pico question for stroke patients

The full social, physical, emotional, and psychological potential of the patient is pursued, so that disabled is not confined in a state of sorry and or a state of despair. customers. The rehabilitation methods often include psychological, emotional, and physical therapy. Does Constraint-induced Aphasia Therapy, https://libguides.uthscsa.edu/neurology_libguide. cookies policy for more information. Get a language sample and check in with teachers and caregivers. We often come across the problem of not being able to identify strengths with formalized assessment, so well explore other ways to gain information. Thanks for your comments. Clinical predictors of dysphagia and aspiration risk: outcome measures in acute stroke patients. Thank you for this great article. The Joint Commission. However, haemodynamic levels such as blood pressure tend to change late and correct early, so may not accurately . These were useful to dissect each study and screen for its applicability for our use. It is in this regard that no particular intervention by way of management method has been singled out to give the best outcome. Noticing this, you say to a coworker that maybe social skills group training . The average cost per patient for the first 90 days after a stroke is $15,000 although 10 percent of those cases exceed $35,000. It incorporates the entire infrastructure of patient care, including the patient, provider, and institution. C-Comparison - Currently, hospitals are using routine NHS physical and occupational therapy to rehabilitate patients with hemorrhagic . They are also coached into mortal skills. Accessed June 14, 2012. 2. 1997;12(4):188-193. It is not normally asked because of a need to make a clinical decision about a specific patient. For ________ (P) does the use of ______ (I) reduce the future risk of ________ (O) compared with _________ (C)? It offers therapeutic measures for stroke patients, based on rehabilitation approaches that especially focus on the wholesomeness of the being. A 68-year-old female patient has recently been diagnosed with high blood pressure. Make a PICO question. Titler MG, Kleiber C, Steelman V, et al. Topic 3 has comprehensively appraised research articles in analyzing the subject matter under consideration. (O). Population Intervention Comparison Outcomes 1 Patient with acute asthma and upper airway infection . Questions around how to select treatments to offer our patients that do moregood than harm and that are worth the efforts and costs of using them. PICO allows you to develop focused relevant questions. P: Population/patient - age, gender, ethnicity, individuals with a certain disorder. Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S. Formal dysphagia screening protocols prevent pneumonia. Note: In some situations, you may not have a specific comparison in your PICO question., O Outcome, What do you want to accomplish, measure, or improve (e.g., upgraded diet level, more intelligible speech, better hearing in background noise)?. (T). As a person with intermittant dysphagia from lower cranial nerve dysfunction that results in facial and oropharyngeal muscle weakness, I had my life saved by a bedside nurse using this type of screening tool. It explains that their spiritual, emotional, psychological, social, physical, among others aspects, must be brought to par to integrate them back into society. This is also a great time to test out some speech sound interventions and different levels of prompting. Get your free access to the exclusive newsletter of, http://www.heart.org/HEARTORG/HealthcareResearch/GetWithTheGuidelinesHFStroke/Get-With-The-Guidelines-Stroke-Home-Page_UCM_306098_SubHomePage.jsp, http://www.jointcommission.org/specifications_manual_joint_commission_national_quality_core_measures.aspx, http://www.hinursing.org/pdf/IowaModel.pdf, http://www.ncbi.nlm.nih.gov/pubmed/11778337, Interpreting statistical significance in nursing research, New lung cancer treatment modalities and their adverse effects, Wound care: Five evidence-based practices, Reduce unnecessary transfers from clinics to EDs, Realizing Our Potential as Psych NPs When Treating the Adult Schizophrenia Community, Journal Peer Review. Example Nursing Picot Questions. Chat with the support team, or the Admin if you encounter any difficulty in making your payment, or proceed to pay for your order using our secure processing method to publish the project for our writers to start working on the task. For young infants (0-2 months) with suspected sepsis managed in health facilities (P), should third-generation cephalosporin monotherapy (I) replace the currently recommended ampicillin-gentamicin combination (C) as first-line empiric treatment for preventing death and sequelae (O)? The only one that had published reliability data using nurses was the Standardized Swallowing Assessment. The PICOT question format is a consistent "formula" for developing answerable, researchable questions. After paying for your project, award a writer of your choice or let the support team match your project with the most appropriate writer. It would not include any food or thickened liquids. For adult men over the age of 70 years what are the effects of adding beta-blockers for lowering blood pressure? There was enough evidence to confirm swallow screening can be performed by nurses, but none of the screening tools we found met our needs. ThePICO framework is often used as a guide for asking clinical questions. Hence, the analysis of topic 3 has demarcated the research gap and the amount of work that is outstanding in zeroing in on the management methods to be used. What triggers affected our need for a nursing bedside swallow screen? I will try to explain the methodology used to search evidence to answer the PICOT question. A bad PICO is usually a background question disguised as a research question. 2001;10:463-473. Your email address will not be published. Asking a focused and relevant question about your client's situation will . In this regard, incorporating technology can be of much use in screening. Narrative Intervention for Children With Autism Spectrum Disorder (ASD). 3. These effects can reduce patient satisfaction, extend length of stay, and increase hospital costs. Dysphagia. This has been a highly lucid presentation of an exemplary project. They seek evidence to answer clinical information related to a specific population, patient, or problem. Int J Lang Commun Disord. IN Emergency Department, does the Application of over-crowding indices, compared to Raw ED volumes, lead to prognostic accuracy for over-crowding-related outcomes (increased error rates, ED length of stay, staff burnout), reliability, physician/patient acceptability, external validity in 3 months? Questions addressing the act or process of identifying or determining the nature and cause of a disease or injury through evaluation. A question root (who, what, when, etc.) In this study, the PICOT statement helped to frame a research question. Overwhelmingly, they said they needed a swallow screen that they could use at the bedside. Running head: STROKE REHABILITATION 2. Among healthy newborn infants in low- and middle-income countries (P), does early skin-to-skin contact of the baby with the mother in the first hour of life (I) compared with drying and wrapping (C) have an impact on neonatal mortality, hypothermia or initiation/exclusivity/ duration of breastfeeding (O)? This measures the level of Independence of a patient. Write a 750-1,000-word paper that analyzes your research and focuses on the population you have chosen. Too often they were admitting patients from the emergency department with orders that read NPO except medication until swallow evaluation by speech therapy. This was frustrating because patients were still at risk for aspirating the medicine. A competent staff member (defined by each institution) should complete the dysphagia screenabnormal results should be referred to the SLP for a complete assessment. We wanted the tool to be short and easy to follow: a one-page screen that incorporated all the validated dysphagia screening criteria. 2) Intervention. Clinical Question: For patient with stroke, is early rehabilitation impairment-based therapy intervention effective compared to usual care (UC) therapy? Your dependent variable. My classmate and I met with the CNS, who emphasized that patients with neurological dysfunction such as stroke are at risk for aspiration due to alteration in swallowing function. It presents the anterograde approach with proximal to distal revascularization and retrograde approach with distal to proximal revascularization. with a verb. We anticipated some resistance to change but surprisingly received very little. Among the matters of ethics that are relevant in this case include ensuring that there is a close associate or a relative of a patient to help her in decision-making, especially on the matters that require his/her input or consent before the final decision is made. (2017) observes that in occlusion cases, the blockage of cervical vessels accounts for 15% of mortality cases among ischemic stroke patients. J Clin Nurs. My anxiety quickly resolved when the professor introduced the tools and resources that we would use to aid in our progress and decision making: The Iowa Model of EBP and The Evidence-Based Practice Manual for Nurses. To get a whole picture of the child/student. For infants is skin-to-skin contact with the mother a more assured way of ensuring neonatal mortality compared to drying and wrapping? In patients with type 2 diabetes and obesity (P), is bariatric surgery (I) more effective than standard medical therapy (C) at increasing the probability of remission of diabetes (O)? Patients with stroke are at a high risk for dysphagia because they often have decreased level of consciousness and lower cranial nerve dysfunction resulting in facial and oropharyngeal muscle weakness. 2001;16(1):7-18. An example of a PICO question is: In an older patient with X disorder, is giving Y treatment rather than Z treatment more likely to result in a shorter stay in hospital? What do the results mean for my patients? Does the use of pain relief medication throughout the process of the surgery reduce the pain more effectively when compared to the intake of the same medicine given post-surgery? This is a guest blog post by Monica, a school-based SLP, on how to streamline your speech and language evaluations by using the PICO question as an evidence-based strategy. Thanks for your help! Top Geriatr Rehabil. We use cookies to give you a better experience. PICO is a popular mnemonic in nursing. You could also use this time to assess overall intelligibility (and figure out what kind of speech sound disorder assessment you want to do if thats an area of need). The activation would increase the work of muscles, improving the blood flow. P stands for Patient/Problem, I for Intervention, C for Comparison, and O for Outcome. We typically have formal and informal assessments, so lets compare the results of those two, and see what we would miss if we only did formal/standardized testing. Telerehabilitation avails the services closer to the patient without much hustle of movement. In this study, the PICOT statement helped to frame a research question. The PICO process is a technique used in evidence-based practice to frame and answer a clinical question in terms of the specific patient's problem that helps clinically relevant for . This is grounded on earlier highlighted the fact that the stroke conditions worsen as time passes. For patients 65 years and older (P), how does the use of an influenza vaccine (I) compared to not received the vaccine (C) influence the risk of developing pneumonia (O) during flu season (T)? We learned that dysphagia, which occurs in 28% to 45% of stroke patients, can be a serious complication, resulting in malnutrition, dehydration, and pneumonia. Furthermore, the input of Rice et al. Our commitment to customer satisfaction has consistently made us the best site to buy a research paper. . Marik P, Kaplan D. Aspiration pneumonia and dysphagia in the elderly. She is otherwise healthy and active. Step 4: Make your Clinical Decision. PICOT question examples such as "How effective is handwashing in reducing infections?" can be broken down in the following manner: Our research paper writers are skilled and dedicated to offering you the best writing services. I think especially when we have a lot of evaluations going on at the same time, posing each evaluation as a PICO question could help to hone in on what you want to get out of the evaluation. This test is a widely accepted functional assessment measure used during inpatient rehabilitation. The feedback from the nurses prompted us to answer Yes to the question: Is this topic a priority for the institution? In addition, length of hospitalization may impact negatively both patient and . Thus, nurses do not have an efficient and reliable method of reducing patient falls. After the patient history has been taken and the researcher has . We also developed a competency check-off form to confirm nurses ability to carry out the bedside screen. Tags: ebp, evidence-based nursing, evidence-based practice, guidelines, literature review, nclex, nurse, nurses, Nursing, nursing research, pico, reviews This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License . This is a methodical undertaking that is systematic. The Iowa Model of EBP guided us throughout the project. The paper I received was totally free from plagiarism. The manual describes each step of EBP, from forming a research question to prioritizing the hierarchy of information. Evidence: 2002;34(5):252-258. Use this worksheet to break down the parts of your PICO question. If you ask a person who is having a stroke to raise both of their arms, one will drift downward. (picot question examples). 2. When choosing to write a PICOT statement or question, the population refers to the people you focus on. A blog created for SLPs--by SLPs! In addition to me, our team included my classmate, our NICUs CNS, the nurse practitioner (NP) from our hospitals neurology stroke department, and the SLP who works with our stroke patients. I use my favorite materials during this portion of the informal assessment, and can get a lot of information that I might have missed with just a standardized assessment. Get a15% DISCOUNT on your first order. Here is my experience, which I hope will help others who wish to implement change. These results looked impressive, but the study had some limitations. We compiled evidence summaries about articles, studies, and dysphagia tools. The swallow screen is a minimally invasive, pass/fail tool for quick identification of patients who require a formal evaluation of swallowing by a speech language pathologist (SLP). P- patients with SLE. (Were you able to get a sound with a quick phonological awareness task? 11 Patient with acute ischemic stroke Statins Placebo Recurrent stroke, all cause mortality 12 Patient undergoing neurosurgery for malignant disease Early These effects can reduce patient satisfaction, extend length of stay, and increase hospital costs. It is, therefore, only ethically right to almost immediately place the patient on a rehabilitation regimen almost immediately. I = virtual reality. You need to decide whether to prescribe her a beta-blocker or an ACE inhibiter. What are the most important elements of the Affordable Care Act in relation to community and public health. Your order will be assigned to the most experienced writer in the relevant discipline. Outcome: Define what youre hoping to accomplish. No part of this website or publication may be reproduced, stored, or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the copyright holder. As result, one will be able to produce the best existing evidence to support clinical decisions and explore alternative treatments and procedures. We made some formatting modifications to the tools that were currently in the literature to create our own tool. Or with some very specific motor-based prompts?). (1) What is the study of physiology? Stroke Rehabilitation. I feel very satisfied with the reply to the discussion topic. Do women, between the age of 25 and 40 years, who takes regular oral contraceptives at greater risk of blood clots when compared to the women in the same age group who avoid oral contraceptives? 2. The first step in the evidence-based practice (EBP) process is to identify the clinical problem or question for which you are seeking evidence. In _______(P), what is the effect of _______(I) on ______(O) compared with _______(C) within ________ (T)? Running head: STROKE REHABILITATION 1. Questions addressing how one experiences a phenomenon. The Iowa Model of Evidence-Based Practice to Promote Quality Care. Nurses and physicians report that the tool is fast and easy to use. The results showed high reliability with sensitivity and specificity 100%. How do pregnant women (P) newly diagnosed with diabetes (I) perceive reporting their blood sugar levels (O) to their healthcare providers during their pregnancy and six weeks postpartum (T)? Research undertakings continue to compare management options with the best outcomes for patients. Step 2: Gather Evidence. We do not resell any papers. Often, when family members tend to be more sympathetic, caring, and warning the patient, whenever he/she makes any moves, to make sure he/she does not incur any bodily harm. Implementing a swallowing screening protocol has been shown to significantly reduce the risk of pneumonia. 1. It also helps formulate the search strategy by identifying the key concepts that need . 9 Congestive heart failure, hypertension, age 75 years . The word PICOT is a mnemonic derived from the elements of a clinical research question - patient, intervention, comparison, outcome and (sometimes) time. By formatting your research question in a PICO (T) format you can gather evidence relevant to your patient's problem. Smith H, Connolly M. Evaluation and treatment of dysphagia following stroke. The PICOT process begins with a case scenario, and the question is phrased to elicit an answer. I- turmeric tea. They are also put in constant check and activeness, so that incidence of recurrent strokes, complications of the acute reducing periods, memory lapses, and incidents of opportunistic infections, among others, are prevented. As a registered nurse working in the neurosurgical intensive care unit (NICU), I returned to school to complete my bachelor of science in nursing degree. Therefore, nurses can apply these findings to teach patients about risks of falls in the healthcare environment during . 8 The risk of stroke increases from 1.5 percent for patients with AF who are 50 to 59 years old to 23 percent for those who are 80 to 89 years old. "The question needs to identify the patient or population we intend to study, the . Several questions were proposed: 1. The SLPs Guide to Virtual Speech Teletherapy & Language Assessments, Summarizing and Main Idea Intervention: A Practical Review , #149: Assessing Speech Sound Disorders: Making Recommendations, #146: Assessing Speech Sound Disorders: Getting Started, #145: Assessing Stuttering: Making Recommendations, Curriculum- and Literacy-Based Speech Therapy Planning & Lesson Plans, Organizing Your Speech Therapy Classroom and Materials. I also tend to get stuck in a rut of doing the same type of evaluations, especially when there is a lot to juggle with my workload. Are 30- to 50- year old women (P) who have high blood pressure (I) compared with those without high blood pressure (C)at increased risk for an acute myocardial infarction (O) during the first year after hysterectomy (T)? In this case, I would do extensive interviews with the teacher/school staff/caregivers and observations. Professional Custom Essay Writing Service. Needless to say that there are instances during therapeutic interventions, where the consent of the patient is mandatory, as a matter of ethical requirement. I hope to be able to explain how giving tissue plasminogen Activator (TPA) can be beneficial to stroke patients between three and four and a half hours after stroke symptoms start. In middle-aged men with suspected myocardial infarction (P), are serial 12-lead ECGs (I) compared with one initial 12-lead ECG (C) more accurate in diagnosing an acute myocardial infarction (O)? A patient might need to accept the new state, as he/she- may be in a state of disability and appreciate the new physical state and new potentials. We asked: Where did each item fit on the hierarchy of evidence? (Were you able to get a sound with a quick phonological awareness task? In choosing the best management method, many considerations are put in place; among these considerations is the cost of the said intervention, the degree of the vessel blockage, and the duration it has taken. Top Writer P - Patient / problem : Identify the problem of the patient / Ask how could you describe a group of patients similar to your patient's case. A stroke will cause weakness in one arm or a feeling of numbness. For example, it holds that the prognosis of these cases has been poor. Indeed, the researchers explain their experiences, when handling the acute ischemic stroke patients, focusing on tandem occlusions and they later went through intravenous thrombolysis. Screening and documentation subsequently improved. 1. Article 1: Emergency intubation for acutely ill and injured patients. https://www.asha.org/research/ebp/frame-your-clinical-question/. Overall results showed that patients who have abnormal screening tests are at increased risk for pneumonia and nutrition problems compared to patients who have normal screening tests. Paper that analyzes your research and focuses on the wholesomeness of the Affordable care act in relation to and!, only ethically right to almost immediately care act in relation to community and public health Kaplan aspiration! Reduce patient satisfaction, extend length of hospitalization may impact negatively both patient and give a! Hustle of movement ; s situation will in the healthcare environment during formula & quot ; for developing,. Alternative treatments and procedures in with teachers and caregivers, so may not accurately using routine NHS and! An efficient and reliable method of reducing patient falls technology can be of use! Or with some very specific motor-based prompts? ) use at the bedside environment during question. Risk of pneumonia had published reliability data using nurses was the Standardized Assessment... Ensuring neonatal mortality compared to drying and wrapping the work of muscles, improving the blood.. A PICOT statement or question, the PICOT statement helped to frame a paper! Iowa Model of Evidence-Based Practice to Promote Quality care this has been shown to significantly reduce the of... Or a feeling of numbness act in relation to community and public.! The search strategy by identifying the key concepts that need p: Population/patient - age, gender, ethnicity individuals... Hope will help others who wish to implement change female patient has recently been diagnosed with high pressure. Use this worksheet to break down the parts of your PICO question patients about risks falls! Be of much use in screening helped to frame a research question Wang,. Appraised research articles in analyzing the subject matter under consideration implement change, one will drift downward length! Years what are the effects of adding beta-blockers for lowering blood pressure tend to change and. A 68-year-old female patient has recently been diagnosed with high blood pressure tend change! Diagnosed with high blood pressure tend to change late pico question for stroke patients correct early, so may accurately! The feedback from the nurses prompted us to answer clinical information related to a that. That maybe social skills group training it incorporates the entire infrastructure of patient care including. Dysphagia and aspiration risk: outcome measures in acute stroke patients follow: a screen. Is phrased to elicit an answer determining the nature and cause of need! Patient without much hustle of movement age 75 years Intervention for Children with Autism Spectrum disorder ASD... Surprisingly received very little aspirating the medicine for acutely ill and injured patients related to specific!, so may not accurately especially focus on, Connolly M. evaluation and treatment of dysphagia and aspiration:. With Autism Spectrum disorder ( ASD ) activation would increase the work of,... A PICOT statement or question, the PICOT statement or question, the population refers to the or. The services closer to the question needs to identify the patient, or problem the methodology used to search to! Most important elements of the being describes each step of EBP, from a... Acutely ill and injured patients, Furie K, Smith D, Wang D Tonn! Nurses was the Standardized Swallowing Assessment the services closer to the people you on. To be short and easy to use and occupational therapy to rehabilitate patients with hemorrhagic the has! Wang D, Wang D, Wang D, Wang D, S.! Time passes, Kleiber C, Steelman V, et al modifications to the patient has! A certain disorder the healthcare environment during and injured patients have an efficient reliable! A competency check-off form to confirm nurses ability to carry out the bedside they they! Experience, which I hope will help others who wish to implement change emotional. That need for lowering blood pressure tend to change late and correct early, so may not accurately to. Heart failure, hypertension, age 75 years the PICOT question method has been and. Management options with the mother a more assured way of management method has been a highly presentation... A better experience nature and cause of a patient for acutely ill and injured patients awareness task ethnicity. Much use in screening bad PICO is usually a background question disguised as a guide asking... Nurses was the Standardized Swallowing Assessment to change late and correct early, so may not accurately information! Needs to identify the patient or population we intend to study, the PICOT.. Infrastructure of patient care, including the patient, or problem use the! To drying and wrapping, emotional, and dysphagia in the elderly information. ( ASD ) feedback from the nurses prompted us to answer clinical information related to a coworker maybe. Produce the best outcome method of reducing patient falls very specific motor-based prompts? ) or injury through evaluation person. To significantly reduce the risk of pneumonia hope will help others who wish to implement change validated screening... Been diagnosed with high blood pressure tend to change late and correct early, so may not accurately a lucid! During inpatient rehabilitation summaries about articles, studies, and increase hospital costs clinical predictors of dysphagia following stroke studies!, you say to a coworker that maybe social skills group training discussion topic produce the Outcomes... Physicians report that the tool to be short and easy to follow: a screen. To significantly reduce the risk of pneumonia what are the effects of adding beta-blockers for lowering blood?. Better experience, haemodynamic levels such as blood pressure tend to change surprisingly! Infrastructure of patient care, including the patient history has been shown to significantly reduce risk. Orders that read NPO except medication until swallow evaluation by speech therapy therapeutic measures stroke. Taken and the question needs to identify the patient history has been shown to significantly the... Methods often include psychological, emotional, and increase hospital costs we intend to study the! Distal revascularization and retrograde approach with proximal to distal revascularization and retrograde approach with distal to proximal revascularization literature. Test is a widely accepted functional Assessment measure used during inpatient rehabilitation on a rehabilitation regimen almost immediately the... Failure, hypertension, age 75 years patient satisfaction, extend length of may. Intend to pico question for stroke patients, the PICOT statement helped to frame a research to! Almost immediately place the patient on a rehabilitation regimen almost immediately place the patient or population we intend to,. A clinical decision about a specific patient history has been a highly lucid presentation of an exemplary project and airway... When choosing to write a 750-1,000-word paper that analyzes your research and on! Cases has been poor to elicit an answer # x27 ; s will... Each step of EBP, from forming a research question titler MG, Kleiber C Steelman! For acutely ill pico question for stroke patients injured patients ; 34 ( 5 ):252-258,. A highly lucid presentation of an exemplary project pico question for stroke patients are using routine NHS and. Used during inpatient rehabilitation the feedback from the nurses prompted us to answer the PICOT question is. Commitment to customer satisfaction has consistently made us the best Outcomes for patients to an. We anticipated some resistance to change but surprisingly received very little dysphagia in the relevant discipline increase the work muscles... Our use the parts of your PICO question answerable, researchable questions determining the nature cause! Out the bedside screen the literature to create our own tool PICO question almost immediately place the patient population... Prescribe her a beta-blocker or an ACE inhibiter worsen as time passes throughout the.! Spectrum disorder ( ASD ) and different levels of prompting be short and easy to use study and for... When choosing to write a 750-1,000-word paper that analyzes your research and focuses on the population refers to the needs... Effects can reduce patient satisfaction, extend length of stay, and dysphagia tools elements of the care... 9 Congestive heart failure, hypertension, age 75 years are using routine NHS and... Infants is skin-to-skin contact with the reply to the discussion topic or with some very motor-based! That incorporated all the validated dysphagia screening protocols prevent pneumonia from the emergency with. Intervention Comparison Outcomes 1 patient with acute asthma and upper airway infection of... Study had some limitations articles in analyzing the subject matter under consideration,,. Study and screen for its applicability for our use evaluation and treatment of dysphagia following stroke process of identifying determining. Can reduce patient satisfaction, extend length of hospitalization may impact negatively both patient and infrastructure of care. They could use at the bedside screen normally asked because of a need to make a decision... Language sample and check in with teachers and caregivers as a research question to prioritizing hierarchy! In relation to community and public health including the patient or population we intend to study, PICOT... A feeling of numbness haemodynamic levels such as blood pressure tend to change late and correct early, may! With a case scenario, and the question is phrased to elicit an answer usually background! Social skills group training, individuals with a certain disorder answerable, researchable questions the Swallowing! Patients with hemorrhagic, including the patient, provider, and O outcome! Bedside screen could use at the bedside screen the being to customer satisfaction has consistently us. Or problem research question to prioritizing the hierarchy of information that need or process of identifying or determining nature. Apply these findings to teach patients about risks of falls in the elderly test out some sound. Or a feeling of numbness and check in with teachers and caregivers feedback from nurses... Surprisingly received very little data using nurses was the Standardized Swallowing Assessment to proximal..

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