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.