From the 25 articles, 17 articles (68%) discussed the pathophysiology of the swallow and these are described in Table 2.

By reviewing the description of the dysphagia, it appears that the pharyngeal phase is mostly impacted by a high-level SCI as the most reported symptoms were: residue in pyriform sinus or valleculae, poor laryngeal elevation, poor epiglottic closure, poor base of tongue movement, decreased pharyngeal peristalsis, decreased sensation and impaired upper oesophageal sphincter functioning (Ihalainen 2017; Lee et al. 2016; McRae et al. 2019; Papadopoulou et al. 2013; Shem et al. 2012; Valenzo et al. 2016). According to Wolf and Meiners (2003), patients with a cervical SCI have difficulty protecting their airway because of respiratory difficulties, which is important to identify and manage early.

Interestingly, 47% of the articles described the dysphagia as transient in nature within this population. This has implications for the timing of dysphagia screening, assessment and management when considering the development of specific guidelines and practices. If a condition is deemed transient, the need would be to reduce the potential complications in the initial presenting phases. This infers that early identification of dysphagia in this population is required and that screening should be mandatory. This may have an impact on the healthcare team managing these patients because it would be important to agree and collaborate which team members need to conduct the early screening, as SLPs are often not included in the initial management of these patients. It would then become the responsibility of other healthcare team members to be aware of the risk factors of dysphagia and the presentation of the condition. The active engagement of these professions would be important in the early identification process and needs consideration in the planned NHI management procedures.

Given the statements regarding other healthcare team members needing to conduct possible screenings for these patients, it is deemed important to consider each professional’s scope of practice during this development process. It is mentioned in the literature that nursing staff is involved in dysphagia screening, especially in stroke units (Cichero, Heaton & Bassett 2009; Palli et al. 2017). Little to no mention about the role of physiotherapists (PTs) performing the screening of dysphagia is made in the literature and should be considered for further exploration.

From the information in Table 3, it can be hypothesised that if the respiratory system has been compromised requiring the use of a tracheostomy and/or ventilator, then the possibility of developing dysphagia increases. This is because the breath–swallow cycle has been interrupted and the airway is no longer adequately protected during the swallow, as described above. It is known that patients with a tracheostomy tube are more prone to the development of dysphagia because of the impact of the tube on laryngeal elevation, which has a negative impact on airway closure (Batty 2009). The use of a prolonged ventilation can also lead to post-extubation dysphagia, which is a result of laryngeal trauma because of the presence of the endotracheal tube (Marvin, Thibeault & Ehlenbach 2014). These risk factors coupled with the neurological or structural fallouts from the SCI (Table 2) can further increase the prevalence as well as the severity of presenting dysphagia. When considering the development and implementation of screening protocols and early identification procedures for dysphagia in cervical SCI, it would be important for the initial healthcare professionals to be able to identify the most at-risk patients who need to be prioritised for screening and referred for assessment to SLPs.

It is highly plausible that a comorbid traumatic brain injury (TBI) could also result in dysphagia, as dysphagia is reportedly prevalent in 25% – 93% of TBI populations in a developed country context (Lee et al. 2016). In SA, where the mortality rate from trauma incidents is six times higher than the global average (Corrigan, Selassie & Orman 2010), it is pertinent to consider the possible impact of a patient with a TBI and SCI on dysphagia. This requires further investigation.

Only 8 (32%) out of the 25 articles referenced the potential impact that a dysphagia has on the patient and on the healthcare facility. Out of these eight articles, only three stated that if a patient with a high SCI also presents with dysphagia, this would lengthen the hospital stay of the patient and the total cost of care (Hayashi et al. 2020; Ihalainen et al. 2017, 2018). This is a potentially important clinical outcome that needs to be considered by all members of the healthcare team. Further consideration is the need to reduce potential medical complications, which have become even more pertinent in the coronavirus disease 2019 (COVID-19) era, where non-emergent medical cases are being discharged at a faster rate (Adams et al. 2020).

Not only is dysphagia in SCI, a financial concern, as mentioned above, but the same three articles also mention that dysphagia had a negative impact on the patients, including a decrease in their mood as well as their overall quality of life (Iruthayarajah et al. 2018; Shem et al. 2011, 2012). Quality of life and mood could have a significant impact on the patient’s adherence to rehabilitation. Person-centred care (PCC) is therefore an important framework to consider for all healthcare professionals when rehabilitating these patients (Santana et al. 2018), as the rehabilitation of the respiratory functioning by PTs will also have an impact on the management of dysphagia, thereby possibly making rehabilitation more efficient. Through early identification, complications can be minimised, thereby decreasing hospital stay and increasing quality of life (Iruthayarajah et al. 2018). There is again little research that focusses on PCC in dysphagia as well as for SCI management. This framework could be incorporated into both individual and team practice patterns, but needs further exploration.

Out of the 25 articles included in the review, 10 articles focussed on the management team. The team members who were specifically mentioned included: SLPs, PTs, occupational therapists (OTs), dieticians, nurses and physicians. Given the scope of practice for SCI and dysphagia management, these team members are all appropriate for the management of this population and are all present in most healthcare facilities in SA, both within the public and private sectors.

Of the 10 articles mentioned above that considered the management team, not all mentioned a specific practice model that the healthcare team employed to manage this patient population. The question at hand remains, how do these team members work together in the most efficient manner in a complex healthcare setting such as SA? When considering the documents that are provided by the Southern African Spinal Cord Injury Association (SASCA), the only guidelines available are for mobility and assistive devices (SASCA 2016). There is no mention regarding the presence of dysphagia, and subsequently there is little mention of the team members nor potential management approaches for this population. Given the factors discussed above and the clinical gaps that have emerged, this is an area that requires attention and input from multiple professionals. Once again this will become pertinent not only for policy and guideline development generally, but for the rollout of the NHI and possible undergraduate training.

Anecdotally, in the South African context, a multidisciplinary (MDT) approach is typically followed in all settings. This involves team members working collaboratively in terms of communication and consultation but often independently in terms of scope and practice (Logemann 1994). This model has advantages, but considering the impact of limited resources, the need to identify patients early and the heterogeneous nature of dysphagia within this population, perhaps an alternative model to the MDT approach needs to be explored. Given that there were little data on how teams manage this population, it can be hypothesised that these practice patterns vary internationally. However, from this review, two articles specifically mentioned an interdisciplinary approach (Seidl et al. 2010; Vining et al. 2017), which involves members of different professions often practising across disciplines for patient care (Bewer 2017). The articles in this review highlight the advantages of a transdisciplinary approach, the predominant factor being the efficacy of management teams. Other important factors included structured sessions and good communication. All team members were working towards a common goal to decrease the patients’ length of hospital stay and improve their overall quality of life. There is little research on the interdisciplinary approach in the management of patients with an SCI, yet another identified gap that requires further exploration. Circling back to the point of SA being a resource-restricted setting, an interdisciplinary approach would be a potential solution in a more effective and efficient manner when rehabilitating patients to reduce time with the patients as well as decreasing their overall length of hospital stay. In SA, team members would primarily include physicians, nurses, PTs, dieticians, OTs and SLPs. An interdisciplinary approach would require changes in possible undergraduate teaching curricula as well as practical placements. Each profession has a specific skill set that is highly valued when managing a patient with SCI. Given the need to manage these patients efficiently and not in isolation, it may be important to discuss what knowledge and skills each team member may need to improve current services that are provided. This specifically refers to the need of improving the early identification and screening of at-risk patients.

Sub-theme one – Practice patterns regarding early identification and screening: Practice patterns around the early identification of dysphagia are important. It was mentioned as a priority for this population in seven of the articles, and the later management thereof. In SA and other countries, early identification is needed to reduce the long-term impacts of dysphagia. There are only 2643 SLPs registered with the Health Professions Council of South Africa (HPCSA) (Pillay et al. 2020), and not all of those SLPs work in the medical setting, highlighting the limited number of SLPs who are frequently and readily available for screening and early identification of dysphagia. This challenge requires a unique solution. Perhaps the scope of practice documents for physicians, nurses and PTs needs to include the ability to screen and identify at-risk patients for dysphagia, as these team members are responsible for the initial treatment of the patient living with an SCI. The feasibility of this would need to be discussed at individual sites.

Sub-theme two – Practice patterns regarding management of dysphagia in cervical spinal cord injury: One of the primary complications of a cervical SCI is problems in the respiratory system, and the management and rehabilitation thereof fall firmly within the scope of the PT (Harvey 2016). Considering the cause of dysphagia, the management of patients living with SCI will require simultaneous respiratory intervention and the SLP cannot and should not treat dysphagia in isolation. This would also require a different and more collaborative team approach. Currently, there is little to no guidance in terms of policies or frameworks in SA for the management of dysphagia in patients with an SCI. This may require PTs to have a broader understanding about dysphagia and for SLPs to have a more detailed input on the respiratory system, which could both be incorporated at an undergraduate level. In terms of how this would play out clinically, more collaboration, research and discussions would be needed. This review merely identified gaps and provided possible suggestions on the way forward.