- Journal List
- Ultrasound
- v.31(2); 2023 May
- PMC10152317
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Ultrasound. 2023 May; 31(2): 92–103.
Published online 2022 Oct 12. doi:10.1177/1742271X221122562
PMCID: PMC10152317
PMID: 37144231
Jodi Elizabeth Allen,1 Joanne Cleland,2 and Mike Smith3
Author information Article notes Copyright and License information PMC Disclaimer
Abstract
Background:
There is growing evidence to support the use of ultrasound as a tool for theassessment and treatment of speech, voice and swallowing disorders acrossthe Speech and Language Therapy profession. Research has shown thatdevelopment of training competencies, engagement with employers and theprofessional body are vital to progressing ultrasound into practice.
Methods:
We present a framework to support translation of ultrasound into Speech andLanguage Therapy. The framework comprises three elements: (1) scope ofpractice, (2) education and competency and (3) governance. These elementsalign to provide a foundation for sustainable and high-quality ultrasoundapplication across the profession.
Results:
Scope of practice includes the tissues to be imaged, the clinical andsonographic differentials and subsequent clinical decision-making. Definingthis provides transformational clarity to Speech and Language Therapists,other imaging professionals and those designing care pathways. Education andcompetency are explicitly aligned with the scope of practice and includerequisite training content and mechanisms for supervision/support from anappropriately trained individual in this area. Governance elements includelegal, professional and insurance considerations. Quality assurancerecommendations include data protection, storage of images, testing ofultrasound devices as well as continuous professional development and accessto a second opinion.
Conclusion:
The framework provides an adaptable model for supporting expansion ofultrasound across a range of Speech and Language Therapy specialities. Bytaking an integrated approach, this multifaceted solution provides thefoundation for those with speech, voice and swallowing disorders to benefitfrom advances in imaging-informed healthcare.
Keywords: Speech and language therapy, sonography, speech, voice, swallowing
Introduction
The use of ultrasound (US) imaging outside of traditional radiology settings is anarea of rapid growth. In the Speech and Language Therapy (SLT) profession, there isgrowing evidence to support its application as a tool for the assessment andtreatment of speech and swallowing disorders.1–4
There are fundamental constraints to integration of US into SLT clinical practicesuch as cost, availability of equipment and lack of focused training.2,5 There is, however, a driveamong the profession to start adopting US into practice while research to establishreliability of data acquisition and interpretation continues. To do this, mechanismsto address concerns around competency and scope of practice are required.
US imaging is a modality that requires experience to use and interpret. The skill andexperience required by Speech and Language Therapists (SLTs) will vary according tothe purpose for which US is being used. The paper uses a framework to describe thescope of practice, education and governance requirements associated with applicationof US in the profession. This has been used in other allied health professional(AHP) groups in the emerging areas of lung6 and pelvic health7 to address concerns such as quality assurance and professional indemnity.This paper therefore shares some generic content with these publications,6,7 which in turn overlaps withrelevant professional guidance.8,9
Speech & language therapists
In the United Kingdom, SLTs are autonomous clinicians who hold a formal qualificationas a speech and language therapist. Typically, this will be a minimum of a BSc(Hons) Clinical Communication Studies/Speech Pathology and Therapy or post-graduateequivalent (e.g. MMedSci Clinical Communication Studies). Combined with theirprofessional registration with the Health and Care Professions Council (HCPC), theycan use the protected title of ‘Speech and Language Therapist’ and are eligible tojoin the professional body ‘The Royal College of Speech and Language Therapists(RCSLT)’.
SLTs work across a range of patient and client groups across the lifespan(the term patient will henceforth refer to both patients andclients). Their key responsibilities include the assessment, managementand monitoring of swallowing and communication, including speech disorders.Assessment includes clinical history-taking alongside a combination of assessmentprocedures. For swallowing, assessments may include a clinical bedside assessment orinstrumental assessment via videofluoroscopic swallowing study (VFSS) or flexibleendoscopic evaluation of swallowing (FEES), whereas assessment of both speech andvoice quality may include perceptual, acoustic, and instrumental analysis, forexample, electropalatography10 and vocal acoustic analysis.11 Applying a combination of clinical reasoning and patient-centred care, SLTsindependently formulate and apply treatment approaches such as exercises to targetthe underlying speech, voice, or swallowing disorder and/or strategies to reduce thefunctional impact of the impairment.
SLTs work closely with other professionals such as radiologists, audiologists, ear,nose and throat specialists, intensivists, neurologists, respiratory physicians andphysiotherapists to enable interdisciplinary assessment and management of speech,voice and swallowing disorders. In this regard, there may be a degree of overlapwith, and aspects of this framework may apply to, other professional groups.
Applications of US across SLT
There are several possible applications of US across the SLT profession. Someapplications, such as use of US for biofeedback in speech disorder intervention, arean already established part of clinical practice in some areas of the United Kingdom.12 Other applications, such as its use as a tool to assess dysphagia, remainsolely in the research setting. Current and potential application of US across theprofession, plus research evidence, have previously been described13,14 and aresummarised according to SLT role across the full range of patient clinicalpresentations in Table1.
Table 1.
Aims and role of speech and language therapy for speech, voice and swallowingpresentations, including ultrasound role.
| Clinical presentation | Aims and role of speech and language therapy, grouped accordingto (1) assessment and diagnosis, (2) treatment and outcomemeasurement (3) integration with wider MDT (current/potentialrole for ultrasound imaging in bold) |
| Oro-pharyngeal dysphagia | (1) Screening for presence versus absence oforo-pharyngeal dysphagia Differentiate actual or likelyaetiology of oro-pharyngeal dysphagia (more specifically,skill versus strength-basedimpairment via assessment of swallowing muscle size,structure, and kinematics) as a foundation forsubsequent management Assessment of swallowingsymptoms (aspiration andresidue) (2) Informed by the above, treatmentapproaches include education, skill-training(using biofeedback) and strengthtraining Measuring outcomes of skill orstrength-based treatment which includes measurement ofswallowing symptoms (aspiration and residue), changes inswallowing kinematics and changes inmuscle size andstructure (3) Communication offindings and management approach to patient and othercare pathway members. Where appropriate, liaison with otherhealthcare team members for further investigation andintervention |
| Dysphonia (and other diagnosisa caused by an impairment of vocal fold movement) | (1) Differentiate actual or likely aetiologyb of dysphonia (more specifically, structural, orkinematic impairment of vocal fold mobility) asa foundation for subsequent management (2) Informed bythe above, treatment approaches include education,environmental and behavioural adaptation (such as posturaladjustment), surgical intervention (such as vocal foldaugmentation) and exercise-based therapy (includingbiofeedback) Measuring outcomesof treatment interventions which includes measurement of vocalfold movement. (3) Communication of findingsand management approach to patient and other care pathwaymembers. Where appropriate, liaison with other healthcare teammembers for further investigation and intervention |
| Developmental speech sound disorders | (1) Differentiate actual or likely aetiology of speech sounddisorder (more specifically, phonological, or articulatory/motorimpairment of tongue shape, placement, andkinematics) as a foundation for subsequentmanagement (2) Informed by the above, treatmentapproaches includebiofeedback Measuringoutcomes of treatment interventions which includemeasurement of tongue shape andkinematics. (3) Communication offindings and management approach to patient and othercare pathway members. Where appropriate, liaison with otherhealthcare team members for further investigation andintervention |
| Cleft lip and palate | (1) Differentiate actual or likely aetiology of compensatoryarticulations (more specifically, impairment of tongueshape, placement, and kinematics) as a foundation forsubsequent management (2) Informed by the above,treatment approaches includebiofeedback. Measuringoutcomes of treatment interventions which includemeasurement of tongue shape, placement andkinematics (3) Communication offindings and management approach to patient and othercare pathway members. Where appropriate, liaison with otherhealthcare team members for further investigation andintervention |
| Acquired speech disorders associated with neurologicalinsult/injury (i.e. apraxia of speech, dysarthria) orsurgery/radiation to the structures associated with speecharticulation (such as glossectomy) | (4) Differentiate actual or likely aetiology of speech disorder(more specifically, dysarthria or apraxia or impairment oftongue shape, placement and kinematics) as afoundation for subsequent management (5) Informed by theabove, treatment approaches includebiofeedback Measuringoutcomes of treatment interventions which includesmeasurement of tongue shape andkinematics (6) Communication offindings and management approach to patient and othercare pathway members. Where appropriate, liaison with otherhealthcare team members for further investigation andintervention |
| Injection of botulinum toxin (botox) into the salivaryglands | (1) Anatomical location of the (parotid, submandibular& sub-lingual) salivaryglands Confirmation of injectionlocation for botulinum toxin into the salivaryglands |
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aFor example, stridor, laryngospasm, inducible laryngeal obstruction(ILO).
bIn conjunction with ENT (and/or consultant respiratory physician fordiagnosis of ILO).
In order to define SLT scope of practice, education and governance, the applicationsdescribed in Table 1have been categorised into three domains. These are
Static imaging of speech, voice, and swallowing structures
Qualitative evaluation of speech, voice and swallowing movement
Quantitative analysis of speech, voice and swallowing movement
The three domains are described in Table 2.
Table 2.
Applications of ultrasound across speech and language therapy divided intothree domains: (1) static imaging of speech, voice and swallowingstructures; (2) qualitative evaluation of speech, voice and swallowingmovement; (3) quantitative analysis of speech, voice, and swallowingmovement.
| Domain | Purpose | Example | Useful references | Patient group | Alternative approach(es)a |
|---|---|---|---|---|---|
| Static imaging of structures involved in speech,voice & swallowing | Professional training | Pre-registration SLTs to support knowledge acquisition ofspeech, voice and swallowing anatomy | (1,2) | Not applicable | X-ray, computed tomography (CT), magnetic resonance imaging(MRI) Medical illustrations Cadaver |
| Post-registration SLTs to support knowledge acquisition of headand neck imaging modalities and/or as a pre-cursor for use as aspeech and swallowing assessment tool | As above | Not applicable | X-ray, computerised tomography (CT), magnetic resonance imaging(MRI) Medical illustrations Cadaver | ||
| Patient education | To educate patients in the anatomy associated with normalspeech, voice, and swallowing | As above | Any patients able to participate in US assessment & besupported to understand the findings | Medical illustrations 3D models Videoclips/education Apps | |
| To educate patients in the altered anatomy affecting speech,voice and swallowing associated with their condition | As above | May include (but not limited to) patients with head and neckcancer pre- and post-surgical resection or patients with cleftlip and palate | Medical illustrations 3D models Videoclips/education Apps | ||
| Clinical assessmentb (+/– outcome measurement) | Detection of bolus* material in the pharynx or larynx toidentify the symptoms (aspiration or residues) of swallowingdisorder | (3–5) | Patients with dysphagia thought to cause residue oraspiration | Flexible endoscopic evaluation of swallowing(FEES) Videofluoroscopic evaluation of swallowing(VFSS) | |
| Assessment of the upper and large airway for a range of possiblefunctions, for example, identifying subglottic stenosis,tracheomalacia or predicting endotracheal or tracheostomysize | (6,7) | Patients requiring elective or urgent airway assessment | Endoscopic evaluation of the larynx(EEL) Bronchoscopy MRI CT Microlaryngoscopy | ||
| Measurement of the size and echogenicity of the muscles involvedin swallowing to determine atrophy and fat infiltration | (8–10) | Patients with a disease known (or suspected) to cause musclewasting/atrophy (e.g. motor neuron disease) Patients whohave undergone treatments known to cause structural changes inmuscle fibres (e.g. radiotherapy) Patients who have notused their speech/swallowing muscles for a period time and haveanticipated muscle changes associated with disuse | Magnetic resonance imaging (MR) | ||
| Clinical treatment | Detection of salivary glands for the purpose of botulin toxininjection | (11) | Patients with sialorrhea | Anatomical palpation | |
| Qualitative evaluation of movement involved inspeech, voice and swallowing | Clinical treatment | Treatment of speech sound disorders, including cleft lip andpalate | (12–15) | Patients with hearing impairment, Down’s syndrome, cleft lip andpalate, childhood apraxia of speech, childhood dysarthria, andpersistent or residual speech sound disorder of unknownorigin | Perception-basedinterventions Electropalatography Acousticbiofeedback Electromagnetic articulography |
| Treatment of swallowing disorders | (16) | Patients undergoing dysphagia therapy which target movementsvisible on US | Surface electromyography (sEMG) Anatomical palpation | ||
| Clinical Assessment (+/– outcome measurement) | Assessment of vocal fold adduction and abduction to assess, forexample, presence/absence of vocal fold palsy, paradoxical vocalfold movements/inducible laryngeal obstruction, airwayprotection for swallowing | (17–19) | Patients with suspected impairment of vocal fold mobility | Perceptual assessment Fibreoptic nasendoscopicexamination (FNE) Videolaryngoscopy CT | |
| Assessment of tongue kinematics | (20,21) | Patients with diagnosis known to cause disorders of tonguemovement related to speech or swallowing, for example, thosewith hearing impairment, craniofacial abnormalities, tumour,apraxia | Electropalatography Electromagnetic articulography | ||
| Quantitative analysis of movement involved inspeech, voice and swallowing | Clinical Assessment (+/– outcome measurement) | A screening tool to determine the presence or absence ofswallowing disorder | (22,23) | Various including timed water swallow test and patient-reportedtools | |
| An assessment tool to determine the severity of specificparameters of movement associated with speech, voice orswallowing disorder | (24) | Patients with a diagnosis known to cause disorders of speech,voice or swallowing. | VFSS FEES FNE Electropalatography Acousticor aerodynamic analysis |
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aUnder IR(MR)R 2019, only non-medical referrers that are suitably stateregistered are permitted to request imaging tests that involveradiation.
bWhile image analysis for clinical assessment is likelyto be static for bolus residue and the upper airway, imageacquisition may be dynamic (e.g. bolus residue maybe assessed over a specified time). For this reason, clinical assessmentwithin this domain may be considered under the categories of eitherqualitative or quantitative analysis of movement, depending on the exactpurpose of the examination.
*Bolus refers to food and drink material that has been swallowed.
A framework approach to supporting use of US in SLT
The movement towards use of US as an SLT assessment or diagnostic tool necessitatesthe need for quality assurance and clarity of the SLT role. Recognising this, wepropose the use of a framework to support application of US in SLT (Figure 1), comprising theelements of (1) scope of practice, (2) education and competency and (3) governancefor each of the uses of US in the SLT profession. The framework uses each element toensure robust delivery of US across the profession. The same approach has beenutilised by other professional groups6,7 and therefore ensuresapplication of US in SLT is consistent with other AHP groups. In the same way, newareas of US activity can be established by developing or revising one or more of theelements, thereby ensuring alignment across the framework.
Figure 1.
A framework approach to supporting use of US in SLT comprising the elementsof (1) scope of practice, (2) education and competency and (3)governance.
Scope of practice: clinical and sonographic
Scope of practice refers to numerous elements, including the tissues to be imaged,the clinical and sonographic differentials, subsequent clinical decision-making andreporting.
As the uses of US in SLT are at different stages of development, scope of practicewill depend on the specific area in which the SLT wishes to practice and themultidisciplinary support available to them. The combined (1) clinical usability and(2) clinical utility of US imaging according to the literature are key determinantsof the scope of practice in this area.
Table 3 provides anindicative list of imaging that may be performed according to the domains describedin Table 2. How thedevice is used depends on the purpose for which US has been selected by SLTclinicians. Emphasis is currently upon static imaging of structures involved inspeech, voice and swallowing as part of staff and patient education as well asqualitative evaluation of structures involved in speech, voice and swallowing forthe purpose of biofeedback therapy.
Table 3.
Indicative imaging performed and how this information is used by US SLTclinicians.
| Domain | Indicative imaging performed | Role of the imaging of these structures | Role of SLT clinicians in context of patientmanagement |
|---|---|---|---|
| Static imaging of structures involved in speech,voice & swallowing | Identification of normal anatomy associated with speech and swallowing Bones/cartilagesa: • Hyoid • Thyroid • Cricoid • Epiglottis • Arytenoid(left & right) • Hard palate • Trachealrings Soft tissue structures/muscle: • Tongue(genioglossus) • Softpalate • Geniohyoid • Anterior bellydigastric • Mylohyoid • False vocal folds (left& right) • True vocal folds (left &right) • Salivary glands • Masseter • Upperoesophageal sphincter Further imaging (asappropriate to role and emerging research evidence) Bolusresidue/presence within head/neck structures toinclude • Pyriform fossae (left &right) • Valleculae (left & right) • Laryngealvestibule • Tracheal rings(subglottis) Measurements of muscle size &echogenicity toinclude: • Genioglossus • Masseter • Anteriorbelly digastric • Geniohyoid | • Awareness of spectrum of ‘normal’presentations • Landmark identification serves asmechanism to enhance accuracy of imaging; integral aspect ofprotocol-based imaging | Recognition of ‘normal’ as part of sonographic and clinicaldifferential diagnosis process Standardised approach toimaging as quality assurance mechanism |
| Qualitative evaluation of movement involved inspeech, voice and swallowing | Identification of ultrasound appearances of normal position andgross (normal) dynamics • Binary vocal fold movement(unilateral & bilateral) • Tongue movement inswallowing • Tongue movement for speechsounds • Presence/absence of hyoidmovement Further imaging (as appropriateto role and emerging research evidence) • Disorders oftiming | • Awareness of ‘normal’ movement for speech, voice andswallow • Gross differential between normal anddisordered movements which include (e.g. glossopalatal sealduring bolus hold, bilateral vs unilateral vocal fold movement,fronting/backing/distortion of speech sounds, sustained versusnon-sustained hyoid movement) • Biofeedback/therapyfunction to support therapy from disordered to normalfunction. • Dysphagia screening tool | Recognition of ‘normal’ versus abnormal speech and swallowingmovement as part of sonographic and clinical differentialdiagnosis process To serve as a therapy/biofeedback toolfor gross disorders of swallowing or speech |
| Quantitative analysis of movement involved inspeech, voice and swallowing | Identification of ultrasound appearances of normal position andrefined dynamics • Grades of vocal foldmovement • Grades of tongue movement • Grades ofhyoid movement Further imaging may evolve asresearch evidence emerges. | Allows for refined sonographic identification ofnon-normal/pathological presentations | Initially as an educational mechanism for both SLT staff, MDT& patient (as appropriate) Provides foundation forexploration of US as a potential assessment adjunct (alongsideexisting assessment approaches) This aligns withexploring potential prognostic capabilities and as an outcomemeasure for monitoring effectiveness of treatment |
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aAcknowledgement that bones/cartilages cannot directly be ‘viewed’ on US,only inferred.
US can support the likely differentials generated from the SLT clinical assessment,providing a foundation to move towards the use of US as a ‘rule in’ screening orassessment tool. For example, poor oral containment of a liquid bolus may behypothesised from the SLT clinical swallowing assessment and further supported (orconfirmed) with US when the soft tissue structures of the tongue-base and softpalate are not observed to contact during the oral phase of swallowing. Thiscontrasts with a ‘rule out’ approach (more typically employed by imagingprofessionals such as radiologists and sonographers) where a range of potentialsonographic findings (and subsequent clinical differentials) may be ruled out viathe imaging. In the example above, US would/could not be used to ‘rule out’ otherswallowing deficits, such as delayed initiation.
Describing US scope of practice for SLT clinicians also determines which imagingpractises should not be performed. Examples of imaging not listed in Table 3 and thereforeconsidered outside the SLT scope of practice might include
space occupying lesions in the head and neck;
vascular imaging of the head and neck;
musculoskeletal or maxillofacial issues related to the head and neck, such astemporomandibular junction (TMJ) disorders;
head and neck movements outside that of speech, voice and swallowing, such asblepharospasm and fasciculations.
While the above lie outside of SLT scope of practice, they may be identified aseither incidental or concurrent imaging findings. Just as an SLT has a duty of careto escalate patient elements that may be strictly out of remit such as evidence ofabuse or risk of self-harm, it is also necessary that they can act upon anyunexpected imaging concerns.15 In this regard, a clear protocol must be in place for the clinician to beable to discuss concerns and for the clinical assessment and/or imaging of thepatient to be escalated. A precedent for this has been established in other emergingSLT service models16,17 and could include lines of established communication with thosewho have more specialist US imaging expertise, access to other imaging modalitiesand/or surgical or medical opinion. The benefits of SLTs undertaking their USimaging as part of a wider clinical and/or imaging team become apparent in suchsituations.
The US report should be written and issued by the SLT undertaking the US activity andviewed as an integral part of the process or examination.15 Findings should be clearly and accurately communicated to the patient andother care pathway members either orally and/or via a written report. The format andnature of the reporting will vary according to the purpose for which US has beenused; however, a formal written report is required where US has been applied forassessment or diagnostic purposes.18,19
Education and competency
As per Figure 1, theeducation and competency elements must align with, and should be reflective of, thescope of practice. In this regard, a description of SLT-specific components isoutside the remit of this paper, but would include both formal and informaltraining, supervision and support from an appropriately trained individual in thisarea, mentoring and feedback regarding pathology, clinical reasoning and clinicalmanagement.
A core consideration for any area of US is that while the scope of the scan may belimited, the standards must be the same as for imaging professionals such asradiographers and sonographers.15 Certified training courses specifically for SLTs do not currently exist;however, best practice guidance for the acquisition and maintenance of SLTcompetence can be developed via expert consensus, utilising occupational trainingstandards19–22 and those developed for otherprofessions as appropriate.8
A ‘foundation’ US curriculum is initially proposed in Table 4. Levels 1 (foundation), 2(intermediate) and 3 (advanced) have been used to guide the level of skill requiredfor each application (or scope of US practice) described in Table 2.
Table 4.
Proposed curriculum for Speech and Language Therapists who wish to integrateultrasound into their clinical practice. Educational elements have beendivided into three components: (1) theoretical understanding, (2) technicalskill and (3) analysis and interpretation.
| Education elements | Level of ultrasound application | ||
|---|---|---|---|
| Foundation (level 1) | Intermediate (level 2) | Advanced (level 3) | |
| Theoretical understanding | |||
| 1. Understanding of how an ultrasound image isgenerated Includes: • Fundamentalphysics as applied to ultrasound • Artefacts and how tomanage / interpret them | Basic level of knowledge required; to include physics ofultrasound, echogenicity of tissues limited to those they areimaging. | Moderate-level knowledge required; allows operator to understandwhat grey-scale images of all speech/swallowing structurerepresent. | High-level knowledge required; includes extended US imaging suchas Doppler or quantitative muscle US. Provides foundation forthe operator to apply this core knowledge to assist inundertaking a differential diagnosis. |
| 2. Safety and professional considerationsIncludes: • Thermal and non-thermal effects; ALARAprinciples • Awareness of limitations of ultrasoundimaging and awareness of role of other imagingmodalities • Infection control • Use of protocols;taking and labelling of standardised views • Reportingterminology; secure storage of images | Basic level of knowledge required due to limited scanningduration, and non-diagnostic, non-invasive role. | Moderate level of knowledge required; due to increased scanningduration and biofeedback role. | High-level knowledge required due to potential scanningduration; and diagnostic (potentially invasive) role. |
| ii) Technical skill | |||
| 3. Image acquisition &optimisation Includes: • The function ofultrasound machine settings (relating back to fundamentalphysics principles) • Knowledge of different types andpurposes of ultrasound transducers • ‘Knobology’a and application of image optimisations strategies inpractical scenarios • Adaptation of imaging based onfactors such as high BMI, poor patient positioning or anatomicalvariants. | Basic level of skill required to enable ‘plug and go’application and simple adjustments to account for range ofnormal differences in size of head/neck anatomy. US isinaccessible if ‘fine tuning’ is required. | Moderate-level skill required; allows operator to ‘drive’ themachine to accurately identify and optimise the image for thetarget tissue(s). | High-level skill required; allows operator to ‘drive’ themachine to accurately identify a range of normal andpathological presentations in a range of tissuetypes. May include settings related to avoidance ofneurovascular structures and accurate needle placement such asSpectral Doppler, Power Doppler, needleguidance/enhancement. |
| Analysis & Interpretation | |||
| 4. Static imaging of speech, voice, and swallowingstructures Includes: • Ability to usestandardised protocols, recognise normal structures andvariation in anatomy. | Basic level of skill required, limited to just one structure ofinterest. | Moderate-level knowledge, skill and demonstrable competencyrequired applied to a limited range of target tissue types. | High-level knowledge, skill and demonstrable competency requireddue to wide range of target tissue. |
| 5. Qualitative evaluation of speech, voice, and swallowingmovement Includes: • Ability to usestandardised protocols, recognise normal vs abnormal variationin speech/swallowing movement. | Basic level of skill required, limited to just one set ofmovements and one function (speech vs swallowing) of a singlestructure (non-diagnostic). | Moderate level of skill required, limited to just one sets ofmovements and one function (speech vs swallowing) of more thanone structure (non-diagnostic). | High-level knowledge required extended to more than one sets ofmovements and/or function (speech vs swallowing) in more thanone structure (may be diagnostic). |
| 6. Quantitative analysis of speech, voice, and swallowingmovement Includes: Ability to usestandardised protocols, measurement of speech/swallowingmovements. | Not applicable. | Moderate level of skill required, limited to just one set ofmovements and one function (speech vs swallowing) of one or morestructures (likely to be diagnostic). | High level of skill required, extended to more than one set ofmovements and/or function (speech vs swallowing) in more thanone structures or modality (which may include quantitativemuscle ultrasound or Doppler) (likely to be diagnostic). |
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aUltrasound-specific term referring to the competency of the operator indetermining and refining ultrasound settings for image acquisition.
Parts of the curriculum (e.g. foundation level) have potential to be integrated atundergraduate/pre-registration level, whereas the intermediate and advancedcurriculum might align with the aspirational scope of practice as a diagnostic tool,prognostic indicator or outcome measure for monitoring effectiveness of treatment.Training at this level is likely to be undertaken by more experiencedclinicians.
The level of education and training an SLT requires will be dictated predominantly bythe requirements of their job role, rather than their banding or years of expertise.For example, injection of botulinum toxin into the salivary glands is likely torequire advanced training as well as governance and recognition as an extended scopeof practice, compared with the skills and competency required for providingbiofeedback for speech sound disorders. The SLT must have the pre-requisitecompetencies required for their job role prior to integration of US as an education,treatment and/or assessment tool. Training programmes should include the principlesand practicalities of ergonomic US practice as well as the safe use and potentialhazards of diagnostic ultrasound equipment.23
Advanced clinical practice agenda
As a progressive area of highly skilled practice, the use of US for assessmentand diagnostic purposes would seem to naturally align with the advanced clinicalpractice agenda.24 We advocate though that US has the potential to become a routine part ofSLT practice and that as such these clinicians do not need tobe operating at ‘advanced level’ or above. Nonetheless, the four pillars ofadvanced practice (clinical practice, leadership and management, education andresearch) overlap substantially with the expanding role, that is, the use of USby SLTs.24 As such, we encourage US adopters to explore how use of the imagingmodality can further advanced clinical practice and consultant roles.
Insurance and governance
US is a non-regulated imaging modality; thus, no legal restrictions inhibit practicein this area. The use of US is recognised by RCSLT as an ‘extended scope’ ofpractice. As such, insurance is provided to its members provided the appropriatetraining and competency elements are in place; however, insurance is not an ‘exactscience’ and each claim is usually assessed on its own merits. Activities that falloutside the remit of an SLT (e.g. use of US for muscle biopsy) require alternativecover and accountability agreed with the employer/provider.
Defining the scope of practice confers numerous governance and care pathway benefits.This includes awareness by other care pathway members of what the scan is and is notundertaken for, and support from clinical managers in care pathway design andstaffing.
The use of terminology to explicitly clarify the nature of the scan is encouraged. Anexample of the professional context to the imaging process that could becommunicated to colleagues is
Aligning with the scope of clinical and sonographic practice outlined forSLTs performing US (**this publication**), this scan is undertaken for thepurposes of assessing/treating XXX as an adjunct to XXX as part of SLTmanagement. The identification of other anatomical or pathological elementsis explicitly beyond the scope of practice of the clinician. Therefore, thescan cannot be relied upon to either confirm or exclude any such anatomicalor pathological elements.
Quality assurance considerations include data protection, storage of images/videos,testing of ultrasound devices23 as well as continuous professional development, and access to a secondopinion. As US is often undertaken in non-radiology settings, direct access topicture archiving and communication system (PACS) for secure storage and backing upof sonographic images may not be available. This may pose a risk to data security aswell as continuity of care and the ability to review image quality. Mechanisms forthe secure storage of sonographic images/videos will need to be addressed in linewith the information governance policy of the employer. Storage may include bespokemechanisms to upload to PACS, or the use of other secure image storage capacity asadvised by a data compliance officer. There are circ*mstances where recording of USdata is often not required, for example, when used for professional trainingpurposes or biofeedback therapy.
Peer review of the ultrasound images and reports should form part of the qualityassurance process, particularly in the emerging areas of assessment and diagnosticpractice. A peer-review audit tool for such purposes is offered by The BritishMedical Ultrasound Society (BMUS).25
Broader considerations
Expansion of scope of practice
Description of SLT clinical and sonographic scope of practice is not intended tostifle innovation or development of clinical practice or roles. Examples ofexpanded scope are provided in Table 2 and align with the advancedclinical practice agenda.24 Such activity may include the potential for SLTs to use US to maketracheal measurements for the purpose of tracheostomy insertion26–28 as well as confirmationof injection site of botulinum toxin in patients with sialorrhea.29 Applying the principles outlined in this paper means that where theactivity demonstrably sits within the SLT management of a patient, thenprofessional regulation and RCSLT insurance considerations would conceivablyhave already been addressed. Education and demonstrable competencyconsiderations would need to be satisfied as well as any documentation requiredby the employer clinical governance committees that demonstrates the change inclinical practice is safe and regularly evaluated.
Another permutation might be where an SLT commences a parallel or advancedclinical activity which involves US imaging in a role that sits outside of whatwould otherwise be considered part of the SLT management of patients with speechor swallowing disorder. An example might include US-guided muscle biopsy of themuscles involved in speech and/or swallowing to support neurological diagnosis.RCSLT insurance considerations may not apply in such cases; therefore, apotential alternative route would be to arrange indemnity insurance via anemployer. Again, education and demonstrable competency considerations would needto be satisfied along with agreement with clinical managers.
Research
Given the sparsity of research evidence to support the application of US in theSLT profession, it is imperative to develop the evidence base relating to if,where and how US can enhance clinical effectiveness and efficiency of SLTassessment and treatment pathways. This includes consideration of optimaleducation and service delivery models as well as whether the use of imaging mayhave a negative impact on clinical outcomes or efficiency of resource use. Theresearch priorities in this area are described in a recently published consensus paper.5
In relation to SLTs performing diagnostic US, some evidence, including adiagnostic test accuracy analysis in relation to the use of US to detect vocalfold palsy, can be drawn from other professional groups such as intensivists,anaesthetists and ear, nose and throat (ENT) medical practitioners.30,31Nonetheless, the evidence base for the use of diagnostic US by SLTs needsdevelopment. The overlap with ENT practitioners, intensivists and head and necksonographers provides potential opportunity for pooled research andinter-professional collaboration.
In addition to research which seeks to demonstrate the effectiveness of USbiofeedback and evaluate assessment protocols, ongoing work seeks to improve theUS technology. For speech assessment, systems are now available whichsynchronise the audio and US signals for play back and analysis.32 To analyse tongue shape and movement, the surface of the tongue must betracked accurately. Ongoing work seeks to refine automatic tracking for bothspeech and swallowing assessment,33–35 allowing the analyst toextract numerical values to measure movement. Another approach involves machinelearning to classify images. An example of this includes recent work todetermine the correctness of articulatory gestures in children with speechdisorders automatically,36 an approach which can also be used for outcome measurement. Further workusing machine learning to classify various speech, swallow and laryngealfunctions is likely in the future.
A direction of travel for other specialities and geographical regions
This paper specifically reflects the situation for SLTs in the United Kingdom,and in this regard, it is noted that the level of autonomy is perhaps greaterthan that of some professionals in other countries. It is hoped therefore thatthe generic mechanisms outlined in this paper will provide a potential directionof travel for such professions and regions to advance their use of US imaging ina robust and sustainable manner.
Conclusion
This paper presents a framework approach to support use of US in the SLT profession.As the uses of US in SLT are at different stages of development, scope of practicewill depend on the specific area in which the SLT wishes to practice and themultidisciplinary support available to them. The combined (1) clinical usability and(2) clinical utility of US imaging according to the literature are key determinantsof the scope of practice in this area. This encompasses a broad range of imagingelements relating to the assessment and therapeutic management of patients withspeech, voice and/or swallowing disorders.
Education and competency assessment considerations are explicitly aligned with theclinical and sonographic scope of practice and provide the foundation for robustlysatisfying a range of governance requirements. These are further addressed withelements such as data security and continuing professional development.
The framework provides an adaptable model for supporting expansion of US across arange of SLT specialities, including those outside of the current scope of SLTpractice.
Acknowledgments
With thanks to the following people who provided a pre-submission review of thismanuscript: Gemma Clunie, Helen Newman, Claire Slinger, Lisa Crampin, and LindsayCampbell; plus representatives of The Royal College of Speech and LanguageTherapists (RCSLT) Amit Kulkarni (Research & Development Manager) and TomGriffin (Enquiries Coordinator).
Footnotes
Confirm that you are aware that permission from a previous publisher forreproducing any previously published material will be required should yourarticle be accepted for publication and that you will be responsible forobtaining that permission: Not applicable.
Contributed by
Contributors: All authors made a substantial contribution to the development of thismanuscript. The framework concept was provided by MS and is based on hisprevious work with other allied health professional groups in this area. JA ledon the manuscript draft, revision and pre-submission peer review. JC providedall information relating to use of US in speech disorders as well as criticalreview of the manuscript.
The author(s) declared no potential conflicts of interest with respect to theresearch, authorship and/or publication of this article.
Ethical approval: Not applicable.
Funding: The author(s) disclosed receipt of the following financial support for theresearch, authorship and/or publication of this article: Dr Joanne Clelandreceives funding from the Chief Scientist Office of Scotland (TCS/20/02) andEconomic and Social Research Council (ES/V012401/1).
Guarantor: Mike Smith is the guarantor of this article.
Permission from patient(s) or subject(s) obtained in writing for publishingtheir case report: Not applicable.
Permission obtained in writing from patient or any person whose photo isincluded for publishing their photographs and images: Not applicable.
ORCID iD: Jodi Elizabeth Allen 
https://orcid.org/0000-0001-7918-5463
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