We Can’t Treat What We Don’t Know

Call it what you like, a bedside swallowing evaluation, a bedside swallow, a clinical swallow evaluation. No matter what you call it it’s never the same.

At a recent ASHA convention there was a session by Leder, Coyle and McCullough which addressed the clinical swallow evaluation versus instrumental evaluation. Dr. Coyle stated that the bedside evaluation is merely a series of pass and fail screens. You can visit many facilities whether they be hospital skilled nursing acute rehab or home health and rarely will you see two SLP’s complete the clinical bedside evaluation the same.

McCullough also has an interesting article on the ASHA website with various resources titles To See or Not to See.

There are always various views.

“A Modified Barium Swallow Study is just a moment in time.”

“I can assess a patient without an instrumental using palpation, observation and clinical judgment.”

“You can’t accurately assess a patient without doing an instrumental.”

One of the main problems with all of our assessments are they are not standardized, whether it’s a Clinical Exam or Instrumental.

The work of Bonnie Martin Harris has started the standardization process for the Modified Barium Swallow Study through the MBSImP (Modified Barium Swallow Impairment Profile), however not everyone has to take this course to complete the MBSS. Not only does the MBSImP have an aim to standardize the MBSS, it also addresses identifying and reporting functional deficits or physiological impairments rather than commenting on what happens with every consistency.  The goal of the MBSImP is to find impairment through trials of a set of consistencies rather than to identify every consistency which is difficult for the patient.  Martin-Harris, B., Brodsky, M. B., Michel, Y., Castell, D. O., Schleicher, M., Sandidge, J., … & Blair, J. (2008). MBS measurement tool for swallow impairment—MBSImp: establishing a standard. Dysphagia, 23(4), 392-405.

FEES has had tools to help standardize interpretation, including interpretation of the residue amount through the Yale Pharyngeal Residue Scale.   There are numerous courses available to teach the anatomy and physiology of the pharynx as viewed through the endoscope.

You can also find tools to help you with standardization of your instrumental assessments on my Outcome Measures post.

What does ASHA say?

The American Speech Language and Hearing Association (ASHA) has given us guidelines for “best practice”.   Within the ASHA Rules of Ethics, it states:  “Individuals shall use every resource, including referral and/or interprofessional collaboration when appropriate, to ensure that quality service is provided.”

ASHA provides us with guidelines for SLPs performing MBSS which you can find here.   There are also guidelines for those performing FEES which you can find here.

So why do we need instrumentation?  What’s the big deal?

There are many areas that we can and cannot view with a Clinical Dysphagia Examination.

You can’t see the epiglottis.  In fact, you can’t see anything in the pharynx.  It’s always difficult to assess movement and physiology of an area you can’t see.  I recently had a patient for an MBSS that told me that during the Clinical Evaluation they were told that their epiglottis is not moving.  During the MBSS, the epiglottis moved just as it should.  You can’t just assume by a symptom such as coughing that it is an airway protection deficit.

You can’t assess bolus flow.  If you have attended the Critical Thinking in Dysphagia Management course you know that assessment is broken down in 2 main areas.  Bolus flow and Airway Protection.   The point is though, once the mouth is closed, you just can’t see where the food or drink is going and how it reaches it’s final destination.

You can’t assess airway protection.  Have you ever assessed a patient at bedside and after palpation of the larynx feel pretty confident that the larynx is moving?  Then you start trying to figure out why the patient has a wet cough later in the day.  You take the patient downstairs for a swallow study and low and behold, there is no laryngeal elevation.  What you felt was the tongue moving trying to initiate a swallow.  Go ahead, put your fingers on your larynx and move your tongue.  What do you feel?

Compensatory Strategies.  My friends Theresa wrote a blog post about compensatory strategies that is definitely worth a look.  You can also read more on compensatory strategies from one of my previous posts.   How do we know for sure that a compensatory strategy is effective or that the patient is actually able to do the strategy in the correct way?  You might remember a post I wrote earlier about the chin tuck.   There was also a great post on SwallowStudy.com about the chin tuck.

Remember that by not providing our patients with best practice in assessment we may be putting them at higher risk for:

• dehydration
• aspiration pneumonia
• malnutrition
• increased length of stay
• re-admission to the hospital

Our patients deserve the best.  instrumentals aren’t always necessary for all, but they do answer many questions beyond did the person aspirate.

References:

Daniels, S. K., McAdam, C. P., Brailey, K., & Foundas, A. L. (1997). Clinical assessment of swallowing and prediction of dysphagia severity. American journal of speech-language pathology, 6(4), 17-24.

Garand, K. L., McCullough, G., Crary, M., Arvedson, J. C., & Dodrill, P. (2020). Assessment across the life span: The clinical swallow evaluation. American Journal of Speech-Language Pathology, 29(2S), 919-933.

Mathers–Schmidt, B. A., & Kurlinski, M. (2003). Dysphagia evaluation practices: inconsistencies in clinical assessment and instrumental examination decision-making. Dysphagia, 18(2), 114-125.

Logemann, J. A. (1998). Evaluation and treatment of swallowing disorders.

McCullough, G. H., Wertz, R. T., Rosenbek, J. C., Mills, R. H., Ross, K. B., & Ashford, J. R. (2000). Inter-and intrajudge reliability of a clinical examination of swallowing in adults. Dysphagia, 15(2), 58-67.

Hoffmeister, J. D. (2020). Clinical Evaluation of Swallow. In Multidisciplinary Management of Pediatric Voice and Swallowing Disorders (pp. 143-152). Springer, Cham.

Stoeckli, S. J., Huisman, T. A., Seifert, B. A., & Martin–Harris, B. J. (2003). Interrater reliability of videofluoroscopic swallow evaluation. Dysphagia, 18(1), 53-57.

McCullough, G. H., Wertz, R. T., Rosenbek, J. C., Mills, R. H., Webb, W. G., & Ross, K. B. (2001). Inter-and intrajudge reliability for videofluoroscopic swallowing evaluation measures. Dysphagia, 16(2), 110-118.

Leder, S. B. (2015). Comparing simultaneous clinical swallow evaluations and fiberoptic endoscopic evaluations of swallowing: Findings and consequences. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 24(1), 12-17.

Linnemeyer, K., & Blumenfeld, L. (2020). Evaluation of swallow. In Neurologic and neurodegenerative diseases of the larynx (pp. 79-95). Springer, Cham.

 

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