**2. The biopsychosocial effects of dysphagia**

Dysphagia is traditionally defined as a difficulty or abnormality in swallowing. In adulthood, it is predominantly an acquired condition and may result from a wide variety of etiologies. It can also result from changes associated with the effects of normal aging [1]. Over the past four decades, the bulk of research conducted in the field of dysphagia and its management has focused on understanding this condition at an impairment level. Through this historical body of work, swallowing is now understood to be a complex physiological process that involves precision timing and coordination of multiple structures within the neuromuscular system. Oropharyngeal dysphagia can be associated with a range of physiological impairments, which may lead to difficulty in oral preparation of the bolus, moving the bolus posteriorly toward the pharynx, triggering and coordinating the pharyngeal swallow, clearing the bolus into the upper esophagus, and protecting the airway from food and fluid entry [2]. Depending on the etiology of the condition causing dysphagia, individuals may also be affected by associated impairments such as xerostomia (dry mouth), taste changes, or excessive secretions that may

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further impact capacity, motivation, and desire to eat. The associated medical effects resulting from difficulty in swallowing may include dehydration, malnutrition [3], and respiratory dysfunction (including pneumonia) [4], and ultimately can lead to death in severe cases [5].

The traditional management approaches that have evolved in parallel with our understanding of the process of normal swallowing have also been predominantly based on impairment. Interventions including postural strategies, swallowing techniques, and modification of food and fluid textures are used as first-line treatment options to compensate for specific physio‐ logical impairments and to improve the efficiency and safety of oropharyngeal swallowing function. Active rehabilitation programs, which are typically implemented in parallel to compensatory measures, are developed following a combination of clinical and objective assessments (videofluoroscopy or fiber-optic endoscopic evaluation of swallowing) and involve behavioral and medical interventions designed to improve swallowing physiology for long-term gain.

While management services for adult-acquired dysphagia remain predominantly focused on remediating physiological impairments, in particular, the need to consider the wider psycho‐ social impacts of dysphagia has been highlighted in the past decade. It is now recognized that health professionals must consider dysphagia and its effects more broadly, and that dysphagia is, in fact, a multifaceted condition. In addition to its impact on the medical condition of the individual, dysphagia has also been demonstrated to effect functioning in daily life and overall quality of life [6]. Eating and drinking is a source of human pleasure. Dysphagia can make this process and the activities surrounding it laborious, uncomfortable, and difficult [7]. Irrespec‐ tive of the cause, dysphagia has been found to have a significant negative impact on the quality of life both immediately and months or years following its onset [5, 6, 8]. In the geriatric population, reduced quality of life has been associated with self-perceived swallowing difficulties, a condition that older people did not necessarily associate with normal aging [9].

Recent studies have also demonstrated the impact of dysphagia on psychosocial health. In a population-based study, dysphagia was reported by 16% of those surveyed, with intermittent dysphagia associated with anxiety and progressive dysphagia associated with depression [10]. Anxiety and depression are also significantly worse in head and neck cancer survivors with dysphagia than those without dysphagia, irrespective of treatment type [8, 11]. For people with dysphagia, difficulty in swallowing has been found to affect socialization, eating out, family rituals, cooking, and shopping [12-14]. As such, the concept of dysphagia needs to be reconsidered. Dysphagia is more than simply a physical difficulty. Rather it represents a complex and multilayered condition that may impact on a person's physical, emotional, and social life and carries significant burden surrounding functioning in everyday activities.

In order to embrace a wider view of dysphagia, a new conceptual framework is required. The International Classification of Functioning, Disability and Health (ICF) [15] (Figure 1) has been both proposed [16] and used [17-21] as a consistent and universal taxonomy to report research outcomes regarding dysphagia. The ICF is a conceptual framework that provides a biopsy‐ chosocial perspective of functioning, and uses an internationally recognized language [15]. It has the potential to describe the far-reaching complexities of dysphagia through the consid‐ eration of functioning from the perspective of the body, the individual, and society in two parts: (1) functioning and disability and (2) contextual factors [15]. Functioning and disability comprises (a) the body functions and body structures and (b) activities and participation. The contextual factors are comprised of (a) environmental factors and (b) personal factors (WHO, 2001) (Figure 1).

further impact capacity, motivation, and desire to eat. The associated medical effects resulting from difficulty in swallowing may include dehydration, malnutrition [3], and respiratory dysfunction (including pneumonia) [4], and ultimately can lead to death in severe cases [5]. The traditional management approaches that have evolved in parallel with our understanding of the process of normal swallowing have also been predominantly based on impairment. Interventions including postural strategies, swallowing techniques, and modification of food and fluid textures are used as first-line treatment options to compensate for specific physio‐ logical impairments and to improve the efficiency and safety of oropharyngeal swallowing function. Active rehabilitation programs, which are typically implemented in parallel to compensatory measures, are developed following a combination of clinical and objective assessments (videofluoroscopy or fiber-optic endoscopic evaluation of swallowing) and involve behavioral and medical interventions designed to improve swallowing physiology for

While management services for adult-acquired dysphagia remain predominantly focused on remediating physiological impairments, in particular, the need to consider the wider psycho‐ social impacts of dysphagia has been highlighted in the past decade. It is now recognized that health professionals must consider dysphagia and its effects more broadly, and that dysphagia is, in fact, a multifaceted condition. In addition to its impact on the medical condition of the individual, dysphagia has also been demonstrated to effect functioning in daily life and overall quality of life [6]. Eating and drinking is a source of human pleasure. Dysphagia can make this process and the activities surrounding it laborious, uncomfortable, and difficult [7]. Irrespec‐ tive of the cause, dysphagia has been found to have a significant negative impact on the quality of life both immediately and months or years following its onset [5, 6, 8]. In the geriatric population, reduced quality of life has been associated with self-perceived swallowing difficulties, a condition that older people did not necessarily associate with normal aging [9]. Recent studies have also demonstrated the impact of dysphagia on psychosocial health. In a population-based study, dysphagia was reported by 16% of those surveyed, with intermittent dysphagia associated with anxiety and progressive dysphagia associated with depression [10]. Anxiety and depression are also significantly worse in head and neck cancer survivors with dysphagia than those without dysphagia, irrespective of treatment type [8, 11]. For people with dysphagia, difficulty in swallowing has been found to affect socialization, eating out, family rituals, cooking, and shopping [12-14]. As such, the concept of dysphagia needs to be reconsidered. Dysphagia is more than simply a physical difficulty. Rather it represents a complex and multilayered condition that may impact on a person's physical, emotional, and social life and carries significant burden surrounding functioning in everyday activities.

In order to embrace a wider view of dysphagia, a new conceptual framework is required. The International Classification of Functioning, Disability and Health (ICF) [15] (Figure 1) has been both proposed [16] and used [17-21] as a consistent and universal taxonomy to report research outcomes regarding dysphagia. The ICF is a conceptual framework that provides a biopsy‐ chosocial perspective of functioning, and uses an internationally recognized language [15]. It has the potential to describe the far-reaching complexities of dysphagia through the consid‐ eration of functioning from the perspective of the body, the individual, and society in two

long-term gain.

160 Seminars in Dysphagia

Each of the components of the ICF consists of various domains and categories that are referred to as the units of classification. Therefore, the functioning of an individual with a health condition can be documented using the appropriate category code and then adding qualifiers, which are numeric codes that specify the magnitude of the individual's functioning or disability within that category [15]. An alphanumeric coding system is used for coding health conditions in the ICF. The letters *b, s, d,* and *e* represent body functions, body structures, activities and participation, and environmental factors respectively. A numeric code then follows these letters, which denotes the domain (or chapter number), followed by additional sublevels of coding, and then the qualifiers (WHO, 2001). For example, changes to taste would be linked to the code b250 - taste function where *b* represents the body functions domain and the numbers (i.e., 250) represent the various levels of classification.

**Figure 1.** International Classification of Functioning, Disability and Health (ICF) [15]

Recently, a study examining the consumer's perspective of living with dysphagia following management for head and neck cancer utilized the ICF to classify patients' physical, emotional, and psychosocial concerns relating to their dysphagia [20]. The results demonstrated that dysphagia impacted on body functions, activities and participation, and environmental factors almost equally, with changes to body structures rarely mentioned by people with dysphagia. Therefore when dysphagia is examined more broadly, using a framework such as the ICF, it clearly has far-reaching life effects beyond the physiological changes to the swallow and the medical implications of dysphagia.
