Category: research review

On Free Water

In my previous post, I discussed the impact of thickened fluid prescriptions on quality of life and hydration. The hospital where I’m currently completing an entry-level placement has implemented a quasi-Free Water Protocol along the lines of the famous Frazier Water Protocol. The protocol was developed as the result of a series of underlying assumptions:

  • Water is safe
  • Water is good for you
  • Patients want water – they like it more and it’s easier for them to get.

Indeed, as is now well know, dysphagia is not a primary cause of aspiration pneumonia [1]. People aspirate all the time, and restricting their fluid intake will not stop them aspirating their secretions or reflux; which can transport oral colonies of bacteria to the lungs anyway.

The protocol is fairly straightforward:

  • Patients who are not impulsive, or do not cough excessively on water are permitted free access to water between meals (they recommend a 30min gap post-meal, but this is arbitrary).
  • Compensations (e.g. single-sips, with a teaspoon, postural compensations, etc.) are advised on a case-by-case basis.
  • Oral health is closely monitored, and oral hygiene is provided for patients unable to attend to it themselves.

free-clip-art-waterThe Evidence

  • An early study [2] found that access to free water did not significantly increase oral intake of fluids, but the group with access to free water reported much greater satisfaction with this option. None of the clients (10 controls, 10 in trial – all in the acute stage of stroke, with strict inclusion criteria) experienced dehydration or pneumonia. The authors did not look at any of the factors identified as risks for pneumonia in Langmore’s study [1].
  • An Australian study carried out at a tertiary hospital in regional Victoria [3] found that about 15% of the acute patients on a free-water protocol developed lung related complications (six patients: two with Alzheimer’s, two with Parkinsons, one with an Intellectual Disabiltiy, and one with Cancer; all were immobile or had poor mobility). The intervention group did drink >300mL more fluids on average than those on thickened fluids only; and was much happier about the fluids provided, their level of thirst and mouth cleanliness.
  • A much smaller follow-up to this study [4] found that restricting the protocol to those without poor/no mobility or severe degenerative neurological dysfunction, resulted in none of the intervention group developing pneumonia.
    • Neither of the papers noted if the patients with poor mobility/cognition were supervised when they access to free water – this is explicitly mentioned in the protocol for those with impulsivity.

Oral care is extremely important for reducing the risk of pneumonia:

  • An exciting study from Japan conducted in 1996 on 417 nursing home residents found that an aggressive oral care plan (nurses cleaned teeth after each meal and swabbed with povidone iodine when necessary. Dental hygienists provided weekly care) resulted in half as many patients dying from pneumonia as controls who were given business-as-usual care [5].
  • Nasogastric (NG) and percutaneous enterogastric (PEG) tube-fed patients are far more likely to develop potentially dangerous bacterial colonisations. A study of 215 patients from Israel, found that 81% of NGT-fed patients, and 51% of PED-fed patients had dangerous bacterial colonies in their oral cavity and pharynx; whereas only 17.5% of oral-fed patients did [6].

Implications for Practice

  • Given that the consequences of dehydration are severe, that only drinking thickened fluids decreases fluid intake, and that aspiration alone is generally insufficient to cause pneumonia, Free Water seems like a good idea.
  • Vigorous monitoring of oral health is vital for the success of a protocol.
  • Consideration must be given to cognition and mobility.


  1. Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., & Loesche, W. J. (1998). Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia, 13(2), 69-81
  2. Garon, B. R., Engle, M., & Ormiston, C. (1997). A Randomized Control Study to Determine the Effects of Unlimited Oral Intake of Water in Patients with Identified Aspiration. Neurorehabilitation and Neural Repair, 11(3), 139-148
  3. Karagiannis, M. J., Chivers, L., & Karagiannis, T. C. (2011). Effects of oral intake of water in patients with oropharyngeal dysphagia. BMC Geriatr, 11, 9. doi: 10.1186/1471-2318-11-9
  4. Karagiannis, M., & Karagiannis, T. C. (2014). Oropharyngeal dysphagia, free water protocol and quality of life: an update from a prospective clinical trial. Hell J Nucl Med, 17 Suppl 1, 26-29.
  5. Yoneyama, T., Yoshida, M., Ohrui, T., Mukaiyama, H., Okamoto, H., Hoshiba, K., . . . Oral Care Working, G. (2002). Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc, 50(3), 430-433.
  6. Leibovitz, A., Plotnikov, G., Habot, B., Rosenberg, M., & Segal, R. (2003). Pathogenic colonization of oral flora in frail elderly patients fed by nasogastric tube or percutaneous enterogastric tube. J Gerontol A Biol Sci Med Sci, 58(1), 52-55.

Like drinking paste

I saw a patient last Monday for a review in the hospital. Reading through the progress notes I felt an gradually increasing feeling of dread. Every professional from the night nurse to the geriatrician had noted “hates thickened H2O!” What if I reviewed her and she wasn’t safe for thickened fluids?

A very recent review has confirmed the common knowledge that thickened fluids are effective at reducing aspiration in dysphagic clients. To the final-year Speech Pathology student, the acute clinician seems to be in charge of two levers: which texture and which thickness. Superior clinicians look beyond this two-dimensional measure to attempt to tailor a diet to patient’s needs, expertly balancing nutritional and hydration needs with swallowing safety.thickened fluids

Texture-modified foods and thickened fluids have had standard definitions in Australia since 2007. However, these standards “were not intended to address the nutritional adequacy nor patient acceptability” of them [1]. During their development, some clinicians pushed for more gradations, but it was noted that Clinicians could always “use their clinical judgement to prescribe any additional textures on a case-by-case basis.” [emphasis mine] It’s always more complicated than simply matching a patient to a texture/thickness.

SP’s don’t really have responsibility for ensuring adequate nutrition and hydration – this job belongs to dieticians (in the Multidisciplinary model anyway). This may mean SPs are sometimes less aware of the outcomes of their decisions.

Why don’t people like pasty fluids?

  • Acute patients (not on a stroke ward) appear to prefer pre-thickened fluids rather than power-thickened fluids (I agree with them! Powder thickener is foul) [2]
  • A small study suggested than extended care patients on pre-thickened fluids had better nutritional outcomes than those on power-thickened fluids [3]
  • A review by Cichero suggests that this ‘preference’ boils down to two factors: “physiological expectations that thick fluids will make them feel full”, i.e. 300mL of thickened water feels like more than 300mL of thin water; and the fact that thickening suppresses flavour, which reduced the desire to drink more [4].

Clinical Practice

A review of Australian practice (surveying SPs, nurses and dieticians) from 2014 found that while 98% of those surveyed supplied thickened fluids to their patients (82% using pre-thickened fluids) [5]. Only 17% routinely monitor fluid-intake for their patients on thickened fluids (8% never did this!). 9% believed their patients drank enough, and 51% thought their patients on thickened fluids did not drink enough!

Interestingly, one-third of the SPs did not know how hydration was measured. The authors note that “some
may argue it is not the role of a speech pathologist to know about optimum fluid intake and how hydration is monitored, the counter argument is that the speech pathologist, who prescribes the thickened fluid, should be aware of the impact this will have on an individual’s fluid intake and potential health complications.”

Unsurprisingly the most common strategies for addressing poor-fluid-intake was ‘pushing’ (87%) the patient to drink more, supplementary methods such as IV (66%), education (64%) and dietetics/medical referral. Encouragingly, SPs would offer different flavours, or offer foods with higher fluid contents. 14% implemented free-water protocols (I’ll talk about these in a later post).

Apparently a good technique is to set “small but regular targets for fluid intake throughout the day with increased monitoring.”


When I saw the patient, it became thankfully clear that she simply didn’t like thickened water, not thickened fluids in general. She tried a thickened juice and deemed it acceptable – hopefully her intake will increase from here!


  1. Dietitians Association of, A., & The Speech Pathology Association of Australia, L. (2007). Texture-modified foods and thickened fluids as used for individuals with dysphagia: Australian standardised labels and definitions. Nutrition & Dietetics, 64, S53-S76. doi: 10.1111/j.1747-0080.2007.00153.x
  2. Whelan, K. (2001). Inadequate fluid intakes in dysphagic acute stroke. Clinical Nutrition, 20(5), 423-428. doi: 10.1054/clnu.2001.0467
  3. McCormick, S. E., Stafford, K. M., Saqib, G., Chroinin, D. N., & Power, D. (2008). The efficacy of pre-thickened fluids on total fluid and nutrient consumption among extended care residents requiring thickened fluids due to risk of aspiration. Age and Ageing, 37(6), 714-715. doi: 10.1093/ageing/afn204
  4. Cichero, J. A. (2013). Thickening agents used for dysphagia management: effect on bioavailability of water, medication and feelings of satiety. Nutrition Journal, 12, 54. doi: 10.1186/1475-2891-12-54
  5. Murray, J., Doeltgen, S., Miller, M., & Scholten, I. (2014). A survey of thickened fluid prescribing and monitoring practices of Australian health professionals. Journal of Evaluation in Clinical Practice, 20(5), 596-600. doi: 10.1111/jep.12154

Maintaining fluency – The Risk of Relapse

After a busy week, with three days at the hospital and two at the fluency clinic, I must admit I’ve missed out on a few posts. However, after a conversation with a Clinical Educator, I felt like investigating the ‘dark side’ of stuttering treatments: Relapse.

I was told that relapse rates were enormously high (>50%), and that the risk factors were contested. Here’s a smattering of the literature

  • Andrews and Craig [1] identified three factors:
    • “Skill mastery as evidenced by no stuttering”
    • “normal attitudes to communication”
    • “internalisation of the locus of control”
    • They found pre-treatment severity to be only a small predictor.
  • A 1996 study [2] claimed “that 12 subjects who remained with the entire 2-3-year program achieved zero or near-zero stuttering”
    • Since I’ve only got the abstract, it’s impossible to say how many subjects were in the trial at its beginning, and therefore how many may have dropped out because it didn’t work.
  • Dayalu and Kalinowski [3] supposed that therapy only provides ‘pseudofluency’, masking rather than removing the stuttering; and suggested that this explains high rates of relapse.
  • A detailed study [4] into the experiences of people after they received prolonged speech treatment found:
    • Risk of stuttering continues, even after therapy.
    • “the maximum benefits of prolonged speech are attained when clients use a strategic approach to control stuttered speech and daily communication.”
  • A few years later, researchers from La Trobe and Sydney Uni found [5] that only stuttering severity predicted short or long-term outcomes for people who stuttered who sought therapy.

Colin-Firth-in-The-Kings--007My experience

I saw a client at a review day on Friday that had been through an intensive Smooth Speech program, and attended many review days. Upon arrival I noted they were quite severe, with many blocks exceeding 5 seconds in duration. However, within an hour of therapy they ‘miraculously’ became fluent — well not miraculously, as I was creating a fluency-inducing environment. Why couldn’t they do this at the beginning of the session.

I thought they needed to be able to self-cue at home and work to create their own fluency-inducements. I asked them to practice in the mirror, before high-stakes interactions and just for the hell of it, to maintain the pattern. I also told them to record themselves during our session being fluent, and to play it back when they were having trouble with fluency: a reminder that they could be fluent. This approach (I later discovered) has preliminary evidence, and is very time/cost effective for both clinician and client [6]. As I explained to them, they needed to develop strategies to maintain their fluency actively, and couldn’t rely on the odd review day to do it for them.

The previous night, another client said they couldn’t wait until the smooth speech became second-nature, and they could talk freely without monitoring what they were doing. Unfortunately, this will probably never happen. They will always need to monitor their speech and actively use the pattern, and this will probably require greater effort than someone who does not stutter. I felt awful delivering this news (in the form of a pep-talk) — if only there were a pill!

This raised interesting questions about whether cognitive constructs like executive-function and attention could be considered prognostic indicators for this type of therapy – a topic for another day.


  1. Andrews, G., & Craig, A. (1988). Prediction of outcome after treatment for stuttering. British Journal of Psychiatry, 153(2), 236-240.
  2. Onslow, M., Costa, L., Andrews, C., Harrison, E., & Packman, A. (1996). Speech outcomes of a prolonged-speech treatment for stuttering. Journal of Speech, Language, and Hearing Research, 39(4), 734-749.
  3. Dayalu, V. N., & Kalinowski, J. (2002). Pseudofluency in adults who stutter: The illusory outcome of therapy. Perceptual and Motor Skills, 94(1), 87-96.
  4. Cream, A., Onslow, M., Packman, A., & Llewellyn, G. (2003). Protection from harm: The experience of adults after therapy with prolonged-speech. International Journal of Language and Communication Disorders, 38(4), 379-395. doi: 10.1080/13682820310001598166
  5. Block, S., Onslow, M., Packman, A., & Dacakis, G. (2006). Connecting stuttering management and measurement: IV. Predictors of outcome for a behavioural treatment for stuttering. International Journal of Language and Communication Disorders, 41(4), 395-406. doi: 10.1080/13682820600623853
  6. Cream, A., O’Brian, S., Onslow, M., Packman, A., & Menzies, R. (2009). Self-modelling as a relapse intervention following speech-restructuring treatment for stuttering. International Journal of Language and Communication Disorders, 44(5), 587-599. doi: 10.1080/13682820802256973

Pan Frying Part Three – Four Recent Papers

The following papers have been referenced a lot in media stories about fry. However, as I show, none of them conclusively prove that fry is new, bad, good, or pathological. The gender difference in fry could be a result of sexual dimorphism (see discussion on Language Log). Given the probably vast speech corpora available, surely it wouldn’t be difficult to improve the state of the literature?

Perceptions of Fry [1]

This study, reported in a linguistics journal, compared perceptual/acoustic findings from 11 male and 12 female speakers of Californian English (students at UC Berkeley). It found American females using creaky voice twice as often as Japanese females or American males.

For the second part of the study, one voice recording from the first part was selected and presented to 175 college students at UC Berkeley and the University of Iowa, who were asked “what kind of impressions” they had of the woman who produced the voice. About four-fifths of listeners reported recognising the feature (interestingly, 90% in Iowa and 60% in California – the disparity is not discussed). The overwhelming impressions were “professional“, “upwardly mobile” and “urban“. No evidence is presented that vocal fry was the phenomenon the listeners associated with these impressions.

Conclusions: Female college students fry more than male college students. One speaker who uses vocal fry is thought of as sophisticatedly urban. It’s a stretch to say that fry is intrinsically urban or professional.

Prevalence in Young Adult Males & Females [2,3]

In this study, the authors worked from the position that fry is both a pathological sign and present in normal speakers – which renders its clinical utility as part of a perceptual profile a bit suspect, no? The goal of the study was to “quantify the prevalence of vocal fry in a population of young, female, SAE [Standard American English], college students” (p.e112 – my emphasis). The protocol involved sentence reading and vowel production.

That’s five modifiers, but we should add two more: firstly, that the students were all at Long Island University; and secondly, that they consented to appear in this study (volunteer bias). This doesn’t affect the validity of a narrow reading of the results, but often a broad reading is reported. Wolk (the lead author) was quoted as saying “Although it’s not exclusively used by young women, they seem to use verbal fry more frequently than young men or older individuals.” – which I suppose is more sexy than saying “Although it’s not exclusively used by young, female, SAE-speaking, Long Island-residing, college students who consented to be in the study…etc.”

The team found a prevalence of about two-thirds (n=34). In the Discussion they note that “knowledge of the extent of vocal fry usage in college students may have very important long-term consequences for vocal health”, citing Colton’s textbook Understanding Voice Disorders as a reference. While Colton is a fine author and clinician, no evidence is provided in this text for this assertion.

In a follow-up study, the team repeated the protocol with male, SAE-speaking, Long Island University-attending, 18-25 yr old students (n=34), but did not recruit further female students, instead choosing to use the old data. No proportion was reported (“vocal fry was rarely used”).

Conclusions: This doesn’t tell us a lot, other than confirming that female college students fry more than male college students. The judges seemed to have difficulty agreeing on fry (which is a fairly noteworthy feature as my previous post shows). Describing Kappas of 0.48 and 0.49 as “high agreement” seems stretched (The standard reference calls for at least .7 for a “reliable” instrument [4]

You won’t get a job with Fry [5]

The PLoS One article which received quite a bit of attention (see Part One of this series). It didn’t begin well, quoting many anecdotal sources as one might quote evidence in an Introduction. 14 speakers (7 male, 7 female) produced the phrase “thank you for considering me for this opportunity” in their “normal tone” and in vocal fry (“mimicking”). These recordings were then presented in random pairs to 800 internet-based listeners who answered questions like “who is more competent?”. The researchers found that the listeners, both male and female, preferred the “normal tones” to fry at a rate greater than chance. The researchers conclude that vocal-fry is perceived negatively, and may result in “negative labor market perceptions”. They also note its prevalence is increasing[citation needed].

Christian DiCanio has pointed out many flaws in this study on Language Log:

  • The fry samples were not real fry but imitation
  • The samples did not differ in just fry but also in
    • duration of the sentence
    • duration of individual words
    • pitch
    • perceived vocal effort
  • The “normal tone” examples had some fry as well!!! (you can listen to all the stimuli on the PLOS website)

To these I’ll add:

  • Nobody would base the decision to hire solely on your voice (except perhaps this person).
  • The judges did not work in recruitment.

Conclusions: This paper’s methodological flaws seem fatal to its conclusion. Perhaps we could say people imitating a vocal style they do not use do not sound trustworthy or convincing?


  1. Yuasa, I. P. (2010). Creaky Voice: A new feminine voice quality for young urban-oriented upwardly mobile American women? American Speech, 85(3), 315-337.
  2. Wolk, L., Abdelli-Beruh, N. B., & Slavin, D. (2012). Habitual use of vocal fry in young adult female speakers. Journal of Voice, 26(3), e111-e116.
  3. Abdelli-Beruh, N. B., Wolk, L. & Slavin, D. (2014) Prevalence of vocal fry in young adult male American speakers. Journal of Voice, 28(2), 185-190.
  4. Landis, J. R., Koch, G. G. (1977). The measurement of observer agreement for categorical data. Biometrics 33:159-174
  5. Anderson, R. C., Klofstad, C. A., Mayew, W. J., & Venkatachalam, M. (2014). Vocal fry may undermine the success of young women in the labor market. PLoS ONE, 9(5)