Learning about the Dynamic Swallowing Process Using anInteractive Multimedia Program

Ingrid Scholten, MS and Alison Russell, PhDSpeech Pathology Department, Flinders University, Adelaide, South Australia, Australia

Abstract. The management of dysphagia is the largestrecognized subspecialty in the field of speech-languagepathology. Practicing speech-language pathologists re-quire a comprehensive theoretical and functional knowl-edge base to underpin the safe and effective managementof people with dysphagia. Students need to develop anunderstanding of the normal integrated swallow and howit can be affected to appreciate the assessment or treat-ment of dysphagia. Although students are well motivatedto learn this material, assimilating knowledge of the dy-namic nature of the swallow has typically been problem-atic because of its complex character. The limitations ofcurrently available teaching resources have been ad-dressed by the production of an interactive multimediaprogram that includes integrated presentation of text,graphics, voice-overs, and video and animation se-quences to highlight various aspects of the swallowingprocess. Students can selectively manipulate parts of thisprocess to understand the normal swallow and to simu-late different aspects of dysfunction and the consequenteffects on swallow safety and efficiency. Feedback fromstudents, faculty, and experts has demonstrated thatTheDynamic Swallowwould be a valued tool in the teachingof dysphagia.

Key words: Teaching — Dysphagia — Interactivemedia — Deglutition — Deglutition disorders.

Swallowing is a smooth, uninterrupted action intimatelylinked with respiration and occurs spontaneously about

once every minute [1]. Disordered swallowing signifi-cantly affects one’s welfare, with grave consequences ofmorbidity and mortality from malnutrition, dehydration,and respiratory tract complications [1]. The incidence ofdysphagia is very high, with particularly significant lev-els in the elderly and those populations with physical andintellectual impairment. The costly disability and depen-dence that result from dysphagia are now recognized asmajor health problems [2–5]. Speech-language patholo-gists working with clients of all ages have a leading rolein the management of people with dysphagia, with morethan 50% of speech-language pathologists regularlytreating swallowing difficulties [6]. Graduates shouldpossess the necessary skills to approach this area of theirclinical case load with optimum competency and confi-dence.

Students need to develop an understanding of thenormal integrated swallow and how it can be affected toappreciate the assessment or treatment of dysphagia. Un-til very recently, this material was learned in the clinicalsetting, after graduation, but at present acquisition of thisinformation generally begins at the graduate level in uni-versity speech-pathology programs through the deliveryof formal lectures. Inclusion of topics related to swal-lowing and dysphagia into university speech-languagepathology courses is only a recent phenomenon (Dys-phagia listserver, personal communication, 7/29/97). Forexample, at Flinders University, the first topic dedicatedto dysphagia was offered in 1997. The amount of timedevoted to this topic differs enormously across institu-tions.

There have been no published studies that exam-ine students’ learning in this field of practice. However,there are implications to be drawn from related work.Most significantly, a recent study of speech-pathologystudents’ learning of anatomy of the head and neck aftertraditional classroom teaching showed particularly poorperformance, with less than 50% accuracy [7]. This re-

A demonstration animation ofThe Dynamic Swallow(which is dis-cussed later in this paper) can be viewed at http://www.flinders.edu.au/SpPathAudiolCorrespondence to:Ingrid Scholten, M.S., Speech Pathology Depart-ment, Flinders University, GPO Box 2100, Adelaide, South Australia5001, Australia

Dysphagia 15:10–16 (2000)DOI: 10.1007/s004559910004

© Springer-Verlag New York Inc. 2000

sult confirms the findings of researchers in allied fieldsof radiology and other spheres of medicine, i.e., thatlectures teach little when they are the sole learningmethod used [8]. Even if students demonstrate recall ofinformation, information is not translated into actionwhen student are faced with real situations involvingpatient care [9]. Templeton believed that students requiredirect personal experience to achieve long-term recall[10]. Likewise, Jones and Vesilind studied changes instudent teachers’ knowledge of teaching practices anddiscovered that major growth took place after the aca-demic content had been delivered, during teaching prac-tica, and that students attributed this change to their stu-dent teaching experiences [11].

Even the most able speech-pathology studentsfind anatomy and related subjects complex, in the sameway that Eizenberg described with medical students [12].Several factors contribute to this complexity, includingheavy schedules, demands on study time, and the factthat this material is presented in a language that is new tostudents. The most common approach to learning suchvast amounts of knowledge is very superficial, with in-formation poorly understood and quickly forgotten.Shifting students from a surface approach to a deep ap-proach to learning is a challenge [12]. The static natureof the teaching materials that cannot accurately representthe dynamic character of the swallow is almost certainlya contributing factor to poor learning in this area. Teach-ing material that does involve a component of motionincludes videofluoroscopic swallow studies originallyproduced for diagnostic purposes. These are rarely ofsufficiently good definition and clarity to facilitate stu-dent learning.

To overcome the limitations of currently avail-able teaching resources in this area, we developed aninteractive multimedia CD-ROM,The Dynamic Swal-low. This program arose from our concern that studentshad difficulty in developing a useful understanding of thedynamic nature of the swallowing process. Our task wasto create a teaching resource that would enhance stu-dents’ understanding of the links between the outwardsigns of swallowing dysfunction seen during clinical as-sessment and a representation of internal function.

Development ofThe Dynamic Swallow

Project Management and Design Process

The project team included the team leaders (IngridScholten and Alison Russell), faculty responsible for theteaching of dysphagia at each of the six undergraduateuniversity speech-language pathology programs in Aus-tralia, and two speech-language pathology students. The

project involved three phases: planning, instructional de-velopment and production, and evaluation.

The approach taken by the project team in theplanning phase was collaborative [13]. The group func-tioned cooperatively by pooling their expertise and cre-ative ideas. The team leaders presented an initial conceptfor the program, and the subsequent design process reliedon an iterative approach [14] in which ideas were brain-stormed and plans were continually revised. The projectteam met for 2 full days to conduct the majority of theplanning for the project. At this meeting, the group fo-cused on the current teaching of dysphagia and its per-ceived limitations, the proposed aims and learning ob-jectives for the program, the pedagogic approach thatwould underpin the project, and prioritized the aspects ofthe swallow to be included. After this initial intensivemeeting, the project team was consulted for ongoing ad-vice and feedback throughout the production and devel-opment phase ofThe Dynamic Swallowand continued tocommunicate regularly by electronic mail and telephone.

Once the planning phase of the project was com-pleted, the team leaders selected and worked closely withthe interactive media designers. A major feature ofTheDynamic Swallowwas the development of a series ofdistinctive, stylized animations of the swallowing pro-cess for both liquids and solids. This was a complex task,requiring accurate representation of anatomy, correct se-quence and timing of movements, and authentic illustra-tion of the consequences of dysfunction. It required closecollaboration with the interactive media designer to en-sure that there was an accurate visual representation ofthe physiology essential to the understanding of the swal-lowing process. Additional resources include videotapesof modified barium swallows to portray the outcome ofdysfunction in actual clients, high-quality annotated dia-grams of the oral cavity and pharynx, voice-overs, andtext. The interactive media design team provided thetechnical and production support for this phase of theproject including the development of flow charts andscreen designs, computer coding, and digitization ofvideo images.

The team leaders evaluatedThe Dynamic Swal-low by following the suggestions made by the projectteam in the planning phase.

Learning Objectives

The primary aim ofThe Dynamic Swallowis to helpstudents to develop internal visual models of the swal-lowing process. This encompasses an understanding ofboth the normal swallowing process and the disorderedswallow.

The opportunity to manipulate the animations inThe Dynamic Swallowsupports experiential learning

I. Scholten and A. Russell: Learning about the Dynamic Swallowing Process 11

through discovery and play, provides the opportunity forqualitative reasoning, and allows for problem solving incontext [15]. The program gives students a sense of therelations between certain parameters and an understand-ing of what constitutes a critical condition by allowingsimulation of effects not possible with pseudo or realpatients. It provides students with access to subtly dif-ferent images of disordered processes and thus contrib-utes to the development of more expert diagnostic skillthat should lead to more targeted and effective interven-tion. One of the features of the program is that the formof presentation (animation) matches the content of thematerial (dynamic biomechanical swallowing process),thereby enhancing learning [16]. Students are able todetermine their learning focus by selecting which fea-tures of the simulation to alter and the sequence of ac-tivities. The time required to complete the program isdependent on the students’ individual learning needs. Acomprehensive overview of the program could be gainedin an hour or less. This program provides students with asafe environment in which to test out ideas in whatwould otherwise be potentially life-threatening situationswith real clients.

Instructional Platform

An interactive multimedia design was selected as theinstructional platform for this project because of its ca-pacity to support a variety of different media includinganimations, video images, text, diagrams, and voice-overs. The multimedia platform allows resources to bearranged in many different structures and sequences thatare vastly different from those that can be provided bytext-based material [17,18]. Another important aspect ofthis format is its interactivity, which gives users manyoptions for navigating through the program. This flex-ibility promotes active rather than passive involvementof the learner and facilitates decision making, problemsolving, and reflection by allowing the students to accessthe information in the way that best suits their learningstyle [15,17–19].

The project was created by using MacromediaDirector 6.0, a cross-platform multimedia authoring en-vironment, on a Macintosh 8500/120 Power PC. TheQuicktime movies and images created for this interactivemultimedia package were also produced on the samecomputer. The movies and animations were digitizedwith the standard audiovisual capabilities of the 8500.The animation sequences were composed and com-pressed in Adobe After Effects. Still images were createdand composed in Adobe Photoshop 4.0. Illustrationswere created with Adobe Illustrator 7.0. The final pack-age is a cross-platform CD-ROM playable on Windowsor Macintosh computers. The base requirements are a

Macintosh Power PC or Windows Pentium computerwith 16 megabytes of RAM, a 14-inch color monitor setto thousands of colors, and high quality external speak-ers. A quad-speed CD-ROM is also necessary.

Description of The Dynamic Swallow

The Dynamic Swallowis a multimedia program that in-cludes diagrams, animations, and videos of the swallow-ing process that can be manipulated to experience theeffects on the swallow efficiency and safety. These ani-mated swallows help to link the outward signs of swal-lowing dysfunction seen during clinical assessment withreal-time X-ray images of the factors at play inside theswallowing mechanism.The Dynamic Swallowdeals pri-marily with the oropharyngeal stages of the swallow be-cause this is the focus of the speech-language patholo-gist’s clinical work in the area of dysphagia. There arefive main menu selections that can be accessed by stu-dents from any part of the program in the sequence thatbest meets their learning needs. The five components aredescribed below.

Introduction

A brief introduction designed to captivate the user’s in-terest and attention is provided in the form of a voice-over and video montage of people eating and drinking.

Swallow

The Swallow section is the major component ofTheDynamic Swallow(Fig. 1) and was designed to help theuser understand the integrated and dynamic nature of theswallowing process. It employs stylized animations ofboth liquid and solid consistencies as well as authenticX-ray videos to highlight aspects of the normal swallowand variations of the swallowing act. Users are able toinvestigate the consequence of failure of the specific el-ements of the swallowing process by clicking on thefeature they want to impair.

The user can pause and repeat the animations andvideos as many times as desired or play sequences inslow motion by using an animation controller. By replay-ing the sequences, the various anatomic landmarks andphysiologic processes can be examined so that the userbecomes acquainted with both normal and abnormalmovement patterns in the oral cavity and pharynx.

Oral Cavity and Pharynx

The Dynamic Swallowpermits more detailed examina-tion of various anatomic landmarks with several dia-

12 I. Scholten and A. Russell: Learning about the Dynamic Swallowing Process

grams. The two sections of the swallowing tract that areillustrated in this program are the oral cavity and pharynx(Figs. 2, 3). These sections contain simple colored dia-grams that can be either fully annotated or interactive.The fully annotated mode contains labeled, colored dia-grams. In the interactive mode, the same diagrams arepresented in black and white. The user can activate thecolor, labels, and voice-overs describing the componentand its function in swallowing by rolling the cursor overthe section of interest.

Students can choose to relate the anatomy of boththe oral cavity and pharynx sections to the stages of theswallowing process by selecting a location from themenu. If students make this selection, they see an ani-mation of the swallow with the relevant stage of theswallowing process highlighted and accompanied by avoice-over.

Glossary

The glossary includes an alphabetical listing of defini-tions of terms used within the program. Students canaccess the glossary from any part of the program, allow-ing them to move freely between sections whenever theyneed explanation of terms. In addition, there are hot linksto other parts of the glossary from within most defini-tions. The glossary can also be viewed and printed byaccessing the relevant file from the Glossary folder lo-cated on the CD-ROM.

Evaluation

The Dynamic Swallowwas evaluated within the curricu-lum of topics being taught during the first semester in1998 in Australian speech-pathology programs. Studentsprovided feedback through questionnaires and direct ob-servation (students’ interactions with the program wereexamined by using video). Feedback was also soughtfrom faculty teaching dysphagia regarding their views on

the quality and usefulness of the program. In addition,The Dynamic Swallowwas sent to international expertsfor review with regard to the content of the program, easeof use, suitability for various users, and applicability ofthe program to teaching.

Student Evaluation Questionnaires

Student input and feedback was critical to the success ofthis project, as indicated by their representation on theproject team. Informal focus testing was conducted pe-riodically during the evolution of the project, and stu-dents were consulted for their views about the text andhow well material addressed their learning needs.

Students from both Flinders University, wherethe program was developed, and the University of New-castle usedThe Dynamic Swallowwhile studying dys-phagia during their first semester in 1998. Thirty-sevenstudents provided written feedback about the programwith a posttask questionnaire. After working with theprogram, students were asked to respond to questionsabout their attitudes related to their experience by usinga 5-point Likert-type equal-appearing interval scale, with1 being “strongly disagree” and 5 being “strongly agree.”They were also given the opportunity to provide detailedfeedback about what they liked and disliked about theprogram. The responses from students of both universi-ties were similar, thus reducing the likelihood that reac-tions were biased as a result of any relationship with thedevelopers.

The majority of students (80.6%) described them-selves as inexperienced computer users. All students saidthat the learning objectives of the program had beencompletely (89.8%) or partly (10.2%) met, and they allagreed that the material fromThe Dynamic Swallowcomplemented their lecture material. As can be seenfrom the responses to the attitude scales summarized inTable 1, the majority of students were positive about theprogram and their learning withThe Dynamic Swallow,with the most common response for all questions being

Fig. 1. The Swallow section showing the liquid bolus animation.Fig. 2. The oral cavity in annotated mode.

Fig. 3. The pharynx in annotated mode.

I. Scholten and A. Russell: Learning about the Dynamic Swallowing Process 13

“strongly agree.” The wide range of responses to thequestion about the usefulness of the glossary possiblyreflected the fact that not all students felt the need toaccess it.

The students consistently reported that they likedthose features of the program that we felt were critical toits success. These features included the high level ofinteractivity, user-friendly format, ease of navigation,ability to slow down and replay the animations and vid-eos, variety of media, clear commentary and detailedexplanations, stylized animations, diagrams, interestingX-rays, and the glossary.

Very few students identified any negative aspectsof the program, and most of these reflected lack of ex-perience using multimedia. For example, one studentsuggested that the sections could have been organizeddifferently, when in fact the order of access is not pre-scribed. The suggestions to label the modified bariumswallows, download diagrams, and include a test hadbeen considered in the planning phase but were not apriority when allocating limited financial resources.

Direct Observation

Two pairs of students from Flinders University volun-teered to be videotaped while usingThe Dynamic Swal-low for the first time to allow the team leaders to evaluatehow students approached the task of learning when usinginteractive multimedia. This proved to be a very infor-mative process. We perceived value in students using theCD-ROM in pairs, not only because it provided usefuldialogue for evaluation purposes but also because it wasapparent that students were able to complement and ex-tend each other’s knowledge, resulting in deeper learn-ing.

We observed a range of both learning styles andlearning quality [20], with each of the pairs approachingthe task differently. One approach was to scan the ma-

terial in a superficial way, in contrast to working throughone section in detail to its natural end point. Overall,however, students approached the task in a very linearfashion, starting with the first option on the menu bar andproceeding sequentially from left to right and from top tobottom and rarely deviating from this approach even forthe simple purpose of clarifying a definition from theglossary. The students’ limited exploration of the poten-tial of the program restricted the depth of informationthat they accessed. This was the first time the studentshad used the program, and their subsequent feedbackindicated that they were much more interactive in ac-cessing the information on subsequent encounters. Theirlimited flexibility in accessing information with thistechnology should not have been surprising given thatthe majority of students described themselves as novicecomputer users. What was surprising were the commonmisconceptions students held about swallowing, consid-ering the information had been covered in a recent lec-ture. Similarly, students showed scant recall of previ-ously learned and assessed material in the area ofanatomy, thereby challenging our preconceptions aboutthe students’ prior knowledge base.

Feedback from Faculty

Only one of the participating universities did not respondto the questionnaire seeking feedback aboutThe Dy-namic Swallowand how it would be used to supportteaching. Two of the five respondents had participated inthe development of the program. Faculty were asked torespond to questions aboutThe Dynamic Swallowbyusing a 5-point Likert-type equal-appearing intervalscale, with 1 being “strongly disagree” and 5 being“strongly agree.” They were also invited to include anyother comments.

Overall, faculty responded favorably to the samefeatures as the students (Table 2). Essentially, these re-lated to characteristics of the program including naviga-bility, interactivity, flexibility, and the program’s visualappeal. There was less agreement about the clarity of theobjectives of the program, although they felt that theimplicit goals had been achieved.

Faculty all agreed thatThe Dynamic Swallowwasan excellent teaching tool to serve as an adjunct to formalclass presentations and clinical work. They also thoughtthat there was merit in using the program in a clinicalsetting, either for review of the clinician’s knowledgebase or to demonstrate the swallowing process and as-pects of dysfunction to clients. They agreed that otherhealth professionals, including nurses and medical staff,would find the program useful.

Table 1. Student responses to attitude scale questions

Question Mean Mode Range

Effective means for learning normal swallow 4.8 5 4–5Effective means for learning disordered

swallow 4.7 5 3–5Increased confidence in interpreting aspects

of swallowing process 4.7 5 3–5Easy to navigate 4.7 5 3–5Screen design esthetically pleasing 4.8 5 4–5High level of interest 4.8 5 4–5Animations suitable for students 4.9 5 4–5Videos suitable for students 4.8 5 3–5Useful diagrams 4.8 5 4–5Useful glossary 4.4 5 1–5

14 I. Scholten and A. Russell: Learning about the Dynamic Swallowing Process

Feedback from International Experts

Several people with international reputations in the fieldof dysphagia were approached to reviewThe DynamicSwallow. All agreed to share their expertise and devotedvaluable time to critique the program. Not all who agreedhave returned their reviews, but those who have done sohave given positive reports along the same lines as thefaculty. Comments included: “very instructive and infor-mative,” “it is really excellent for students,” “the beautyis that it has something for everyone” “provides an extradimension to learning,” “nice features for learning basicanatomy,” and “under direction it would be great forclients.” Helpful suggestions were also made for smallbut important alterations to content.

Discussion

The Dynamic Swallowis an innovative development inthe teaching of dysphagia that assists students in learningabout the dynamic nature of swallowing. Speech-lan-guage pathology students, faculty, and expert reviewershave been positive about the program and its applicationfor teaching. Faculty responsible for teaching dysphagiain speech-language pathology programs throughout Aus-tralia were involved in the development ofThe DynamicSwallowand are fully aware of how this material is cur-rently taught and how the CD-ROM can enhance teach-ing/learning in dysphagia and related courses (e.g.,anatomy). AlthoughThe Dynamic Swallowcould standalone as an instructional tool, we are currently using it inconjunction with other teaching methods, as advocatedby Laurillard [15], to maximize the effectiveness for stu-dent learning. Although students will useThe DynamicSwallowoutside of normal lecture times, lecturers maydemonstrate it in class and make reference to the materialand its application to encourage students to refer back to

it in their subsequent studies. The program could also beused for revisiting previously learned material in the con-text of later clinical practice.

The Dynamic Swallowhas potential applicationsin other fields, including medicine and nursing, and mayalso be of benefit for use with clients in explaining thecomplexities of the swallow and the consequences ofdysfunction.

The evaluations to date from students, faculty,and experts have demonstrated thatThe Dynamic Swal-low would be a valued tool in the teaching of dysphagiainternationally. This evaluation has demonstrated thatstudents’ motivation is increased, which we anticipateshould lead to improved learning. However, we recog-nize that it is essential to investigate systematically theimpact ofThe Dynamic Swallowon students’ knowledgeabout the normal swallowing process. To this end, theevaluation of student learning with this program is cur-rently underway, and the results will be reported.

Acknowledgments. The authors acknowledge the financial support ofthe Committee for University Teaching and Staff Development, theassistance of Dr. Helen Chenery, Pam Kauschke, Jennifer Lambier, Dr.Berenice Mathisen, Patrina Nuske-Small, Kylie Perkins, Cathy Rob-ertson, Christine Sheard, and the speech-pathology staff at the QueenElizabeth Hospital, Adelaide, and the multimedia production skills ofFusion.

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