The Dysphagia Toolbox
I have written about the Dysphagia Toolbox before. The Dysphagia Toolbox used to be a website that offered links to standardized and reliable tools that you can use in dysphagia assessment and with reassessment.
Why a toolbox?
The one thing I can’t help thinking is why we call it a toolbox. Do most of you actually carry a toolbox full of your must-have dysphagia assessment/treatment equipment? Mine is usually jammed in my lab coat pockets or on top of my clipboard, if I remember to even bring that with me! Although I often imagine SLPs running around with a toolbox.
Maybe saying our dysphagia “apron” would be more appropriate?? Now, I have recently seen the SLP fanny pack, which may also be an option!
Anway, I digress…
There are several outcome measures that are freely available for us to use for your Dysphagia Toolbox. Outcomes should be taken at baseline, when therapy is initiated and can be used to show progress during reassessment and to show progress for discharge.
There are questionnaires that the patient completes, indicating current symptoms when eating/drinking including:
Eating Assessment Tool-10 (EAT-10) which has 10 areas where the patient rates their swallowing to determine the impact of dysphagia on the patient’s daily function. The EAT-10 has several open articles of research to support it’s use (including many for use in various languages which are not included here yet…..). You can find the research: Article 1, Article 2, Article 3. There is also support for use of a Pediatric EAT-10 which you can find information: Article 1 or Article 2.
Swallowing Disturbance Questionnaire is a self-questionnaire with 15 items that are rated by the patient on a scale of 0-3 on the frequency of occurrence of various issues related to swallowing. You can download the research Article 1.
Swallowing after Total Laryngectomy Questionnaire (SOAL) a questionnaire to assist patients in rating their swallowing following total laryngectomy.
MD Anderson Dysphagia Inventory (MDADI) is a self-inventory to determine difficulty with swallowing for patients with head and neck cancer.
Swal Qol is a questionnaire about quality of life with dysphagia. (This is a link to Scribd. You can sign up for a free membership for 30 days and download the Swal Qol immediately.)
The Visual Analog Scale can be used to have the patient assess their swallow by pointing to an area on a line. “Using a ruler, the score is determined by measuring the distance (mm) on the 10-cm line between the “no difficulty” anchor and the patient’s mark, providing a range of scores from 0–100. A higher score indicates greater swallowing difficulty.” There are several articles to support use of this scale: Article 1, Article 2, Article 3 and Article 4.
Clinicians may use:
The FOIS is actually much the same as the ASHA NOMS, which can be used to give a numeric patient rating by the diet they are currently consuming. (You do have to take a training to use the NOMS and report findings to be able to use the NOMS.)
The Mann Assessment of Swallowing Ability (MASA) is completed the the SLP as they complete a bedside or clinical swallow evaluation. This gives a numeric score (up to 200) and provides a rating scale (mild, moderate severe) for both dysphagia and aspiration. You can find research (article) to support use of the MASA. You can find the scoring guidelines (with severity ratings). There is also a downloadable version of the Modified MASA. Information on the Modified MASA can be found in this article.
The MASA is also available in a version for patients with cancer called the MASA-C. You can find the scoring guidelines (with severity ratings just scroll down towards the bottom of the page). Research for the MASA-C can be found in Article 1 and Article 2 as well as a poster presented at ESSD. Did you know the MASA is available as an app?
Dysphagia Screening Questionnaire a screening tool for professionals to screen for dysphagia following stroke.
The Reflux Symptom Index is a 9 question rating scale that a clinician can administer to patients to determine if reflux may be a factor in swallowing disorders to make a referral.
The Volume Viscosity Swallow Test (chart can be found in downloadable book) was created to screen for impaired swallowing and accuracy of deglutition during a Clinical Swallow Evaluation. You can download the research behind the V-VST in Article 1, Article 2, or Article 3.
The Gugging Swallowing Screen (the protocol can be found in the article) utilizes liquids, solids and semi-solids with a severity of swallowing rating. The indication is that diets can be modified with use of this tool. You can also find more of the research in Article 1.
TOR-BSST is another tool to use for screening dysphagia. The Toronto Bedside Swallowing Screening Test is a screen that was developed to predict dysphagia in patients that have had a stroke. You can find the research in this article. Use of the TOR-BSST requires training and you can register for that here. To obtain the form, you do have to complete the 4 hour training.
The Metro Health Dysphagia Screen can be found in in this article. This screen was developed for use in the ER for patients that have had a stroke. The Metro is a screen that is administered in emergency room that is pass/fail with no liquids/solids trials. The protocol involves asking 5 questions. One or more “yes” answers is positive for possible dysphagia.
The Guss ICU is a post-extubation screen to determine presence of dysphagia. The protocol can be found in the article. This screen is pass/fail with questions answered by the SLP with follow-up presentation of food and liquid if appropriate.
The Barnes Jewish Hospital Stroke Dysphagia Screen (protocol is included in the link) consists of 5 items that are marked as present or absent. The presence of 1 item equals a fail. If the patient fails, they are made NPO with a speech consult. If they pass, they are placed on a regular diet.
Performance Status Scale for Head and Neck Cancer Patients (link from EATTHINKSPEAK) is a tool to determine the impact of dysphagia on diet and eating out through the use of an interview format. Research for the PSS-HN can be found: Article 1, Article 2, Article 3.
The Dysphagia Screening Tool is a guide for physicians and nurses that are trained in dysphagia to complete to determine if the patient requires further SLP evaluation. The link above includes the tool and instructions.
The Kayser-Jones Brief Oral Health Status Examination (BOHSE) is another oral health assessment tool. The link will take you to the protocol, instructions and references.
Test of Masticating and Swallowing Solids (TOMASS) has been described as being a valid, reliable and broadly normed quantitative clinical assessment of solid bolus ingestion. You can find further studies: Article 1, Article 2. There is also evidence for use with Peds in this article.
The MD Anderson Symptom Inventory Head and Neck (MDASI-HN) is a questionnaire that can be completed with the patient. This tool can help to predict mucositis. You can buy the tool here for $100. You can also find a sample of the tool. There is also research for this tool Article 1, Article 2, Poster, Article 3.
Residue Scales for MBSS/VFSS/FEES:
The Normalized Residue Ratio Scale is a tool to use to measure the amount of residue in the valleculae and pyriform sinus utilized during MBSS/VFSS. You can find research supporting use of the scale in article 1 or article 2.
ASPEKT Method-The Analysis of Swallowing Physiology: Events, Kinematics and Timing is a method to train the clinician to determine the underlying physiology and mechanics that are causing the impairment of the swallow during MBSS/VFSS. This method comes from the lab of Dr. Catriona Steele. You can find more information at the lab website including a free webinar and question and answer session. Research can be found by clicking this link and the reference tables can be downloaded here. There is also a downloadable handout, worksheet, scoring sheet and detailed step-by-step instructions using ImageJ and using TIMS. (You can find more information on TIMS/Dicom or ImageJ).
The Yale Pharyngeal Residue Severity Rating Scale (the scale is available if you scroll down) is a measure of residue in the valleculae and pyriform sinus during FEES. You can also find the scale with pictures at this site. The research can be found for article 1 and article 2 and you can even buy a book dedicated to the scale here.
The Penetration Aspiration Scale gives numbers regarding how deep penetration/aspiration occurs and if it was cleared or not. This can be used during MBSS or during FEES to describe the penetration/aspiration.
The Modified Barium Swallow Impairment Profile is a standardized means to modifieds with rating scores given to each of 17 physiological events during swallows of multiple consistencies. Training is required to become a registered user of the MBSImP. Read more about when I took the MBSImP here.
The Boston Residue and Clearance Scale is an 11-point ordinal residue rating scale that analyzes 3 areas of residue during a fiberoptic endoscopic evaluation of swallowing (FEES) including the amount and location of residue, the presence of spontaneous clearing swallows, and the effectiveness of clearing swallows. Research to support this scale can: Article 1, Article 2, Article 3, Article 4, Article 5.
DIGEST (Dynamic Imaging Grade of Swallowing Toxicity) (click the link and scroll for the scoring guide/protocol) is a measure for oncology trials (i.e., grade 1= mild, grade 2= moderate, grade 3= severe, and grade 4= life threatening pharyngeal dysphagia) that reflects the combined impairment in swallowing safety and efficiency which is used during MBSS/VFSS. You can find the research: Article 1, Article 2, Article 3, Article 4.
Looking for reviews?
A Systematic Review of Current Clinical and Instrumental Swallowing Assessment Methods can be found here.
You can also find Review of Evidence Based Nursing Protocols for Dysphagia Assessment.
Just a small dent…..
This is an ever-growing list of some of the outcome measures available to us. You want to look for measures that are both valid and reliable. Not all measures listed have the same validity or reliability as others. Links to research are provided and links to forms are provided as available. Download, read and determine if these measures are the most beneficial to answer your questions related to dysphagia and the best outcome to determine the presence of dysphagia with your patients. Remember, all assessments we currently have are a series of screeners. Outcomes give us a way to measure progress by stating where the patient began and ended therapy. It is crucial in this day and age with Medicare to measure your outcomes in a clear and precise manner.