The History of the Modified Barium Swallow Study

No matter what you call it…there is a history behind the Modified Barium Swallow Study (MBSS).

Gold Standard?

The Modified Barium Swallow Study has long been called THE gold standard in dysphagia evaluation, however it does have its limitations.   The MBSS definitely continues to be A gold standard in swallowing evaluation.


Early Days

In the 1970’s, Dr. Jeri Logemann developed the MBSS or the Cookie Swallow Test.  She presented on this test at the ASHA convention in 1976.

During the Cookie Swallow Test, patients were given 2 cc of radiopaque liquid, 2 cc of paste, and 1/4 of a cookie coated with barium.  The liquid barium was given first, then paste, and last,  the cookie.   Patients were recorded with 2 swallows of each consistency.

Dr. Logemann then described liquid/food presentation as 3 swallows each of:

  • 1 ml thin liquid by spoon
  • 3 ml thin liquid by spoon
  • 5 ml liquid by syringe
  • 10 ml liquid by syringe
  • (can give larger amounts also)
  • Cup drinks
  • Saliva Swallow (no barium, just watch muscles move with swallow)
  • Pudding with barium (1/3 tsp or 1 ml of 2 parts pudding to 1 part barium)
  • Other food textures mixed with barium

Linden and Siebens,  developed a new approach to the VFSS which was based on patient specific deficits.  They used representative radiopaque foods similar to those the patient ordinarily ate.   The  study started with the food which would be safest for the patient to swallow, as determined by the SLP.  The study then progressed to increasingly difficult foods/liquids ending with those the patient was most likely to aspirate. Compensatory maneuvers (such as modifications of feeding or positioning) were tested  as a basis for developing recommendations for diet and treatment.

Standardized MBSS

Dr. Bonnie Martin Harris recently developed the Modified Barium Swallow Impairment Profile (MBSImP) which is the first standardized assessment of the MBSS.  (More on that to come!)

The Study

The MBSS consists of the patient, usually seated in a special seat, having an X-ray study, examining the oropharyngeal cavity.  The patient is given a variety of liquids and food, all mixed with barium as the barium can be viewed during the real-time video of the study.

The study is typically (should be) recorded for review of the test later.   The video can be slowed down for more accurate view of the swallowing structures.

Often, the MBSS is started and once the patient aspirates on the first consistency, the exam is discontinued.  This should not be the case as modifications can be made to:

  • amount presented
  • method of presentation
  • posture
  • position of head when swallowing
  • texture
  • temperature
  • taste

Although at one point, most SLP’s were completing the MBSS study to determine penetration/aspiration and what the best diet consistency is for the patient to safely consume, we now know better.

The MBSS is a test that allows us to view the oropharyngeal structure from the side (lateral) and from the front (A-P view) to determine the physiology of the swallow, meaning that we determine what muscles are moving and how.

Although we may test a wide variety of consistencies, thin liquid, nectar thick (mildly thick), honey thick (moderately thick) liquids, pureed, mixed consistencies, soft foods and regular foods, there is no way for us to possibly test every single consistency the person may consume.

But Why MBSS?

That is why it is important to look beyond penetration and aspiration and to look at the physiology of the swallow including what is functional and what is not.   This is what leads us to accurate diagnosis and treatment planning for patients.

More to come on the MBSS!


Logemann JA. Manual for the videofluorographic study of swallowing. 2nd ed. ProEd; Austin, TX: 1993.

Logemann JA. Evaluation and treatment of swallowing disorders. ProEd; Austin, TX: 1998.

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. Dysphagia23(4), 392-405.

Linden PL, Siebens AA: Dysphagia: predicting laryngeal penetration. Arch Phys Med Rehab 64:281-284, 1983.

Siebens AA, Linden PL: Dynamic imaging for swallowing reeducation. GastrointestRadio110:251-253, 1985.

Linden P: Videofluoroscopy in the rehabilitation of swallowing dysfunction. Dysphagia 3:189-191, 1989.

Palmer, J. B., Kuhlemeier, K. V., Tippett, D. C., & Lynch, C. (1993). A protocol for the videofluorographic swallowing study. Dysphagia8(3), 209-214.

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. Dysphagia23(4), 392-405.

Martin-Harris, B., Logemann, J. A., McMahon, S., Schleicher, M., & Sandidge, J. (2000). Clinical utility of the modified barium swallow. Dysphagia15(3), 136-141.

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