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 bedside evaluation. 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.