Tag Archives: Patient

Measuring Lingual Range of Motion

For so long, we have focused on lingual strength and range-of-motion.

The Iowa Oral Performance Instrument (IOPI),  the SwallowStrong and the Tongue Press have all been developed to give us visual and numeric strength measurements of the tongue.

We finally have a measurement scale for lingual range of motion.

C.L. Lazarus, H. Husaini, A.S. Jacobson, J.K. Mojica, D. Buchbinder, K. Okay, M.L. Urken.  Development of a New Lingual Range-of-Motion Assessment Scale, Normative Data in Surgically Treated Oral Cancer Patients.  Dysphagia (2014) 29:489-499.

This study compared results in treated surgical patients vs. healthy patients.   36 patients s/p oral tongue surgery with significantly decreased tongue range-of-motion and 31 healthy individuals.

The scale was validated by correlating range-of-motion with performance status, oral outcomes and patient-related Quality of Life.

The scale was made to define lingual deficits.  This is a tool that can be used for baseline and post surgery tongue range-of-motion and to track changes over time with recovery and therapy.

Lingual protrusion was measured using the Therabite jaw range-of-motion measurement discs.

Protrusion Scores:  (100) Normal:  > or = 15 mm past the upper lip margin

(50)   Mild-mod:  >1mm but <15mm pasat the upper lip margin

(25)   Severe:  Some movement but unable to reach upper lip margin

(0)     Total:  No movement

Lateralization Scores:  based on ability of the tongue to touch the commissures of the mouth.  Measure both right and left side.
(100)  Normal:  able to fully touch the corner of the mouth.
(50)    Mild-Moderate:  50% reduction of movement to corner of the mouth in                                              either direction.
(25)    Severe:  >50% reduction in movement.
(0)      Total:  No movement.

Elevation Scores:    (100)  Normal:  complete tongue tip contact with the upper alvoelar                                                                   ridge.
(50)    Moderate:  tongue tip elevation but no contact with the upper alvoelar                                              ridge.
(0)      Severe:  No visible tongue tip elevation

Total Scores were assigned by adding the protrusion score+ right lateralization score + left lateralization score + elevation score divided by 4.

Scores were 0-100:        0=severely impaired/totally impaired
25=Severly impaired
50=mild-moderate impairment

During this study, tongue strength was measured using the Iowa Oral Performance Instrument.

Jaw range-of-motion was measure using the Therabite jaw range-of-motion measurement discs.

Saliva flow was measured using the Saxon test where the patient was asked to chew a sterile 4×4 piece of gauze for 2 minutes then spit the gauze in a cup.  The gauze was weighed before and after mastication.

The Performance Status Scale was used to determine diet type, speech uderstandability, impact of surgery on ability to eat socially.

Quality of Life was measured using the Eating Assessment Tool-10 (EAT-10), MD Anderson Dysphagia Inventory (MDADI) and Speech Handicap Index (SHI).

The study found that lingual range-of-motion can negatively affect all aspects of a patient’s life and correlates with performance and quality of life.

Dysphagia Survey

Recently, I conducted a survey regarding dysphagia management/treatment.  This was inspired after I read the “Dysphagia Usual Care” article and wrote a blog post about that article.

I found the Usual Care article interesting in how we really have no standardized treatment protocols.  While it’s impossible to standardize treatments for all patients or diagnoses we seem to have too wide a variety of treatments.

The results of the survey are as follow:

Which setting do you work?

School 5%

Clinic 14%

Hospital 47%

SNF 43%

LTAC 19%

Outpatient 43%

Home Health Clinic 12%

Physician Office 3%

With which population do you primarily work?

Pediatric 29%

Head/Neck Cancer 39%

CVA 69%

Neuro 69%

Geriatric 78%

Adult 77%

Brain Injury 51%

Other 7% (LTC-DD, IR, NICU, PACE, Psych)

Are you a member of:

SIG 13 100%

BRSS  17.5%

Dysphagia Research Society 15.9%

What screenings do you use?

50 mL Drinking Test 0

3 Ounce Water Swallow Test 53.4%


Massey Bedside Swallowing Screen 9.6%

Clinical Assessment of Swallowing and Prediction of Dysphagia Severity 5.5%

Clinical and Cognitive Predictors of Swallowing Recovery in Stroke 4.1%

Pulse Ox 46.6%

50 mL Water Swallow Test 1.4%

Gag Reflex 15.1%

30 mL Water Swallowing Test 5.5%

Swallowing Provocation Test 0

Standardized Swallowing Assessment (SSA) 9.6%

Timed Test of Swallowing Questionnaire 4.1%

Ox Sat Monitoring 46.6%

Others:  (Frenchay, FOIS, Blue Dye, Facility Specific, MGH, Bedside Swallowing Assessment, C.A., SAFE, Dysphaiga2Go, Informal, MASA, Observation)

What dysphagia assessment tools do you use?

FEES 26.3%

MBSS 74.7%

MASA 18.2%

Informal Assessment Only 34.3%

Cervical Auscultation 23.2%

Hyoid/Laryngeal Palpation 69.7%

Observation at meals 80.8%

Cranial Nerve Exam 47.5%



Other: (Facility Specific oral care tool, clinical bedside, SwalQol, EAT-10, pulse ox)

Do you use MBSImP?

Yes 9.5%

No 74.7%

Do you currently use a standardized assessment form (MASA)?

Yes 15.8%

No 74.7%

What outcome measures do you use?


FOIS 16%

Swal Qol 7.4%

Swal Care 1.2%

EAT-10 18.5%

MASA 12.3%

FIMS 19.8%

Pen/Asp Scale 38.3%

MDADI 4.9%


Waxman 1.2%

Other (Observation, FACS, ROMS)

How do you frequently treat your patients?

During meals 5.1%

As a separate therapy session (outside of meals) 14.3%

Both 80.6%

What therapeutic tools do you use?

VitalStim 42.4%

NMES (other than VS) 9.8%

Ora Light 4.3%

Ice Fingers 21.7%

Laryngeal Mirror 18.5%

Tongue Depressors 71.7%

Chewy Tubes 20.7%

NUK Brushes 18.5%

Z-Vibe 7.6%

Thermo Stim 30.4%

Thera-Sip 6.5%

Tongue Press 5.4%

ARK Probes 2.2%

ARK Grabbers 4.3%

Safe Straws 5.4%

IOPI 15.2%

The Breather 16.3%

EMST-150 8.7%

Spirometer 26.1%

Buttons 17.4%

Horns 6.5%

Straws 48.9%

Provale Cups 40.2%

Wedge Cups 23.9%

Other (Nosey Cups, Maroon Spoons, Beckman Exercises, Myofascial Release, Exercises)

What therapy do you use?

OME 85.4%

Pharyngeal Exercises 93.8%

Shaker 75%

Oral Manipulation 45.8%

BioFeedback (sEMG) 12.5%

NMES 35.4%

Thermal/Tactile Stim 60.4%

Pressure Feedback (IOPI) 10.4%

DPNS 14.6%

LSVT 42.7%

MDTP 3.1%


Beckman 5.2%

Kinesio 4.2%

Weighted Bolus 24%

Other: (Myofasical Release, Other Laryngeal Strengthening, Lingual with Resistance, LSVT-Like, Oropharyngeal Therapy)

What apps do you use for dysphagia therapy?

Dysphagia 7.3%

Dysphagai2Go 6.3%

iSwallow 17.7%

Swallow Now 2.1%

Small Talk Dysphagia 9.4%

Resource Apps (Drug apps, Lab Tests, Cranial Nerves) 15.6%

Other (VU Meter)

What techniques do you employ with your patients?

Diet Alteration 99%

Chin Tuck 91.9%

Multiple Swallows 94.9%

Effortful Swallow 90.0%

Mendelsohn Maneuver 70.7%

Alternate Consistencies 91.9%

Alternate Temperatures 48.5%

Limit Bolus Size 92.9%

No Straws 82.8%

Head Turn (Left/Right) 72.7%

Cough/Throat Clear after the Bolus 85.9%

Supraglottic Swallow 67.7%

Super-SupraGlottic Swallow 54.5%

Lemon Ice After Bolus 11.1%

Other (Sensory Techniques, Masako, Reflux Precautions, Chin up, Olfaction Stim)

The Facebook Dysphagia Therapy Group Professional Edition was asked to define pharyngeal exercises.  Answers included:


Effortful Swallow



Tongue Press

Effortful Swallow with TheraSip

Resistive Breathing

Resistive Jaw Exercises

After conducting this survey, there are a few things that really stand out to me:

First, we finally have 2 standardized assessment tools in the MASA and the MBSImP with approximately 10-15 in 100 SLPs utilizing these tools.

Most SLPs (80%) are treating at meals and separately.  Dr. Logemann specifically states that we should be treating outside of meals, as do many of the major dysphagia researchers.  We also seem to not utilize instrumental assessment as often as mealtime observation.  Unfortunately this may be in large part to denials for instrumental exams due to high cost.

One thing we need to work towards is not only standardizing what we do (as much as possible) but standardizing our terms including modalities, techniques, screenings, assessments and objective measures.

Dysphagia App

What’s changing on Dysphagia Ramblings??


I’m adding to enhance my blogging to include app reviews. Not only will I start reviewing apps (officially) on my blog for dysphagia apps, I will also include some cognitive, language, etc apps.

My first review? Of course it has to be Dysphagia by NSS

App: Dysphagia

What it is: A teaching tool that can be used for families, healthcare professionals, students and SLPs. This app can help as a visual tool in teaching the mechanics of the swallow.

Price: $9.99 ($3.99 for only the normal swallow version called Normal Swallow)

System: iOS (iPhone, iPod Touch and iPad)

Version: 1.3

This app is simple to use, offers amazing graphics and creates a new, animated teaching tool for SLPs educating others in dysphagia.

When you first open the app, you have a picture of the lateral view of the oropharyngeal region called Normal Swallow, Lateral View.


At the bottom of the screen is a play button (the little arrow pointing to the right by the white turning blue line). Above the line is a purple rectangle that tells you what percentage speed you are playing the video. You can touch that rectangle and change the speed of the app from 1% to 100% depending on how fast or slow you want the app to run.


At the top of the screen is a menu rectangular purple button. When you touch this button, it allows you view the menu of available swallows to watch. You have the option of:

Normal Swallow, Lateral View
Normal Swallow, AP View
Example of Penetration with Aspiration
Impairment of Bolus Transport
Impairment of Initiation of Pharyngeal Swallow
Impairment of Anterior Hyoid Excursion
Impairment of Laryngeal Vestibular Closure
Impairment of Pharyngeal Contraction
Impairment of PES Opening
Impairment of Tongue Base Retraction


Pros of this app:

It offers excellent graphics to teach a swallow and the components of the swallow. If you have taken the MBSImP course, you will recognize the animations.

It’s very easy to slow down or speed up the rate of the play of video to enhance learning for all viewers.

It’s easier to show patients and healthcare professionals the swallow process and easier than a traditional swallow study video to visualize the components of the swallow.

Cons of the app:

It is limited to a few swallow deficits. You can’t show your patient their true swallow using this app, however it would be impossible to have that function!!

This is an excellent app to add to your dysphagia technological toolbox!! It is excellent for students, patients, families, caregivers and SLPs that are not familiar with MBSS to demonstrate the function of the swallow.

My grade: A

G-Codes and Insurance and Rehab Optima…….Oh My!

I work in a critical access hospital.  I see patients in acute care, outpatients and do all MBSS in our facility.


I am also the Rehab Director of our deparment.


Our regional manager implemented G-Codes in our facility in early January.  We have been in-serviced on G-Codes and using them in our documentation.


What are G-Codes?


These are required codes when working with Medicare Part B patients.  There are 7 codes from which SLPs can choose to use with their patients.  These areas define the most relevant area with which we are working with our patient and must include an impairment modifier for each.


ASHA offers information on G-Codes and has created a wonderful list of all the codes and modifiers here.  ASHA also recommends using ASHA NOMS which directly correlate with the impairment modifiers.


The bottom line…..if you don’t use the G-Codes and Modifiers, you won’t get paid.  You can only use one code at a time although you can treat multiple impairments at one time.  (i.e., you may code for swallowing, however treat both dysphagia and expressive communication).


ASHA offers an on-demand webinar explaining G-Codes for $99 for ASHA members and $129 for non-members.  The Specialty Board on Swallowing and Swallowing Disorders also offers a webinar by Nancy Swigert for $25.00.




I don’t know how it is in other states, but here in Indiana, insurance has been a major roadblock for therapy.


Medicaid often severely limits our sessions.  They will often give us 12 or 24 sessions.  When you have a patient that just had a stroke and is severely aphasic, 12 sessions at 2 times a week, 12 sessions at 1 time a week followed by a home program, typically does not cut it.  This is what we are allowed.


Even if that patient has Medicare as a primary.  The Medicare is unlimited.  We are not under caps being a Critical Access Hospital.  Medicaid as a secondary limits the sessions because the patient cannot afford to pay the 20% out of pocket.


BCBS typically gives us 20 sessions if they are primary, 60 sessions if they are secondary.  They will not pay for a cognitive therapy code if CVA is the primary medical diagnosis.  There is a list of diagnoses, small I might add, that I can use with specific codes for reimbursement.


If you live in Indiana and have a stroke with BCBS as your insurance…..please don’t have cognitive issues only requiring cognitive therapy.  They won’t pay for that.


I dread to see all the upcoming changes in therapy approvals for insurance with all the healthcare reform coming.  It has definitely changed to this point.


Rehab Optima


Our company primarily staffs nursing homes.  We have an acute care hospital contract for a critical access hospital.


Our company recently switched from Casamba Smart to Rehab Optima.




Smart wasn’t necessarily functional for us, but RO is definitely not.  We have had nothing but issues since we started!!


Hopefully it gets better!

Dysphagia Assessment

So many people assess dysphagia in the same manner, at least from my observations. Sit with them while they eat a meal, feel laryngeal elevation and trial diet modifications. I have rarely seen people do a thorough dysphagia bedside evaluation.


I’m trying to standardize the manner in which I complete my bedsides. I have started using the SOPE, the MASA and the Sage during every assessment, along with a thorough chart review and assessing aspiration risk factors. I can complete a fairly thorough assessment. The SOPE assesses cranial nerves, taste buds and some muscle function. The Sage assesses oral cleanliness and need for oral care. The MASA has been a fairly accurate indicator of dysphagia from my standpoint. I also do the traditional feel for laryngeal elevation, but I also feel for hyoid protraction. I have started assessing with water and graham crackers. If I need to, I will thicken the liquids, but usually wait for an instrumental assessment. I also have started using the 3 ounce water swallow challenge, which has been a good indicator for aspiration from what I have done so far.


It is important to assess cranial nerves and to understand the cranial nerves. For instance CN XII, the hypoglossal nerve has no sensory pathways, only motor. This definitely affects the means by which you will treat. Another point that has been drilled into my head is that sensory input drives motor output. If you can increase the sensory input a person receives you can increase the amount of output in the muscle functions. Cranial nerve assessment is vital in understanding dysphagia. Sensory input such as olfactory and optical help to prepare the person for the swallow by increasing saliva and telling the body that it is going to masticate and swallow food/drink. Sensory input can also be established through tactile, thermal, or NMES input. In fact, Vitalstim placement 1 has the highest sensory input of all the Vitalstim placements. DPNS is highly driven by sensory input to the cranial nerves through use of frozen lemon swabs, along with thermal, tactile stimulation (TTS).


You can actually tell a lot about a person by their oral hygiene. You can tell who will qualify for Frazier Water Protocol. Also, by oral hygiene, you can make an assumption that the person is at higher risk for aspiration pneumonia because of the poor hygiene of the oral cavity. It is important to let nursing and nursing staff know how often to complete oral cavity for patients that are unable to complete this task with independence.


It is vital to assess motoric function. You treat the motor dysfunction, not the symptoms, i.e. aspiration. If you assess a person and can only tell that they are aspirating, but not WHY they are aspirating, you are no better off than you were before the assessment. There are many areas of function that are vital to swallowing, labial closure, lingual to palate contact, bolus management and propulsion (lingual strength), velar elevation, tongue base retraction, pharyngeal sqeeze, hyolaryngeal excursion (laryngeal elevation, hyoid protraction and hyoid thyroid approximation) and UES opening. I am extremely excited about the MBSImP which will be published next year with certification courses to follow!!


The 3 ounce water swallow challenge is fairly new. It is an indicator of aspiration as it is believed, people that silently aspirate small amounts of liquid will choke with larger volumes. 3 ounces of water is enough to make a person choke, as it is stated per this protocol that silent aspiration is volume dependent. With this challenge, the person is given 3 ounces of water, either by straw or cup sip. They drink the water continuously. Any coughing, throat clearing or inability to drink all 3 ounces at one time is considered a fail. If the person can continuously drink the water and not cough during or for a minute after the challenge, they pass. Those that fail are then assessed instrumentally.


Watching a person eat is also very critical to the evaluation. One predictor of aspiration is inability to self-feed. Medication can often affect a person’s ability to swallow, affect amount of saliva a person has to help break-down the food orally or affect the person’s alertness.


A thorough dysphagia exam is vital and necessary for treatment. A good bedside examination with instrumental assessment will aid you in accurate assessment for thorough and appropriate treatment for dysphagia.

It Takes A GOOD Therapist

I was sitting and thinking today. There are so many therapists that I have seen that are sub-par, (none of my friends of course!) It made me stop and think that every patient, client and student deserves to have the best of the best as far as therapy goes. I don’t want to take my children to a sub-par doctor, why shouldn’t I expect expertise from my therapist???


Dysphagia, in that respect, is no different than any other specialty. In fact, dysphagia may be a little more so in needing expertise. Dysphagia is life and death most of the time. I’ve actually seen patients die from poor choices in diet and from upgrading too soon to an inappropriate diet. Residents in nursing homes have died from uneducated staff. This is not acceptable. This is my own personal list of what it takes to be a GOOD therapist, from a dysphagia perspective, of course.


1. You need a therapist that is knowledgeable, to the point that the therapist can make any and all patients, client, etc. understand dysphagia. Every patient/client is entitled to understand their diagnosis and to understand the therapy you are providing. I can’t count how many patients have come to me for therapy, after having previous dysphagia therapy and never understood what the actual problem is!


2. The dysphagia therapist should very much understand the process of the swallow. It’s not enough to know that people aspirate or penetrate and then give them a cookbook sheet of oral-motor exercises to complete every day 10 times, 3 times a day. The dysphagia therapist needs to know the muscles, the structures, the nerves and their functions.


3. Don’t underestimate all the new treatments that are available. So many people will absolutely not touch VitalStim because “it’s not researched enough.” VitalStim and NMES is one of the most researched areas in our field. If you are able, go to these courses and learn what they are about. Read the literature. Make your own educated opinions. I always find that taking a little from each and every course that I go to, and putting it together to create my own therapy plan is more successful than the cookbook sheet of oral motor exercises.


4. Do a COMPLETE assessment of each and every patient. It is not enough to simply sit with the patient at a meal and watch for them to cough or choke. You need to assess all the cranial nerves, do a complete chart review, palpate the structures and functions during the swallow. The 3 ounce water swallow challenge is a new assessment procedure that can give some valuable assessment data. Not so sure I completely believe in it yet, however am using it before all my MBS’s to test the validity on my own terms.


5. When you complete an MBSS, don’t focus on aspiration, penetration, premature spillage, etc. Those are merely symptoms of a bigger dysfunction. You need to look at all the functions of all the structures and report on those. Yes, the person may aspirate, but why and what are you going to treat?? Bonnie Martin-Harris is publishing and providing CE courses next year on the MBSImP, which will be a standardized manner, in which to assess swallowing function during the MBS.


6. NEVER, ever, ever upgrade a patient diet on a Friday, leave for the weekend, and come back on Monday to check how they are doing?? Doctors do not start a new medication then leave the person hanging for days on end. How can you functionally assess a person’s ability to manage the diet upgrade if you are not there to monitor??


7. I so very often see therapists treat, by sitting with a patient at a meal, watching them eat, assisting with compensations and strategies and then doing the cookbook oral motor exercises with the patient. Don’t get me wrong, oral motor exercises can be functional, as a home exercise program in addition to ACTUAL swallowing therapy and compensations/strategies have their place, but they are not therapy. These compensations/strategies and OME do not promote the muscle changes required to constitute rehabilitation, which is what we do. You cannot improve the swallow without having the patient complete swallowing tasks.


It is often debated, what do we, as SLP’s call ourselves?? Some demand Speech Pathologists, Speech Language Pathologists, Speech Therapists, etc. I prefer Speech Therapist, because I rehabilitate people.


My challenge to everyone is to examine yourself and your therapy. Look at how you assess patients, how you complete the instrumental exam, how you treat patients with dysphagia. Ask yourself, what am I doing for my patient, what SHOULD I be doing for my patient and how can I do better for my patients, to rehabilitate their swallowing mechanism and therefore do my job and make my patient better??

Put Yourself in Their Shoes

My number one rule-of-thumb, especially when treating my dysphagic patients is to put myself in their shoes.


First, I need to make this patient and their family member understand just what is going on. No, I don’t explain dysphagia in medical terms, but it is easy to put into layman’s terms when you understand the swallowing process. The patient needs to understand dysphagia, what is compromising their swallowing function and understand how and why dysphagia treatment will make them better and safer. Patients need to understand that this can be a life-threatening dysfunction but that it can be improved through therapy, diet modifications, compensations, etc.


I also have to remember that one of the joys in life is eating. We all go through our day eating and drinking. It’s how we socialize, what we do at holidays. Our patients do not want to continue on a pureed diet with honey thick liquids when there is therapy available to possibly get them to a higher level. I’ve seen too many people discharged from therapy on an altered diet because the therapist has no idea what to do with them. I’ve also seen patients upgraded before they even really have therapy. Upgraded three days after the MBSS with severe dysphagia and aspiration is not an appropriate upgrade.


Remember that our job as dysphagia therapists is to rehabilitate, or bring about change to the swallowing system and the musculature of the swallowing system. We cannot bring about change by sitting with a patient during lunch and reminding them to tuck their chin. We cannot bring about a change by having them stick out their tongue 30 times a day and think that’s going to improve the swallow. The only true exercise for the swallowing system is swallowing and challenging the patient with the swallow.

VitalStim Therapy


I’ve been using VitalStim Therapy for about a year now.  I have to say I was a bit skeptical at first.  I have been wanting to learn VitalStim for several years, but had not found a company that allowed it’s use until I started with my current therapy in July of 2009.  Not only do they support VitalStim, they paid for the course for me and bought me the course CD’s.


I went to the course and learned more about dysphagia than I ever have.  The instructors made dysphagia completely make sense to me!!  It was a great format and I use the manual in therapy daily.


I also went from being the first full-time SLP in our hospital, struggling to start and maintain a caseload, to the most productive therapist in our building.  I was doing approximately 90-150 VitalStim sessions a month from approximately last April through December.  My numbers have dropped a little, but I blame the unpredictable Indiana weather for that.


I also decided to gather some data on my therapy.  I want to PROVE to others that VitalStim works and have some data that I might be able to use in the future.  I’ve actually had a lot of people ask me about VitalStim, so I thought the easiest place to put the results would be here on my blog!


First, I would like to say that I don’t simply place the electrodes and have the patient sit for the hour that the machine runs.  I put my patients through a circuit of exercises, depending on what they need.  My patients are hooked up to VitalStim for the full 60 minutes, unless they are unable to tolerate that time, then I adjust as needed.  I have them exercise, each exercise for 5 minutes in “circuits.”  Exercises include lingual exercises with resistance (lateral, protrusion, depression, elevation), using the Mendelsohn maneuver with water, effortful swallow with differing consistencies, bolus manipulation tasks, tongue base exercises as needed (yawn, gargle, pull tongue back in mouth), sucking pudding through a straw (when patient is able, they have to use a coffee stirrer) followed by effortful swallow and TheraSip microresistant straws using a hard suck followed by effortful swallow.  The exercises while electrodes are placed are followed by the Shaker exercise when appropriate.


My patients and results are as follow: (HLE-hyolaryngeal excursion, TBR=tongue base retraction, P.S.=pharyngeal squeeze, P.S.=pharyngeal squeeze.  FOIS=Functional Oral Intake Scale)


Female, 52 y.o. CVA, dysarthria, oropharyngeal dysphagia.  Presented initially with decreased HLE, decreased lingual strength and ROM, decreased TBR, decreased P.S., penetration of thin liquids.  Following 21 therapy sessions using VitalStim placement 2b, repeat MBSS showed no dysfunction.  She increased her FOIS score from 6 to 7, her Eat-10 score decreased from 14 on the EAT-20 to 2 on the EAT-10.  She went from a 2 to a 1 on the Penetration-Aspiration Scale.  She had no further dysarthria.


Male, 61 y.o., CVA/TIA x4, presents with pharyngeal dysphagia.  Initial MBSS revealed decreased HLE, decreased TBR, decreased P.R. with aspiration of thin liquids.  Following 42 therapy sessions, VitalStim placement 3a, final MBSS showed only trace penetration with large bolus of thin.  Small bolus was WFL.  Patient increased FOIS score from 6 to 7, and decreased EAT-20 from 33 to EAT-10 7 (4 months later EAT 10 was at 2.) and decreased from an 8 to a 2 on the Penetration-Aspiration Scale.


Male, 85 y.o., TIA, oropharyngeal dysphagia.  Initial MBSS revealed decreased HLE, decreased lingual strength and ROM, decreased TBR, decreased P.S. and silent aspiration of thin liquids.  Patient attended 36 therapy sessions, VitalStim place 3a, changing to 3b.  Repeat MBSS after 24 sessions revealed decreased lingual strength, decreased TBR, decreased laryngeal elevation, decrease TBR and decreased PS.  Patient refused a 3rd MBSS following 36 treatment sessions.   At d/c, patient, per re-assessment and palpation, increased HLE, increased lingual strength and ROM.  He went from a FOIS 6 to 7, EAT 20 score of 13 to an EAT 10 score of 6.  Penetration-Aspiration Scale from 8 to 2.


Female, 57 y.o., GERD, Barrett’s Esophagus (both treated), pharyngeal dysphagia.  Initial MBSS revealed decreased lingual strength, decreased TBR, decreased HLE, aspiration of thin liquids.  Patient attended 23 sessions at VitalStim placement 3a.  She started at a FOIS score of 5, EAT-20 score of 29 and Penetration-Aspiration Scale score of 8.  Patient quit attending ST after 23 sessions and has not contacted therapist since therapy.


Female, 68 y.o., lung CA (CN X involvement), oropharyngeal dysphagia.  Initial MBSS revealed decreased lingual strength and ROM, decreased TBR, decreased HLE with silent aspiration of thin liquids and mixed consistencies) and decreased P.S.  Following 82 sessions VitalStim placement 3a, switching to 3b with myofascial release of the neck and larynx, repeat MBSS, patient with mild decreased TBR, mild decreased PS and trace penetration with thin with straws which cleared upon completion of the swallow.  Patient increased FOIS from 5 to 7, EAT-20 at 16, EAT-10 decreased to 0 and Penetration-Aspiration Scale decreased from 8 to 2.


Female, 60 y.o. with hypothyroid and oropharyngeal dysphagia.  Initial MBSS revealed decreased lingual strength and ROM, decreased TBR and decreased PS.  Due to insurance restrictions, patient was only allotted 5 therapy sessions and the initial MBSS.  After 5 sessions at VitalStim placement 3b, patient had no further overt, clinical s/s aspiration.  She increased her FOIS from 6 to 7, EAT-10 score decreased from 10 to 1 and Penetration-Aspiration Scale remained at 1.


Male, 62 y.o. with peptic ulcer, treated GERD and oropharyngeal dysphagia.  Initial MBSS revealed decreased lingual strength and ROM, swallow response delay, decreased TBR, decreased PS.  Patient had 24 sessions, using VitalStim placement 3b.  Final MBSS revealed swallow function WNL.  FOIS increased from 6 to 7, EAT-10 decreased from 31 to 8.  Penetration-Aspiration Scale remained at 1.


Female, 76 y.o. with recent left lower lobe pneumonia and oropharyngeal dysphagia.  Initial MBSS revealed decreased lingual movement, decreased TBR, decreased HLE, decreased PS, penetration with Nectar thick liquids and silent aspiration with thin liquids and mixed consistencies.  Patient had 43 sessions, at placement 3a changing to placement 3b after 2nd MBSS revealed some improvement with swallowing, however aspiration persisted.  Final MBSS revealed slight decreased TBR (improved from before), and flash laryngeal penetration x1 of 4 trials of thin liquids.  FOIS increased from 5-7, EAT-10 decreased from 21 to 0 and Penetration-Aspiration Scale decreased from 8 to 1.


Male, 85 y.o. s/p ilius, DM and pharyngeal dysphagia.  Initial MBSS with decreased HLE, decreased UES opening, decreased PC with aspiration of thin liquids and residue of pudding.  After 25 sessions, VitalStim placment 3b patient with no overt, clinical s/s aspiration  (doctor refused repeat MBSS).  FOIS increased from 3 to 7, EAT 10 decreased to 0.  Penetration-Aspiration Scale went from 8 to 1.


Male, 65 y.o. with severe COPD and pharyngeal orodysphagia.  Initial MBSS revealed decreased mastication of solids, decreased lingual ROM and strength, decreased TBR, decreased HLE and decreased PS, laryngeal penetration with all consistencies, patient with c/o coughing to the point of passing out on several occasions at home and at restaurants.  43 sessions later, VitalStim placement 3b, repeat MBSS revealed slight decreased TBR and trace penetration of thin liquids.  FOIS increased from 5-7, EAT-10 decreased from 48 to 10.  Penetration-Aspiration Scale remained at 2.


Approximately 5 other patients started dysphagia therapy, however did not continue due to various reasons.


Overall, I have seen a significant improvement in my patients.  I have not yet had severe patients, but all patients above have increased in their perception of their eating, have decreased overt clinical s/s aspiration and have overall increased quality of life in regards to eating/drinking.


Rosenbek, JC, Robbins, J, Roecker EV, Coyle, JL, &amp; Woods, JL.  A Penetration-Aspiration Scale.  Dysphagia  11:93-98, 1996.


Crary MA, Carnaby Mann GD, Groher ME. Initial psychometric assessment of a functional oral intake

scale for dysphagia in stroke patients. Arch Phys Med Rehabil 2005;86:1516-20.




As many of you know, if you follow me on Twitter or participate in the Facebook Dysphagia Therapy Group, I went to the MBSImP live conference this past weekend.  For those of you that don’t know what the heck the MBSImP is, it stands for the Modified Barium Swallow Impairment Profile.  What it is, an answer to everyone’s prayers to FINALLY have a standardized method for swallow studies.


This protocol for MBSS is based on more than 10 years of work and research.  A powerpoint presentation is available from Dr. Martin-Harris regarding the MBSImP.   Nancy Swigert also wrote a nice review of the MBSImP.  NSS-NRS is the company that provides the MBSImP training.


The course consists of a “live” course.  You go for a day and a half to learn about the MBSImP from Bonnie Martin-Harris.  The course entails comprehensive review of each physiologic function of the swallow, and goes over scoring for the MBSImP.  The MBSImP consists of 17 components from labial seal to esophageal clearance.  Each component is scored from 0 to either 3, 4 or 5, with the higher number indicating a worse impairment.  After you go to the live course, you have the option to proceed with the MBSImP training through an online module.  The cost of the live course is applied to the online module.


The nice part of the MBSImP is the training slides.  Each MBS frame has a corresponding animation making each component of the swallow easy to see for the training purposes.  The animations are used in the live course and the online module.  With the online module, you go through a training section, a practice section and then a test.  With the test, you have to have 80% reliability on your scoring.  Once you reach the 80% (you can take the test as many times as needed), you become a registered user and have access to a database.  This database allows you to input your patient information, which is de-identified to create a comprehensive report for each swallow study you complete.


Part of the live training is respiration and respiration in relation to swallowing.  One thing we learned is that most people will inhale and partially exhale before swallowing.  When the swallow is complete they will finish the exhalation.  It is important that we as therapists evaluate the respiratory pattern of the patient and take that into account.  One point that was emphasized was to teach an expiratory cough to clear and not cue the patient to inhale then cough.  Also to force “audible” vocal closure, or take a deep breath with an audible “huh”.


There is a complete outline including instruction to patient, what barium to present, when to present each consistency and how much to present.  This is done in a precise manner, however it was emphasized that you DO NOT HAVE TO FOLLOW THE PROTOCOL.  There will be times that you have to use your clinical judgement.  Now, with the database, Bonnie will have access to all of the inputed data, remember, it is de-identified.  To be a part of her collection of data, she needs to protocol to be standardized, but if it is not necessary or safe to standardize it for your patient, then you do it how you need to do it.


With the MBSImP, you score each component with the given scale.  You are working to capture IMPAIRMENT.  This is not focusing on aspiration, penetration or testing every consistency known to man.  This is focusing on the function of the swallow and the dysfunction to create an appropriate therapy plan to rehabilitate the swallow.


I plan to implement this in my practice, although I do to some extent already.  This gives me a standardized score for the swallow study.  This score allows me to demonstrate improvement and to focus on more than just penetration/aspiration, diet consistency, pooling, etc.  You focus more on the actual dysfunction.  The decreased TBR, the decreased pharyngeal stripping wave, they opening of the Pharyngeal Esophageal Segment (PES).  Dr. Martin-Harris uses PES rather than Upper Esophageal Sphincter (UES).


I think that this Profile came at the right time.  More than ever, we as SLP’s need to stand our ground and maintain our status as dysphagia experts.  We are the ones that study this mechanism.  We need to evaluate properly.  A modified should not be merely to determine aspiration or to see if the person if “safe” with thin liquids.  We need to determine dysfunction, rehabilitate the swallow system and re-evaluate to determine improvement of the function.  This will not only create a much nicer and less subjective study (really, what does mild, moderate and severe tell me?)


This brought back a lot of the information that I learned from Mary Simmons through CIAO Seminars.  We don’t treat aspiration, penetration or premature spillage. We treat the dysfunction, the decreased hyoid protraction, the decreased laryngeal elevation.


I think when we realize that dysphagia is muscle-based function of the body that works as a system, we can effectively diagnose and treat the dysphagia, the dyfunction instead of worrying so much about the actual aspiration or sticking our tongues out 10 times.  Then and only then can we call ourselves a dysphagia expert.


All-in-all I’m very excited about this protocol and the direction in which it takes our field.  I highly recommend it to all dysphagia therapists, whether you actually are responsible for MBSS or not, you can still learn quite a lot about the swallow function and I believe it will be much easier to interpret the results if you have a therapist that uses the protocol.

My Patient had Their Modified, Now What Do I Do?

Once upon a time, I worked in a setting and had to send my patients out for the MBSS. Now, I am able to complete my own MBSS. One thing I take into account when I am doing an MBSS for another SLP is making sure they get a complete study. I have actually gone to several CE courses regarding MBSS in the last 2 years. When I say a complete MBSS, I don’t mean that I test 15 different foods using every strategy known to man per spoon, cup, straw, syringe or whatever else I can think of to feed the patient. When I say complete, I mean that I try to find the dysfunction, the abnormality of the swallowing mechanism. I used to get those reports that stated patient so and so aspirated thin liquids with non-functional cough, chin tuck did not eliminate, blah blah blah. That doesn’t tell me WHY the patient is aspirating and what I need to focus my therapy on to STOP the aspiration.


If you are one of those clinicians that have to send your patient out and rely on another clinician to complete your MBSS there are ways to interpret what the therapist is writing into muscle dysfunction.


First, let’s look at the oral phase. You have to look at lip closure. You know that if the person drools or has anterior spillage of the bolus, there are probably some labial seal issues, so you are going to work some on that orbiularis oris and labial seal with resistive labial exercises. The tongue has to move the bolus from side to side, recollect the bolus on the tongue and push it back, pushing up against the palate to create pressure to push the bolus. If the patient has poor bolus formation, residue in the sulci, premature spillage, they are probably not getting good bolus formation, they probably have a weak tongue. If there is reported residue on the tongue and/or palate, they probably are not getting enough tongue-palate contact. You are going to work on resistive lingual exercises. Pocketing in the lateral sulci will indicate poor buccal strength, decreased tension. Resistive cheek exercises are a must.


Premature spillage can indicate that back of the tongue is weak and the tongue is weak and not holding the bolus in a cohesive manner. Again, resistive lingual exercises, Masako, effortful swallow will all focus on the back of the tongue. Pharyngeal residue will always indicate decreased tongue base retraction and may indicate decreased pharyngeal stripping wave. Again, to strengthen that part of the swallow, I use the effortful swallow, large, thick bolus swallows. Penetration/Aspiration is going to indicate poor hyolaryngeal excursion, which can be any of the three areas including anterior motion of the hyoid, laryngeal elevation and hyoid/thyroid approximation or laryngel closure. There is really quite a bit of information needed here, how long does the closure last, when are they aspirating. However, if all you get is penetration and/or aspiration you know you need to work on airway protection through the effortful swallow, lingual strengthening (it is attached to the hyoid, which is part of the excursion), Mendelsohn Maneuver. You will also have evidence of decreased airway protection through evidence of decreased epiglottic inversion. If you get a report of pyriform sinus residue, there is possbily an issue with Pharyngeal Esophageal Segment (PES/UES) opening. Now, the PES is opened through Hyolaryngeal excursion and the force of the bolus. The bolus is pushed through the oropharyngeal region by pressure of the tongue, so for PES opening issues, I work on lingual strengthening, Shaker, Mendelsohn, effortful swallow and change the bolus size and consistency.


Many times, I have observed therapists altering patient diets, teaching chin tuck, double swallow, etc. While I agree that we have those patients that diet alterations, compensations are appropriate, we also have those patients that have the potential for rehabilitation that don’t want to look at their lap every time they swallow. I know I wouldn’t want that.


As therapists, we have to become better at not only investigating and determining the dysfunction of the swallow, but at writing the report so that other clinicians can TREAT the dysphagia. We don’t treat symptoms. I can’t treat aspiration. In fact, many people CAN, in fact have dysphagia without aspiration or penetration. Think of how short a time we have the patient in radiology. Who knows that they weren’t going to aspirate the next bite that we never gave. We can, however, determine that the patient has decreased laryngeal elevation, with or without penetration/aspiration and TREAT that. We can determine that the patient has decreased lingual strength, (which will probably affect a huge portion of the swallow) and TREAT that.


My modifieds have changed drastically. I don’t test every consistency. I test thin, nectar, honey-if absolutely necessary, pudding and cookie. I’m not looking for every consistency and what they do with it. I’m looking at the dysfunction of the swallowing mechanism. Once we start doing that, we become competent in what we do.