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 laryngeal 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 possibly 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.

One thought on “My Patient had Their Modified, Now What Do I Do?

  1. I have been on a feeding tube for 3yrs. I was tested for ALS and Myastaniagravis disease but tests were negative. I had radiation treatments back in 1974 for a tumor in my throat. The doctors think I may have a buildup of scar tissues. I recently visited Dr. Johnathan Aviv in N.Y. and he prescribed Shaker and speech therapy since my voice is very hoarse. I just started these treatments 2 weeks ago. No on has every gotten to the bottom of my problem. My throat muscles I’m told are like cylinder blocks, my pallet does not work, my larnyx is not working and the back of my tongue is not working. Any suggestions would be appreciated. I am a 64yr old female.

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