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 and FEES.
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 several 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 to give my patient a functional swallow.
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 or limited movement of the 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 can indicate poor buccal strength, decreased tension or even decreased ability to clear the residue from using the tongue. Resistive cheek exercises are probably a good way to go along with some exercises using the tongue. Sometimes patients just need to use a swab to remove the residue.
Premature spillage or posterior loss of bolus can indicate that back of the tongue is maybe not doing what it’s supposed to do containing the bolus in the oral cavity. Again, resistive lingual exercises, back of tongue exercises or effortful swallow can all focus on the back of the tongue.
What Happens in the Pharynx?
Pharyngeal residue can indicate decreased tongue base retraction and may indicate decreased pharyngeal stripping wave. There may be a problem with pharyngeal pressure to help drive the bolus. The effortful swallow or using large, thick bolus swallows can increase facilitation of the pharyngeal muscles.
Penetration/Aspiration can indicate poor hyolaryngeal excursion, which can include anterior motion of the hyoid, laryngeal elevation, hyoid/thyroid approximation or laryngel closure. There is really quite a bit of information needed here, how long does the closure last, when are they aspirating, etc. Is it a timing issue, is there decreased sensation?
You can work on airway protection through the effortful swallow focusing on hard and fast, lingual strengthening with resistance (it is attached to the hyoid, which is part of the excursion), Mendelsohn Maneuver, the Supraglottic Swallow or the Super Supraglottic Swallow.
You may 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, relaxation of the sphincter and the force of the bolus. The bolus is pushed through the oropharyngeal region by pressure of the tongue, so for PES opening issues, you may utilize the Shaker, Mendelsohn Maneuver, effortful swallow, Chin Tuck Against Resistance (CTAR) or change the bolus size and consistency.
Why do We Jump Straight to Altering Diets?
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, hopefully for a short time, 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.
What is the Dysfunction?
We don’t treat symptoms. I can’t treat aspiration. In fact, many people CAN, in fact have dysphagia without aspiration or penetration. Many people can continue to eat WITH aspiration.
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.
It’s Time for a Change
My modifieds/FEES have changed drastically. I don’t test every consistency. I test thin, nectar (mildly thick), honey (moderately thick)-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.
Don’t, Just Don’t
Use compensatory strategies, maneuvers, think about what we can do to change the sensory system. Don’t stop after the first aspiration! That’s when the study begins!
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