Interjudge Reliability to Analyze the Application of the Functional Oral Intake Scale in Head and Neck Cancer

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Interjudge Reliability to Analyze the Application of the Functional Oral Intake Scale in Head and Neck Cancer
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Mofsky, Allison
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Master's ( M.A.)
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University of Florida
Degree Disciplines:
Communication Sciences and Disorders, Speech, Language and Hearing Sciences
Committee Chair:
Crary, Michael A
Committee Members:
Mann, Giselle D

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cancer -- dysphagia -- fois -- interjudge -- interrater -- oral-intake -- reliability -- scale
Speech, Language and Hearing Sciences -- Dissertations, Academic -- UF
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Communication Sciences and Disorders thesis, M.A.
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Abstract:
The Functional Oral Intake Scale (FOIS) is a scale used to document the safe and adequate oral intake of patients with dysphagia. It was initially validated in a population of patients with neurogenic dysphagia. The present study represents an initial psychometric evaluation of the FOIS scale in patients with head and neck cancer. This is a secondary analysis of a study on prophylactic treatment for dysphagia in head/neck cancer patients treated with chemoradiation. Records from 128 head and neck cancer patients were examined at baseline, 3 weeks, 6 weeks, and 3 months post treatment with dietary data including FOIS score, feeding method, diet type and liquid type. 35 exemplars were randomly selected and provided to 5 expert judges with experience in dysphagia in head and neck cancer and experience using the FOIS scale. Intraclass correlations were completed to evaluate interrater reliability. Reliability was estimated for the overall scale and for each of 7 FOIS levels. Results demonstrated high overall interrater agreement using the original FOIS scale on exemplars obtained from patients with head and neck caner. Analysis of individual FOIS Levels revealed high agreement on Levels 1,2,3, and 6. Low agreement was obtained for Levels 4 and 5, with moderate agreement identified on Level 7. The FOIS is a reliable scale to document oral intake in patients with head and neck cancer. Clinicians using the scale should exercise caution when scoring oral intake represented by Levels 4 and 5. Level 7 may benefit from simple clarification. Future direction includes possible modifications or clarifications of Level 4, as well as clarification of Levels 5 and 7. If revised, the modified FOIS must be revalidated on a cohort of head/neck cancer patients.
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by Allison Mofsky.
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Thesis (M.A.)--University of Florida, 2012.
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Adviser: Crary, Michael A.
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1 INTERJUDGE RELIABILITY TO ANALYZE THE APPLICATION OF THE FUNCTIONAL ORAL INTAKE SCALE IN HEAD AND NECK CANCER By ALLISON MOFSKY A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS UNIVERSITY OF FLORIDA 2012

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2 2012 Allison Mofsky

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3 ACKNOWLEDGMENTS I thank Dr. Crary and Dr. Carnaby for their guidance and tremendous patience in mentoring me through this process. From day on e they actively included me in multiple research projects, at the same facilitating my path and encouraging independence. Allowing me the opportunity to be a contributing member in the Swallow Research Laboratory led me to this project. Their time and ex pert input was invaluable in terms of project completion and my own academic growth. I hope as I go forth in future endeavors I am afforded an opportunity to give back to them with the same kindness they have afforded me. I also thank my raters: Michael G roher, Jan Pryor, Robert Miller, Cathy Lazarus, and Joy Granziano. As experts in dysphasia with years of clinical experience in head and neck cancer, they provided a perspective necessary to begin the revalidation of the Functional Oral Intake Scale [1] in t his population Without their participation this project would not have been possible.

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4 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 2 LIST OF TABLES ................................ ................................ ................................ ............ 5 ABSTRACT ................................ ................................ ................................ ..................... 6 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ ...... 8 2 METHODS ................................ ................................ ................................ .............. 11 Overview ................................ ................................ ................................ ................. 11 Data Collection ................................ ................................ ................................ ....... 11 Interratter Reliability ................................ ................................ ................................ 12 Item Analysis ................................ ................................ ................................ .......... 12 3 RESULTS ................................ ................................ ................................ ............... 15 Interrater Agreement ................................ ................................ ............................... 15 Quali tative Analysis ................................ ................................ ................................ 15 Level 4 ................................ ................................ ................................ .............. 15 Lev el 5 ................................ ................................ ................................ .............. 16 Level 7 ................................ ................................ ................................ .............. 16 4 DISCUSSION ................................ ................................ ................................ ......... 18 LIST OF REFERENCES ................................ ................................ ............................... 22 BIOGRAPHICAL SKETCH ................................ ................................ ............................ 25

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5 LIST OF TABLES Table page 2 1 Tri level diet classification ................................ ................................ ................... 14 2 2 The Functional Oral Intake Scale [1] ................................ ................................ .. 14 3 1 Reliabi lity. Intraclass correlation coefficients ................................ ..................... 17

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6 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requi rements for the Master of Arts INTERJUDGE RELIABILITY TO ANALYZE THE APPLICATION OF THE FUNCTIONAL ORAL INTAKE SCALE IN HEA D AND NECK CANCER By Allison Mofsky May 2012 Chair: Michael Crar y Major: Communication Sciences and Disorders The Functional Oral Intake Scale (FOIS) is a scale used to document the safe and adequate oral intake of patients with dysphagia. It was initially validated in a population of patients with neurogenic dysphagi a. The present study represents an initial psychometric evaluation of the FOIS scale in patients with head and neck cancer. This is a secondary analysis of a study on prophylactic treatment for dysphagia in head/neck cancer patients treated with chemorad iation. Records f rom 128 head and neck cancer patients were examined at baseline, 3 weeks, 6 weeks, and 3 months post treatment with dietary data including FOIS score, feeding method, diet type and liquid type 35 exemplars were randomly selected and prov ided to 5 expert judges with experience in dysphagia in head and neck cancer and experience using the FOIS scale. Intraclass correlations were completed to evaluate interrater reliability R eliability was estimated for the overall scale and for each of 7 FOIS level s Results demonstrated h igh overall interrater agreement using the original FOIS scale on exemplars obtained from patients with head and neck can c er. Analysis of individual FOIS Level s reveal ed high agreement on Level s 1,2,3, and 6. Low

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7 agr eement was obtained for Levels 4 and 5, with moderate agreement identified on Level 7. The FOIS is a reliable scale to document oral intake in patients with head and neck cancer. Clinicians using the scale should exercise caution when scoring oral intak e represented by Level s 4 and 5 Level 7 may benefit from simple clarification Future direction includes possible modifications or clarifications of Level 4 as well as clarification of Levels 5 and 7. If revised, the modified FOIS must be revalidated o n a cohort of head/neck cancer patients.

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8 CHAPTER 1 INTRODUCTION The F unctional O ral I ntake S cale (FOIS) was initially published in 2005 as a tool to document the level of safe and adequate oral intake in patients with neurogenic dysphagia [1]. Initially validated on a population of acute stroke patients, this tool has been used as an independent outcome measure with traumatic brain injury [2] head and neck cancer [3,4], and pediatrics [5]; however the FOIS has not been validated in these populations. Just as the prevalence of swallowing impairment is high in stroke, some estimate as high as 65 % [6], i t is also high in head and neck cancer with prevalence rates as high as 28.2% of patients with stage T2 or more oral cancer, 50.9% of patients with pharyn geal cancer and 28.6% of patients with laryngeal cancer [7]. In the year following treatment, patient reports of swallowing impairment are as high as 23% for surgery alone, 63.6% for surgery with adjunctive radiation, and 70% with adjunctive chemoradiatio n [8]. Additionally, dysphagia is worse for patients treated with external beam radiation than surgery alone. [9,10,11]. Post treatment features of dysphagia in head and neck cancer are influenced by the nature of treatment [12] but they may include decre ased swallowing frequency [13] and aspiration of pharyngeal residue post swallow [14]. Patients report oropharyngeal mucositis, xerostomia, odynophagia, and taste changes as the most troublesome acute effects of radiation on swallow function [15]; howeve r the long term sequela of radiation effects causing dysphagia include tissue fibrosis, altered sensation and necrosis [16]. Functional impacts of dysphagia in this population include i ncreased solid food dysphagia resulting in reliance on a single cons is tency liquid or puree diet [8,17 ] as well

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9 as need for alternative feeding methods [18]. The American Head and Neck Cancer percutaneous endoscopic tube (PEG) prior to starting ther apy enables a patient to research suggests that total nutritional reliance on PEG and prophylactic PEG placement results in worse diet outcomes post treatment [20]. Document ing functional oral intake in head/neck cancer patients is problematic, as no reliable and valid oral intake scale exists for this population. Though health related quality of life scales might include mention of oral intake limitations they are disease s pecific [21,22], part of a broader measure of impairment [23,24,25] or lack psychometric data establishing them as reliable and valid outcome measures [26,27]. Reliability refers to results that are consistent and reproducible. Interrater reliability re presents agreement between two or more raters [28]. While only two raters are necessary to establish level of agreement, generalizability increases with additional raters [28]. Validity examines whether an instrument measures what it purports to measure [29] predict of results based on a gold standard [29], and cross validation: a procedure for estimating performance to predict future data [30]. Reliability and validity are necessary components of evidence based practice [31] and cornerstones of clinical research [32] and practice [33]. As such, these components can identify which diagnostic tools and interventions are the most effective [34]. The FOIS, which has been used to document oral intake change in diverse dysphagic populations, has only been validated in stroke. In that initial study, multiple

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10 forms of validity were investigat ed. Consensual validity across raters was high with criterion validity was demonstrated with significant Chi Modified Rankin Scale [35], Modified Barthel Index [36], and the Mann Assessment of Swallowing Ability [37]. Additiona lly, cross validation revealed significant associations between the FOIS and videoflouroscopic examinations of swallowing function for the presence of dysphagia and aspiration, as well as severity of dysphagia [1]. Thus, while the FOIS has demonstrated validity and reliability in a neurogenic population, differences in swallowing characteristics and function before and following treatment of head and neck cancer necessitate evaluation of the psychometric properties of the FOIS applied to this population. In this study we estimated interrater reliability of the original FOIS scale applied to oral intake exemplars obtained from a cohort of patients treated for head/neck cancer. Intraclass correlation coefficients (ICC) were calculated from FOIS ratings f rom 5 expert judges. We further analyzed FOIS levels that resulted in poor interrater agreement to identify any overt patterns among exemplars that might direct modification of the FOIS for application in this population.

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11 CHAPTER 2 METHODS Overview This is a secondary analysis of a study on prophylactic treatment for dysphagia in head and neck cancer patients treated with chemoradiation. The study investigated the impact of a high and low intensity treatment of swallowing exercise aimed at maintaining or al and pharyngeal muscle function during radiation therapy. All subjects had a head and neck cancer diagnosis, received external beam radiation and or radiation and chemotherapy, and had no history of non oral feeding for cancer related illness. No surgi cal case or case with neurological comorbidities was included. Subjects were examined at baseline (prior to chemoradiation), 3 weeks, 6 weeks, and 3 months post treatment onset. As part of the primary study, nutritional information was collected and two experts interpreted these data into FOIS scores. Data Collection All data were collected at a cancer center within a university medical center. Retrospective review of data obtained from 128 head and neck cancer patients who participated in a swallowing treatment study were examined at baseline, 3 weeks, 6 weeks and 3 months post treatment. Dietary exemplars are composed of multiple aspects of diet data obtained from individual time points (baseline, 3 weeks, 6 weeks, 3 months) recorded in subject books maintained during the initial study. To be included as a dietary exemplar in the present study, the following information must have been present: 1) a description of dietary intake, 2) a FOIS score, and 3) a tri level diet classification. Refer to Table 2 1 for the tri level diet classification Any item in the original study not meeting these criteria was

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12 excluded from consideration in the present study. The only exception to th ese criteria was for baseline ratings when subjects were identified as Lev el 6 or 7 reflecting no significant dysphagia prior to cancer treatment. Based on inclusion criteria, 230 dietary exemplars were included in the data set out of a total of 512 potential exemplars. Subsequently, five exemplars for each FOIS level (based o n the original FOIS ratings) were selected from the total set of exemplars using a block randomization method to develop a final set of 35 exemplars representing all FOIS levels equally. Interratter R eliability To evaluate interrater reliability five exp ert judges with experience in dysphagia in head and neck cancer and prior experience with the original FOIS scale applied FOIS ratings to 35 dietary exemplars. Raters had a mean of 28 years of clinical experience, with a range of twenty five to thirty two years. All raters were asked to assign each dietary exemplar a FOIS rating between Level 1 and Level 7. Refer to T abl e 2 2 for the description of each FOIS level. Each rater was also asked to provide comment if they had difficulty or confusion with a p articular item. No additional training was provided to the expert raters. Agreement between the five expert raters was computed with intraclass correlations both for the overall FOIS ratings and for ratings from each individual FOIS level. In any instan was computed to estimate agreement. Item Analysis Any FOIS level demonstrating low interrater agreement, as defined by lack of statistically significant ICC or kappa value less than 0.60, was further analyzed to evaluate potential sources of disagreement. Comments provided by the raters for specific exemplars were qualitatively analyzed to identify patterns across raters that

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13 might address the need to modify or clarify FOIS levels that contributed to poor int errater agreement.

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14 Table 2 1. Tri level diet classification Feeding Method Diet Type Liquid Type 1. nothing by mouth 2. intravenous diet 3. percutaneous endoscopic gastrostomy tube 4. nasogastric tube 5. oral diet 1. nothing by mouth 2. oral supplements only 3. liquid 4. puree 5. soft mechanical 6. regular 1. nothing by mouth 2. honey 3. nectar 4. thin Table 2 2. The Functional Oral Intake Scale [1] FOIS Level FOIS level description Level 1 Nothing by mouth Level 2 Tube d ependent with consistent oral intake of food or liquid Level 3 Tube dependent with consistent oral intake of food or liquid Level 4 Total oral diet of a single consistency Level 5 Total oral diet with multiple consistencies, but requiring s pecial preparation or compensations Level 6 Total oral diet with multiple consistencies without special preparation, but with specific food limitations Level 7 Total oral diet with no restrictions

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15 CHAPTER 3 RESULTS Interrater Agreement Inter rater agreement across all FOIS levels was high (ICC = .992) as was interrrater agreement for FOIS Levels 1 and 6. Refer to Table 3 1 for detailed results Interrater a greement at FOIS Level s 4 and 5 was low, while agreement at FOIS Level 7 was moderate. An ICC could not be computed for FOIS Level 2 because one disagreement was noted across 25 ratings from five judges. Rater five provided the single discrepant rating. Perfect agreement was noted on Level 2 for raters 1 4. mparing rater five with each of the other raters on Level 2. Average kappa value was .6 0 suggesting good agreement. FOIS Level 3 demonstrated perfect agreement across all raters ( = 1.00). Qualitative Analysis FOIS Level 4 Total Oral Diet of a Single C onsistency FOIS Level 4 resulted in a total of 12 disagreements among the 25 possible comparisons. All disagreements resulted from exemplar ratings higher than Level 4, with nin e scored as a Level 5 and three scored as Level 6. Disagreement was present amongst four out of five raters and all exemplars were involved. Three raters provided five comments total regarding single consistency oral diets. Comments were provided for fo ur out of five exemplars. Analysis of rater comments and scores reveals a pattern of confusion regarding what constitutes a single consistency diet. All comments were related to thickness of the single consistency diet. For example, one rater stated that puree with thin liquids is

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16 higher ratings assigned for this level also revealed rater disagr eement about whether to classify puree as a single consistency diet (FOIS Level 4) or a special preparation (FOIS Level 5). FOIS Level 5 Total Oral Diet with Multiple Consistencies, but Requiring Special Preparation or C ompensations FOIS Level 5 resulted in a total of 8 disagreements among the 25 possible comparisons. All disagreements resulted from higher ratings than the original FOIS scores, with seven ratings being a Level 6 and one rating a Level 7. Disagreements were noted on four out of five exemplars. Comments were provided for two exemplars on this level. Analysis of rater comments and scores indicates substantial rater confusion about what constitutes a compensation. Rater comments indicate confusion regarding scoring an exemplar 6 cans of Ensure postulating that Ensure is a form of compensation and another stating confusion whether Ensure is a liquid diet or food limitation. Other disagreements on what constituted a compensation also i ncluded confusion over small bites, hypermastication and liquid wash. FOIS Level 7 Total Oral Diet with No Restrictions Two raters scored a single exemplar of FOIS 7 as a FOIS 6. The single comment on this item addressed the avoidance of spicy foods wi th the rater questioning whether avoidance was due to mucositis or subject preference. The exemplar was unclear regarding the reason for this avoidance preference or swallow related issues.

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17 Table 3 1. Reliability. Intraclass correlation c oefficients Intraclass Correlation Coefficient 95% Confidence Interval p value Lower Bound Upper Bound All Levels .992 .987 .996 p<.0001 Level 1 .972 .902 .997 p<.0001 Level 2 .60* Level 3 1.0* Level 4 .495 .146 .926 P<.062 Level 5 .455 .282 .923 p<.102 Level 6 .823 .350 .980 p<.006 Level 7 .625 .329 .956 p<.071 *Average kappa value included as intraclass correlation coefficient could not be computed

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18 CHAPTER 4 DISCUSSION Results of this study indicate overall high interrater agreeme nt applying the FOIS scale on dietary exemplars obtained from patients with head and neck cancer. As such, the FOIS appears to be an appropriate tool to document change in functional oral intake in patients with dysphagia following head and neck cancer. However, obtained low reliability on Levels 4 and 5 indicate that caution must be used when scoring these FOIS levels. Furthermore, based on low interrater agreement, these FOIS levels should be examined for revision when applied to this clinical populati on as substantial variability exits among rater definitions for single consistency diets and for special compensations. Revision of FOIS levels may include clarification or modification of the descriptions for each level as well as clarification of how t hese levels apply to patients with head and neck cancer. Clarification would entail additional explanation of the terminology used in level descriptions as well as explanation of appropriate application of each level to a lies adapting the scale to increase specificity of description related to functional oral intake patterns in patients with head and neck cancer. When examining individual levels, poor agreement is noted on Levels 4 and 5 with only moderate agreement on Le vel 7. Collective results indicate that Level 4 is an appropriate candidate for modification plus/minus clarification, while Levels 5 and 7 emerge as candidates for clarification without need for modification. Modification of FOIS Level 4 should address the issue of liquids vs food consumption, both in combination (eg. puree vs thin or thick liquids) and in isolation (eg. puree vs. liquid diet). This FOIS level should be further clarified to indicate that a puree

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19 diet is a single consistency diet and th at this item ranks lower than multi consistency diets that employ compensations. For example, a puree diet with thin liquids ranks lower than a mechanical soft diet with thin liquid wash. Clarification of FOIS Level 5 should include a description of wha t constitutes a special compensation/preparation and may also address the role of special compensations and preparation of oral diets. Rater scores on four out of five exemplars varied among Levels 5, 6 and 7; however limited commentary was provided for q ualitative review. Overall, raters were inconsistent in their ranking of exemplars including supplemental nutrition, small bites, hyper mastication, and liquid wash as compensations. Clarification of FOIS Levels 4 and 5 should also address application of these levels to patients with head and neck cancer. Raters in this study consistently scored these exemplars higher than the expert raters in the initial study. In a clinical environment, a higher FOIS rating may attribute swallowing abilities to patien ts that do not exist. This is problematic because an accurate assessment of swallowing function at different points along the continuum of treatment is necessary to determine patient progress and treatment success. Likewise, it is problematic to assume a patient with dysphagia has abilities he does not have thereby assigning him a higher FOIS rating. If manage with complications resulting. Clarification of FOIS Level 7 sh ould focus on distinctions between food avoidance based on preference vs. based on swallow ability. Likewise, clarification may provide a distinction between FOIS Level 6 and 7 regarding avoidance. FOIS Level 6 includes

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20 avoidance based on swallow functio n while FOIS Level 7 may include avoidance based on preference with no deficit in swallow function. C larification of this level would serve to explain that functional oral intake is not based on patient taste preferences or clinician perception of patient physiology. Rather the scale is intended to document a A limitation of the present study is the small number of exemplars as well as the small pool of raters. The small number of exemplars limits the nu mber of opportunities to identify sources of disagreement amongst raters. Disagreement among raters was targeted in this study as it suggests the scale may require clarification or modification to increase reliability. The large confidence intervals not ed for Level s 4, 5, and 7 ref lect the small sample size. They may also indicate difficulty making generalizations about the data because FOIS level agreement in a small number of raters may not reflect agreement in a larger population of clinicians worki ng in head and neck cancer. Expert raters were chosen for this study based on direct clinical experience with head and neck cancer and prior use of the FOIS scale with the direct purpose of identifying limitations in the original FOIS as applied to head an d neck cancer. T his limitation may be overcome by repeating this investigation f ollowing clarific ation and or modification of FOIS Levels 4, 5 and 7 with a larger sample o f clinicians in the area of head and neck cancer. In summary, current results sugg est the FOIS is an appropriate tool to document functional change in oral intake in patients with head and neck cancer. Clinicians using the scale should be sensitive to scoring errors in Levels 4 and 5 especially with items that require modified consist encies or special compensations. Future directions include

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21 additional validation of the FOIS in patients with head and neck cancer by comparing the FOIS with previously validated head and neck cancer performance indexes and increasing the number of raters to minimize limitations in psychometric analysis. Additionally, given the breadth of clinician experience and clinical application in this profession, comparisons should include raters with different amount of clinical experience. Future research shoul d examine whether this disparity in experience is a factor in FOIS rating.

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22 LIST OF REFERENCES 1. Cra ry M, Carnaby Mann G, Groher, M: Initial Psychometric Assessment of a Functional Scale for Dysphagia in Stroke Patients. Dysphagia 86 :1516 20 2005 2. H ansen T, Larsen K, Engberg A: The Association of Functional Oral Intake and Pneumonia in Patients W ith Severe Traumatic Brain Injury. Arch Phys Med Rehabil 89 :2114 20 2008 3. Schache A, Lieger O, Kelly A, Newman L, Kalavrezos N: Predictors of swallowing outcome in patients treated with surgery and radiotherapy for advanced oral and oropharyn geal cancer Eur J Cancer B Oral Oncol 49 (9):803 8 2009 4. van der Molen L, Rossum M, Ackerstaff A, Smeele L, Rasch C, Hilgers F: Pretreatment organ function in pati ents with advanced head and neck cancer: BMC Ear Nose Throat Disord 9 :10 2009 5. Christiaanse ME, Mabe B, Russell G, Smeone TL, Fortnato J, Rubin B: Neuromuscular electrical stimulation is no more effective than usual care for the treatment of primary dysphagia in children. Pedia tr Pulmonol 46 :559 65, 2011 6. Mann,G, Hankey GJ, Cameron, D: Swallowing Disorders following acute stroke: prevelance and diagnostic accuracy Cerebrovasc Dis 10 :380 6, 2000 7. Lo gemann JA, Rademaker AW, Paulowski BR et al.: Site of disease and treatment protocol as correlates of swallow function in patients with head and neck cancer treated with chemoradiation. Head Neck 28 :64 73 2006 8. Garcia Peris P, Par on L, Velasco C, de l a Cuerda C: Long term prevalence of oropharyngeal dysphagia in head and neck cancer patients: impact on quality of life. Clin l Nutr 26 :710 17 2007 9. Lazarus C: Effects of radiation therapy and voluntary maneuvers on swallow functioning in head and neck cancer patients. Clin Commun Disorders 3 :11 20, 1993 10. Lazarus C Logemann J, Pauloski B, et al.: Swallowing disorders in head and neck cancer patients treated with radiotherapy and adjuvant chemotherapy. Laryngoscope 106 :1157 66, 1996 11. Pauloski B, Logemann J, Rademaker A, et al.: Speech and swallowing function after oral and oropharyngeal resections: one year follow up. Head Neck 16 :313 22, 1994

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23 12. Mittal, B, Pauloski, B, Haraf, D, et al.: Swallowing dysfunction preventative and rehabilitative s trategies in patients with head and neck cancer treated with surgery, radiotherapy, and chemotherapy: A critical review Int J Radi at Oncol Bio l Phy 57 (5): 1219 30, 2003 13. Zuydam AC, Rogers SN, Brown JS, et al.: Swallowing rehabilitation after oro pharyn geal resection for squamous cell carcinoma. Br J Oral Maxillofac Surg 38 :513 518, 2000 14. Lazarus CL, Logemann JA, Kahrilas P J, Mittal BB: (1994) Swallow recovery in an oral cancer patient following surgery, radiotherapy, and hyperthermia. Head Neck 16 (3) :259 65, 1994 15. Rose Ped A, Bellm L, Epstein J: Complications of radiation therapy for head and Cancer Nursing 25 (6):461 7 2002 16. Raber Durla cher J, Brennan M, Veronck de L: Swallowing dysfunction in cancer pati ents. Support Care Cancer 20 :433 43 2012 17. Finlay P, Dawson F, Robertson A: An evaluation of functional outcome after surgery and radiotherapy for intraoral cancer. Br J or Oral and Maxiofac Surg 30 :14 7, 1992 18. Magne N, Marcy PY, Foa C et al. : Com parison between nasogastric tube feeding and percutaneous fluoroscopic gastrostomy in advanced head and neck cancer patients. Eur Arch Otohinolaryngol 258 (2):89 92, 2001 19. National comprehensive cancer network clinical practice guidelines in oncology, 20 08. Available at http://www.nccn.org/ professionals/physician_gls/f_guidelines.asp (accessed 201 2) 20. Langmore S, Krisciunas G, Miloro K, et al.: Does PEG use cause dysphagia in head and neck cancer patients? Dysphagia 2011 ; Aug 18. (Epub ahead of print) 21. Hillel AD, Miller RM, Yorkston K, McD onald E, Norris FH, & Konikow N: Amyotrophic lateral sclerosis severity scale. Neuroepidemiology 8 :142 50 1989 22. Manor Y, Giladi N, Cohen A, Fliss DM, Cohen JT: Validation of a swallowing disturbance questionn aire for detecting dysphagia in patients with Parkinson's disease. M ov Disord 22 (13 ):1917 21, 2007 23. Hall K: The functional assessment measure (FAM ). J Rehabil Outcomes Measure 1 :63 5, 1997 24. Skeat J, Perry A: Outcome measurement in dysphagia: not so hard to swallow. Dysphagia 20 (4):390 9, 2005

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24 25. List MA, Ritter Sterr C, Lansky S B: A performance status scale for head and neck cancer patients. Cancer 66 : 564 9 1990 26. Salassa JR: A functional outcome swallowing scale for staging oropharyngeal dys phagia. Dig Dis 17:230 4, 1999 il KH, Purdy M, Falk J, Gallo L: The dysphagia outcome and severity scale. Dysphagia 14 : 139 45, 1999 28. Hobart JC, Lamping DD, and Thompson A J: Evaluating neurologic outcome measures: the bare essentials (editorial ). J. Neurol. Neuro surg. Psychiatry 60 :127 30, 1996 29. Portney LG, Watkins MP : Foundations of Clinical Research: Applications to Practice. Upper Saddle River: Pearson Education; 2009 30. Refaeilzadeh P, Tang L, Liu H: Cross Validation. Encyclope dia of Database Systems 1 :532 8, 2009 31. Rosenberg W, Donald A: Evidence based medicine: An approach to clinical problem solving. British Medical Journal 310 :1122 5, 1995 32. Bargaje, C: Good documentation practice in clinical research. Perspect Clin Res 2 (2) :59 63, 2011 33. Ferve rs B, Carretier J, Bataillard A: Clinical Practice Guidelines. J Visc Surg 147 (6):341 9, 2012 34. Herbert RD, She rrington C, Maher C, Moseley AM: Evidence based practice imperfect but necessary. Physiother Theory Pract 17 :201 11, 2001 35 Swieten JV, Koudstaal P, Visser M, Schouten H, Gijn JV: Interobserver agreement for the assessment of handicap in stroke patients. Stroke 19 :604 607, 1988 36 Coll in C, Wade DT, Davis S, Horne V: The Barthel ADL index: a reliability st udy. Int Di sabil Stud 10 :61 3 1988 37. Mann GD : The Mann Assessment of Swallowing Ability. Clifton Park: Singular Thomas Learning; 2001

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25 BIOGRAPHICAL SKETCH Allison Mofsky was born into a family that encouraged excellence in all endeavors. At an early age she was taught the value of persistence, perseverance and work ethic. Her father, a lawyer and law professor at the University of Miami, was renowned in his field and encouraged all academic pursuits eighth birthday. Her mother, a vice president of mortgage banking in a large local bank in south Florida encouraged personal growth of any kind. The avocation were planted in the classroom. She hold s a Bachelor of Science in special e ducation and Bach elor of Arts in p sychology. B eginning in 2005, she taught special education and English as a foreign language for five years in Miami, Florida and South Korea before returning to school. In 2012 Allison completed her degree in the D epartment of Communication Sciences and Disoders th ereby earning a Master of Arts. disabilities, the accomodations she made for them and their struggles in literacy and language initially piqued her interest in speech language pathology. Her research and clinical experiences at the University of Florida helped her to refine her focus and instilled in her a passion for medical speech pathology, particularly for dysphagia. Her externship at MD Anderson Cancer Center in Orlando provided a unique opportunity to train in voice and dyspha gia evaluation and rehabilitation with head and neck cancer patients. Allison hopes to continue her clinical and research training in an effort to provide her own patients with the excellent standard of care provided by her supervisors and mentors.