / nasal obstruction / severe edema Laryngospasms Bleeding disorders / high INR / low platelet level High anxiety / combativeness <1% risk of complications Epistaxis Gag Laryngospasm Vasovagal response Langmore SE. Endoscopic Evaluation and Treatment of Swallowing Disorders. Thieme Med Pub., NY, NY (2001) 12

13 Brady, S., & Donzelli, J. (2013). The Modified Barium Swallow and the Functional Endoscopic Evaluation of Swallowing. Otolaryngologic Clinics of North America,46(6), PART 2: Specificity of practice Target specific dysphagia exercise(s) based on primary deficit Kitchen sink approach Quick Review: DYSPHAGIA EXERCISES 13

Press tongue flat to roof of mouth Swallow hard pressing tongue harder to the roof of mouth Research Clark and Shelton (2014) lingual palatal pressures significantly increased after training Crary

14 Effortful Swallow What does it target? Has effects on oropharyngeal closure, increase in posterior motion of the tongue base, and anterior motion of the posterior pharyngeal wall 13 Pharyngeal strength How do you do it? Press tongue flat to roof of mouth Swallow hard pressing tongue harder to the roof of mouth Research Clark and Shelton (2014) lingual palatal pressures significantly increased after training Crary (1995) used semg as biofeedback; 5 out of 6 demonstrated dramatic functional and physiological improvement Carnaby-Mann and Crary (2008) significant clinical improvement and enhancement laryngeal elevation in five patients in three week program where they were instructed to swallow hard and fast for each bolus Contraindications Odynophagia Showa What does it target? Laryngeal-vestibular closure reduced airway protection How do you do it? Grunt like a football player (feel subglottic/chest pressure and hold) Complete effortful swallow without releasing breath Research Hirano et al. (1999) Openings at the levels of the entrance and vocal folds were remarkably narrowed during the maneuver; hyoid bone elevated during the maneuver (evidence of changes in physiology during but no evidence yet of changes after using this as a form of exercise ). Contraindications Vocal fold/laryngeal trauma Pain with exercise Masako (Tongue-Hold) What does it target? Compensating for weak base of tongue by increasing pharyngeal constriction 1,6 Designed to target glossopharyngeus muscle (superior constrictor) 6 How do you do it? Stick out tongue Bite tongue or hold it in place with lips Swallow without pulling tongue back into mouth Research No clinical evidence exists to support potential exercise-related benefits of the tongue-hold maneuver 1 Fujiu and Logemann (1996) significant increase in posterior pharyngeal wall bulging with maneuver Doeltgen et al. (2009) reduction in pharyngeal motor performance but greater relaxation of UES Doeltgen et al. (2011) lower peak pressure and increase in UES pressure (increase in pharyngeal residue) Fujiu et. Al (2013) increase in extent of tongue protrusion resulted in irregular and variable pressure generation patterns, but the duration of pressure generation increased Contraindications Surgical interventions to tongue/posterior pharyngeal wall consult MD Why not use it as a compensatory maneuver? 14

Mendelsohn What does it target? Hyolaryngeal excursion 1 Indirectly UES opening 1 How do you do it?

extent of hyoid movement and UES opening and improvement in coordination of structural movements McCullough and Kim (2013) distance of hyoid elevation in millimeters improved Lazerus et al.

Upper esophageal sphincter (UES) opening 1, 3 Can be used for those that can t do Mendelsohn to target hyolaryngeal excursion Intended to strengthen the suprahyoid muscles to increase hyolaryngeal

Lie as flat as possible on bed or floor Lift head up to look at feet Return your head to bed/floor Try to keep shoulders from moving Extended hold 3 one-minute extended holds with one-minute rest

(2009) significantly less aspiration post-shaker than group with traditional exercises only Contraindications Cervical collar or any spinal injuries Tracheostomy?

15 Mendelsohn What does it target? Hyolaryngeal excursion 1 Indirectly UES opening 1 How do you do it? Start to swallow When swallow reaches highest point, squeeze muscles in throat, lower jaw to hold Adam s Apple in place for 1-2 seconds Finish swallow Research McCullough and Kim (2012) gains in the extent of hyoid movement and UES opening and improvement in coordination of structural movements McCullough and Kim (2013) distance of hyoid elevation in millimeters improved Lazerus et al. (1993) Immediate improvement in timing and coordination Contraindications Cognition Odynophagia Shaker What does it target? Upper esophageal sphincter (UES) opening 1, 3 Can be used for those that can t do Mendelsohn to target hyolaryngeal excursion Intended to strengthen the suprahyoid muscles to increase hyolaryngeal excursion helps pull open the UES 1 How do you do it? Lie as flat as possible on bed or floor Lift head up to look at feet Return your head to bed/floor Try to keep shoulders from moving Extended hold 3 one-minute extended holds with one-minute rest breaks, 30 short raises isokinetic and isometric 2,3 Modified shaker? Research Shaker et al. (1997) increased anterior laryngeal excursion and UES opening in healthy elder adults Logemann et al.(2009) significantly less aspiration post-shaker than group with traditional exercises only Contraindications Cervical collar or any spinal injuries Tracheostomy? Reports of pain in neck/back compliance? Chin Tuck Against Resistance What does it target? Dysphagia due to UES dysfunction ( remember, what is causing this impairment?) specifically related to reduced hyolaryngeal excursion 2 How do you do it? Isokinetic and Isometric (just like Shaker) 10 second hold and 10 successive repetitions (structure of study only clinical use?) Rubber ball which patient places between chin and manubrium sterni Tuck chin against ball as hard as possible Keep shoulders stationary! Research Yoon, Khoo, and Liow (2014) Subjective reports from participants less strenuous Significantly greater maximum semg values compared to Shaker Need clinical trials Contraindications Head/neck/spine trauma Tracheostomy 15

Respiratory Muscle Strength Training (RMT) What does it target?

Measure MIP and MEP Set training devices (often 70-80% of maximum, 25 repetitions each x3/day) Different populations may require special considerations Research Troche et al.

(2000) significant improvement in objectively and subjectively rated cough efficacy post-emst Wheeler et al.

Designed to target laryngeal and pharyngeal muscles How do you do it?

16 Respiratory Muscle Strength Training (RMT) What does it target? Hyolaryngeal excursion Cough strength/productivity Aspiration pneumonia may be reduced with the increase of cough effectiveness 16 (Motor speech!) How do you do it? Measure MIP and MEP Set training devices (often 70-80% of maximum, 25 repetitions each x3/day) Different populations may require special considerations Research Troche et al. (2013) improved swallow safety as evidenced by improved penetration-aspiration scores; improved hyolaryngeal function Gosselink et al. (2000) significant improvement in objectively and subjectively rated cough efficacy post-emst Wheeler et al. longer duration of activation and amplitude of semg in the submental muscle group during EMST than swallowing events Contraindications Pneumothorax Effortful pitch glide What does it target? Designed to target laryngeal and pharyngeal muscles How do you do it? Combination of falsetto and pharyngeal squeeze maneuver Research Pearson, Hindson, Langmore, and Zumwalt (2013) fmri demonstrated significantly greater muscle activation in suprahyoid and longitudinal pharyngeal muscles during EPG compared to swallowing Miloro, Pearson, and Langmore (2014) compared the mechanics of the exercise with the mechanics of swallowing None of the biomechanics measured from EPG proved to have greater excursion than swallowing suggests the kinematics of EPG resembled the kinematics of swallowing Superior movement of the hyoid was statistically greater in swallowing than compared with EPG Tactile-thermal Stimulation What does it target? Stimulating the swallow reflex 6 Improve triggering of the pharyngeal swallow How do you do it? Vertically rubbing the anterior faucial pillars prior to presentation of bolus Laryngeal mirror, cold swab, cold+sour swab Repeated three to four times a day for 5 to 10 minutes Research Lazzaara et al. (1986) facilitate faster triggering of the pharyngeal swallow after the stimulation; reduces the delays for several swallows after Rosenbeck et al. (1991) found an immediate effect of the stimulation, but no evidence to support a therapeutic effect as penetration/aspiration did not improve and any short-term improvements were not maintained after 1 month. Knauer et al. (1990) and Ali et al. (1996) no effect of cold bolus No evidence in reduction of aspiration, only on swallow delay What about sour? Conflicting evidence Contraindications Trauma 16

Neuromuscular Electrical Stimulation (NMES, E-stim, Vital Stim) What does it target? Intended to facilitate improving the contractions of weakened muscles How do you do it?

results Leder and Ruark (2006) studied 2 weeks of daily NMES without exercise in 10 healthy adults measured submental muscle activity via semg before and after and found no difference in

hour sessions) Reported improvement in clinical swallowing ability, functional oral intake, weight gain, patient perception of swallowing ability.

17 Neuromuscular Electrical Stimulation (NMES, E-stim, Vital Stim) What does it target? Intended to facilitate improving the contractions of weakened muscles How do you do it? Electrodes are applied on the skin, via intramuscular placement, or can be fully implanted Stimulation should be applied during functional movement Research Available studies offer conflicting results Leder and Ruark (2006) studied 2 weeks of daily NMES without exercise in 10 healthy adults measured submental muscle activity via semg before and after and found no difference in swallow-related muscle activity Several studies site improvement in swallowing ability Carnaby-Mann and Crary (2008): patients completed traditional dysphagia exercises in conjunction with NMES (1 hour sessions) Reported improvement in clinical swallowing ability, functional oral intake, weight gain, patient perception of swallowing ability. Maintained functional gains for 6 months after treatment National survey of clinicians using NMES show that 80% of clinicians feel that more than half of their patients showed swallow improvement Humbert et al laryngeal and hyoid descent at rest and reduced laryngeal and hyoid elevation during swallowing in healthy adults (think about task specificity ) Kiger, Brown, and Watkins (2007) and Bulow et al (2008) no significant changes of dysphagia therapy with and without NMES PART 3: Case Studies 17

18 Resources: ASHA Practice Portal Resources: Questions? 18

The Clinical Swallow Evaluation: What it can and cannot tell us. Introduction

The Clinical Swallow Evaluation: What it can and cannot tell us Debra M. Suiter, Ph.D., CCC-SLP, BCS-S Director, Voice & Swallow Clinic Associate Professor, Division of Communication Sciences & Disorders