L&L Therapy Services, LLC

In this opinion piece, I present my major reasons for advocating for the free water protocol (FWP). Although there is a lack of strong direct evidence in support of the FWP, there are multiple bits of indirect evidence supporting it: patients do not like thick liquids and avoid them; thick liquids are more harmful to the lungs than are thin liquids; feeding tubes are associated with high rates of pneumonia; and thin liquids, especially water, are relatively benign to the lungs. We need solid evidence in the form of a randomized clinical trial, but, in the meantime, decisions regarding allowing free water to patients who aspirate this consistency should be made on a case-by-case basis.

This article is one side of the debate about the use of neuromuscular electrical stimulation (NMES or "VitalStim") in dysphagia treatment and presents the case supporting the use of this modality. I present published results of clinical trials examining the effectiveness of NMES and acknowledge some flaws in the trials. The evidence shows that, when added to traditional therapy, NMES makes a statistically significant positive difference for a variety of traditional treatment approaches to which it may be added.

Free water protocols have become common in the management of patients with dysphagia. Their popularity has blossomed in the near-complete absence of any empirical data regarding their safety, efficacy and effectiveness. Proponents point to anecdotal reports and opinion pieces, while recent peer-reviewed investigation shows a mixed bag of safety and efficacy outcomes. This paper presents the argument against administration of "free water" without consideration of numerous factors besides the presence of dysphagia, and strongly urges the developers of the method to submit their data to peer review.

Surface electrical stimulation for dysphagia is still a controversial subject. Some studies tout the benefits of using electrical stimulation (e-stim) for improving a disordered swallow. It is important to ensure that the discussion about e-stim is balanced. In this article, I discuss selected counterpoints, including e-stim's intended use, the objective findings of scientific findings, and whether speech-language pathology training in the area of swallowing anatomy and physiology adequately prepares clinicians to use e-stim for dysphagia. Overall, clinicians are urged to take into account all sides of this debate and make educated decisions about whether it should be a part of their clinical practice.

Evidence-based practice requires astute clinicians to blend our best clinical judgment with the best available external evidence and the patient's own values and expectations. Sometimes, we value one more than another during clinical decision-making, though it is never wise to do so, and sometimes other factors that we are unaware of produce unanticipated clinical outcomes. Sometimes, we feel very strongly about one clinical method or another, and hopefully that belief is founded in evidence. Some beliefs, however, are not founded in evidence. The sound use of evidence is the best way to navigate the debates within our field of practice.