PTs, Are You Ready for the IDDSI?

Dysphagia, or difficulty swallowing, is a common issue for patients with neurological disorders, stroke, or other conditions that affect muscle control.

Physical therapists (PTs) play an important role in helping these patients maintain or regain mobility and strength, but understanding how to support their nutritional needs through safe swallowing practices is equally important. This is where the International Dysphagia Diet Standardisation Initiative (IDDSI) Framework comes into play.  

This article will introduce PTs to the IDDSI Framework, explaining its relevance and use in physical therapy practice. 

Related: Dysphagia Therapy in Skilled Nursing: Is What We Know REALLY What We Know?

What is the IDDSI framework? 

The IDDSI was created to provide a global standardized approach to managing dysphagia across all healthcare settings. It’s a framework that categorizes foods and liquids into different levels based on their texture and consistency to make sure they are safe for patients with swallowing difficulties. 

The IDDSI Framework includes 8 levels that range from thin liquids to regular foods. These levels are designed to prevent choking by making sure that the patient’s food or drink matches their swallowing ability. 

The levels are: 

Levels 0-4 address liquids: 

• Level 0: Thin (e.g., water, juice) 
• Level 1: Slightly thick (e.g., thicker than water, but still flowable) 
• Level 2: Mildly thick (e.g., milkshake consistency) 
• Level 3: Moderately thick (e.g., liquidized soup) 
• Level 4: Extremely thick (e.g., pureed) 

Levels 3-7 address foods: 

• Level 3: Liquidized (similar to moderately thick liquid) 
• Level 4: Pureed (no chewing required) 
• Level 5: Minced & moist (minimal chewing required) 
• Level 6: Soft & bite-sized (soft and easy to chew) 
• Level 7: Regular (normal food consistency) 

Why PTs need to understand the IDDSI framework 

Physical therapists need to understand the IDDSI Framework for several reasons: 

1. Supporting holistic patient care

Physical therapists are often part of interdisciplinary teams working with patients who have dysphagia, particularly those recovering from stroke, traumatic brain injury, or progressive neurological disorders like Parkinson’s disease.  

Understanding the IDDSI Framework allows PTs to collaborate more effectively with speech-language pathologists (SLPs), dietitians, and nurses who are involved in the patient’s care plan. 

2. Promoting patient safety

Dysphagia can lead to serious complications like aspiration pneumonia if food or liquids enter the airway. By understanding IDDSI levels, PTs can help make sure that patients are consuming foods and liquids that are safe for their swallowing level, reducing the risk of these dangerous issues. 

3. Improving rehabilitation outcomes

Rehabilitation isn’t just about mobility. It’s about making sure that patients maintain overall health and well-being. PTs who understand how to apply the IDDSI Framework in their practice can better support their patients’ nutritional intake, which is key for energy, healing, and participation in physical therapy. 

IDDSI framework levels explained for PTs 

Understanding the different IDDSI levels and how they apply to patients is very important when working with individuals who have swallowing difficulties.  

Here’s a breakdown of the IDDSI levels most relevant to physical therapy practice, especially when providing care for patients with dysphagia. 

Liquids: Levels 0-4 

• Level 0: Thin. This is the consistency of regular water, juices, or broths. Patients on this level are those who can manage normal liquids without coughing or choking. Physical therapists may encounter patients on this diet level who do not require any modification to their fluid intake. 
• Level 1: Slightly thick. Slightly thick liquids flow more slowly than water. This is often the first level of modification for patients who experience minor difficulty with thin liquids. PTs should note that even small changes in thickness can really affect the safety of swallowing for some patients. 
• Level 2: Mildly thick. Mildly thick liquids have a consistency similar to thickened juices or milkshakes. PTs working with patients who experience occasional coughing or choking may see this as part of their nutritional care plan. 
• Level 3: Moderately thick. Moderately thick liquids are similar to blended soups or smoothies. Patients who are at high risk of aspiration or who struggle with thin liquids often require more consistent thickening, and PTs should work closely with SLPs to monitor the patient’s hydration status. 
• Level 4: Extremely thick/pureed. Pureed foods and thickened liquids at this level don’t flow at all and require spoon feeding. PTs working with patients with severe dysphagia or those at risk of aspiration might need to assist with mobility techniques that allow patients to maintain proper posture during feeding, which can improve swallowing safety. 

Foods: Levels 3-7 

• Level 3: Liquidized foods. These foods are fully blended to the consistency of a thick liquid. Patients may need help during feeding, especially if they have difficulty coordinating eating and breathing. 
• Level 4: Pureed foods. Pureed foods are soft and smooth, requiring no chewing. Patients recovering from a stroke or neurological injury may benefit from pureed foods if they have a lot of difficulty chewing or controlling food in their mouth. 
• Level 5: Minced & moist. Foods at this level need minimal chewing and should be easy to form into a bolus (a ball of food). This is ideal for patients that have some chewing ability but need extra assistance. PTs can work with SLPs to assess a patient’s head, neck, and trunk control to ensure safe swallowing. 
• Level 6: Soft & bite-sized. These foods are soft and can be easily chewed. They are cut into bite-sized pieces, making it easier for patients to handle smaller portions safely. PTs should make sure that patients keep a good posture while eating to minimize choking risk. 
• Level 7: Regular foods. Regular food consistency is suitable for patients who do not need any texture modification. For PTs, this might be the goal for patients in long-term recovery who have regained full swallowing function. 

How PTs can apply the IDDSI framework in practice 

Properly applying the IDDSI Framework in practice is just as important as understanding it. Some ways PTs can use it include: 

Collaborating with the dysphagia care team 

Physical therapists should regularly communicate with the entire care team, including SLPs and dietitians, to make sure that the food and liquid modifications for each patient align with the patient's rehabilitation goals.  

This can include adjusting exercise routines to accommodate patients who may need more energy or making sure that patients maintain proper posture during meals to allow for safer swallowing. 

Educating patients and caregivers 

Educating patients and their caregivers about the IDDSI Framework can help ensure that the dietary modifications are followed outside the clinical setting. For example, caregivers need to understand the importance of proper food preparation, how to thicken liquids appropriately, and how to assist with eating. 

Monitoring nutrition and hydration during rehabilitation 

Patients with dysphagia are at a higher risk of malnutrition and dehydration, which can negatively impact physical therapy outcomes. By monitoring patients’ food and fluid intake and recognizing the signs of poor nutrition, PTs can intervene early and make referrals to dietitians as necessary.  

In some cases, PTs can adjust and modify rehabilitation exercises based on the patient's energy levels and nutritional status. 

Facilitating safe swallowing during physical therapy sessions 

For patients with dysphagia, maintaining a safe posture is very important during eating and drinking. PTs can teach patients postural control exercises to improve head, neck, and trunk alignment during meals, which can improve swallowing safety.  

Physical therapists should also be aware of any modifications to the patient's diet that might affect their therapy sessions, such as the need for extra breaks due to low energy levels. 

Challenges and considerations for PTs using IDDSI 

PTs may face challenges when integrating this knowledge into their practice: 

• Time constraints: PTs often have limited time with patients, making it difficult to fully assess how the IDDSI levels interact with their therapy goals. Collaborating with the interdisciplinary team can help PTs optimize their time with patients. 
• Patient adherence: Some patients might resist texture-modified diets, especially if they are used to eating regular foods. PTs can play a role in motivating patients to adhere to their prescribed diet by explaining the risks of non-compliance. 
• Ongoing education: Dysphagia management is a specialized area, and not all PTs may feel comfortable applying the IDDSI Framework. Continuing education courses can provide PTs with the knowledge and skills needed to better understand and apply the framework. 

Conclusion 

Physical therapists' role in the management of dysphagia goes beyond mobility and strength training. Understanding and applying the IDDSI Framework allows a PT to collaborate more effectively with an interdisciplinary team and provide holistic care for patients with dysphagia.  

By making sure that patients are consuming foods and liquids at the appropriate IDDSI level, PTs can help prevent complications, improve nutrition, and optimize rehabilitation outcomes.