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.

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.  If you haven’t yet attended the CTDM course, it is highly suggested you do!  There is even an online version.   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.  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

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

Better Hearing, Speech and Swallowing Month


Many people ask me what I do. When I say Speech Language Pathologist, I often get a blank stare. I am a Speech Therapist also, but Speech Language Pathologist means that I not only treat, but assess and diagnose.  
I work with a variety of speech, language, voice and swallowing deficits including aphasia, apraxia, cognition, articulation. I do not only work with kids that have trouble saying their sounds, I work with adults to help them regain their swallowing and/or their communication.
My job is not easy. I get attached. I very recently had a patient (head and neck cancer patient with whom I worked 5-6 years ago) passed away, after choking on a piece of meat. Although there’s always that little bit of guilt there, maybe I didn’t do enough, I rest easy because I know I did do everything I could to make their life better. 
This person taught me a lot about becoming a better professional and listening. This person never completely regained their swallowing ability. This person aspirated on their very last swallow study. We knew this was happening. This person had excellent oral care, was very active and knew to take small bites, chew carefully and take their time swallowing. This person functioned for 5 years with no consequence until recently.
Although it is so hard to lose a patient and friend, I’m looking at the bright side of what I gave back to this person. I gave them their independence so they could socialize, vacation, work, meet with friends and family without the burden of a feeding tube.  
I recently saw another former patient of mine who told me the perfect words and I will carry this with me forever…. “You took something that we had that was very bad and you made it good again.”
I am a Speech Language Pathologist and I help people regain their independence, one swallow at a time.

#BHSM #slpeeps #medslp #dysphagia #swallowingmatters #dontforgettheswallow #idomorethanjustspeech

Four Things You May Not Know

                                                       Knowledge

A couple of weeks ago,  as I was driving around from home to home I stopped at McDonald’s because 1.  I had to use the bathroom and 2.  I really needed something to drink. Seeing my scrubs the cashier asked me if I was a nurse. I said no I’m a speech language pathologist but I’m often called the nurse and drive a nurse car. It was National Nurse’s Day and McDonald’s was giving a free coffee drink to any nurse that came in and showed their badge or some form of ID. I did get a free caramel latte.

It made me think though that we have so many days to honor and appreciate other professionals. We have a month for speech language pathology  that nobody really celebrates but us.

Continue reading

Standardizing Dysphagia Assessment and Treatment

Sometimes in our professional career we see, read or hear something that goes against everything we’ve learned where everything we think we know. I recently wrote a blog post about three things we need to stop doing and dysphagia assessment and treatment. That post was a challenge.

Sometimes we have to step out of our comfort zone and realize that what we’re doing needs an upgrade. Research and dysphagia is constantly evolving and showing us what we should and should not be doing.

There is no all or nothing and there is no cookbook recipe to assessing or treating dysphagia. What we need to become competent in is reading the research articles. These articles are not all or nothing. We may have a patient that the Mendelsohn maneuver is a perfect contribution to their therapy program however have 10 other patients for whom the Mendelsohn maneuver is not an option.

Research gives us a guide to help us develop an appropriate program for each patient.

When we sit in the dining room day after day and watch patients eat it downplays our role as a pathologist.  We become an aid or a waitress to many of the patients in the dining room.  Now that’s not to say that there aren’t appropriate times to assess the patient in the dining room.  What better way to assess the patient at mealtime? It is however not a skilled treatment when we sit in the dining room day after day assessing or monitoring patient tolerance.

What we need to do as a profession is to become skilled at prescribing an appropriate therapy program for dysphagia. There is an article by Dr. Gisele Carnaby called usual care and dysphagia therapy that was very eye-opening.  Dr. Carnaby and colleagues found that given one scenario they were provided with over 90 treatment plans and no two treatment plans were the same.

When we keep up with the research and new developments in our field we know that we can begin to standardized our assessment and treatment with programs such as:

  • The Modified Barium Swallow Impairment Profile- A standardized protocol to completing and analyzing the MBSS (modified barium swallow study).
  • The McNeil Dysphagia Therapy Program- A systematic, exercise based therapy program using food as resistance.
  • Pharyngocize- A protocol developed for patients with head and neck cancer.
  • Expiratory Muscle Strength Training- A program developed to increase respiratory muscle strength for increased cough response and swallowing ability.

Let me know your favorite evidence-based protocol.

Carnaby, G. D., & Harenberg, L. (2013). What is “usual care” in dysphagia rehabilitation: A survey of USA dysphagia practice patterns. Dysphagia, 28(4), 567-574.

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.

Carnaby-Mann, G. D., & Crary, M. A. (2010). McNeill dysphagia therapy program: a case-control study. Archives of physical medicine and rehabilitation, 91(5), 743-749.

Crary, M. A., Carnaby, G. D., LaGorio, L. A., & Carvajal, P. J. (2012). Functional and physiological outcomes from an exercise-based dysphagia therapy: a pilot investigation of the McNeill Dysphagia Therapy Program. Archives of physical medicine and rehabilitation, 93(7), 1173-1178.

Lan, Y., Ohkubo, M., Berretin-Felix, G., Sia, I., Carnaby-Mann, G. D., & Crary, M. A. (2012). Normalization of temporal aspects of swallowing physiology after the McNeill dysphagia therapy program. Annals of Otology Rhinology and Laryngology-Including Supplements, 121(8), 525.

Carnaby-Mann, G., Crary, M. A., Schmalfuss, I., & Amdur, R. (2012). “Pharyngocise”: randomized controlled trial of preventative exercises to maintain muscle structure and swallowing function during head-and-neck chemoradiotherapy. International Journal of Radiation Oncology* Biology* Physics, 83(1), 210-219.

Kim, J., Davenport, P., & Sapienza, C. (2009). Effect of expiratory muscle strength training on elderly cough function. Archives of gerontology and geriatrics, 48(3), 361-366.

Pitts, T., Bolser, D., Rosenbek, J., Troche, M., Okun, M. S., & Sapienza, C. (2009). Impact of expiratory muscle strength training on voluntary cough and swallow function in Parkinson disease. Chest Journal, 135(5), 1301-1308.

Kim, J., & Sapienza, C. M. (2005). Implications of expiratory muscle strength training for rehabilitation of the elderly: Tutorial. Journal of rehabilitation research and development, 42(2), 211.

3 Things to Stop Doing in Dysphagia Assessment and Treatment

                                              Books

Have you ever taken a moment to look at and assess your own treatment and  evaluation techniques?

Too often we become content with what we’re doing and stop looking to new research to continue to grow in our profession.

Dysphagia is it with growing in rapidly progressing field with new research  published.

How often are we completing the same clinical swallowing evaluation without modifying the technique?  We often do the same oral motor assessment and watch the patient eat. We don’t always assess using measurable techniques such as peak flow, lingual measurements from Lazarus, or even a cranial nerve exam.

Perhaps we are not providing enough education to other medical professionals to actually understand what we’re doing. Somewhere along the line we have educated physicians and nurses that we complete a modified barium swallow study to rule out or confirm aspiration or penetration. They often don’t realize the extent of our assessment and how we are assessing anatomy and physiology including tech Meeks to change both to increase efficiency of the swallow.

  1.  Stop “watching” patients in the dining room.

In her evaluation and treatment book Dr. Logan wrote that therapy should be separate from the dining room. That we should not be sitting with the patient at the table watching them eat and then billing for therapy.

Dr. Carnaby gave us a list including a dissection of water treatment session should look like. The treatment session, according to Dr. Carnaby should include:

  • No talking (chit chat)
  • No compensation
  • Agressive Intervention
  • Verbal, visual feedback
  • Direct in repetitions, effort, control

A dysphagia therapy session should focus on rehabilitation of the swallow, when the patient is appropriate.

2.  Stop not recommending instrumental assessment.

There is no way to accurately determine bolus flow once the mouth has closed and to see anything pharyngeally without instrumentation.  Instrumental assessments are critical to our accurate diagnosis of dysphagia and treatment planning.  Doctors can look at a patient and see that they’ve had a stroke, but will require a CT scan or MRI to determine the location and nature of the stroke, which is critical to treatment.  Not every person will require instrumentation however with the increasing availability of Flexible Endoscopic Evaluation of Swallowing (FEES) and Modified Barium Swallow Studies (MBSS) we need to use utilize these assessments when appropriate.

3.  Stop asking for an instrumental assessment to determine if the patient is aspirating.

Instrumentation has so many uses beyond identifying aspiration.  A radiologist can determine if a patient is aspirating.  As an SLP we should be using the MBSS to determine “why” the person is aspirating.  We should be looking at anatomy and physiology, trialling compensatory strategies, determining accuracy of completion of maneuvers such as the Mendelsohn and maybe even watching NMES under fluoro.  This should be an assessment to develop an appropriate therapy protocol.

We are skilled Speech Language Pathologists.  We need to show this through our assessment and treatment, particularly with changes to healthcare and changes to payment systems.  Let’s start using the skills we have acquired!

MedBridge

 

medbridge-dr

Quality education can be hard to find. Not all continuing education is evidenced-based or even good quality.

So how do you know which company to choose? To meet ASHA guidelines all continuing education is supposed to be peer-reviewed by Speech Language Pathologists with experience in the area being taught.

Remember that just because a course is offered for ASHA see use does not mean that it is endorsed by ASHA.   ASHA does provide requirements for CE providers which can be found here.

There are a handful of companies that I trust for my continuing education one of those being MedBridge. MedBridge is a subscription service or pay by course. They offer peer reviewed continuing education courses top by leading experts and ASHA Fellows in the field.

MedBridge courses are offered online making learning convenient and easy in the comfort of your own home.  MedBridge also offers their courses on mobile devices making it easy to take your learning on the go.  (I work in home health and often have long drives.)  Listening to a course on the go is easy with MedBridge.

When considering what to look for and avoid in continuing education, MedBridge hits the mark with quality courses.

I’ve had the pleasure to take several great and well taught evidence based courses including:

Stopping Falls: Evaluation of Community-Dwelling Older Adults

Introduction to Critical Care for Speech Language Pathologists

Fraud, Waste, Abuse and Other Legal Considerations

Attacking the Literature: From Journal to Bedside

Pharmocology for Geriatric Patients 

Interested in checking out MedBridge for yourself?  Use the code  DysphagiaRamblings        to sign up!  (You can click on the link for a discounted rate!)

Modified Barium Swallow Study: Gold Standard or Old News?


Instrumental assessments are always a hot topic on social media.  For many years now the Modified Barium Swallow Study (MBSS) also known as Videofluoroscopic Swallow Study or the Cookie Swallow, has been considered the gold standard for dysphagia assessment.  Flexible Endoscopic Examination of Swallowing (FEES) has become increasingly more popular and utilized, but for the purposes of this post only the MBSS will be discussed.
Why are we only looking at Aspiration and Penetration?

Often the reason for completing a Modified Barium Swallow Study is to determine the “presence of aspiration and to choose the most appropriate diet for the patient.”   An MBSS should be completed to assess the anatomy and physiology of the swallow to determine the appropriate treatment plan.  When the SLP evaluates a patient clinically, once that patient closes the mouth we can only infer what is happening.  We may have a good judgement, however an instrumental assessment can confirm or deny that judgement.

Not only does the MBSS confirm the anatomy and physiology, but should also be used to determine the effectiveness of compensatory strategies such as a chin tuck or head turn.  You can also view the effects of NMES (Vitalstim, Ampcare, eSwallow, Guardian) on the swallow with the MBSS.  For example, how do you know the Mendelsohn is effective or that the patient is even completing it in the correct manner if you haven’t viewed it under fluoroscopy?

Dr. Jeri Logemann described the Modified Barium Swallow Study as having a primary purpose to determine the presence and reason for aspiration as a basis for treatment.  (Logemann, Jeri A., and Jeri A. Logemann. “Evaluation and treatment of swallowing disorders.” (1983): 210.)

Dr. Logemann has set a protocol for administration of barium as 2 swallows of each:  thin liquids (1 ml, 3 ml, 5 ml, 10 ml, and cup drinks), pudding and 1/4 of a Lorna Doone cookie with barium.  (Logemann, Jeri A. Manual for the videofluorographic study of swallowing. Pro ed, 1993.)

The MBSS is used for more than determining a diet level.

The MBSS is not meant to test every consistency available.  It is often referred to as a “moment in time” or “not realistic to everyday consumption of a patient.”   The MBSS is meant to be a measure of the swallowing physiology, not a test of every consistency the patient may or may not consume.  Fatigue can be addressed during the swallow study by turning off the fluoro after the initial swallows, allowing the person to eat or drink and then continuing the fluoro.

In an article by Robbins et al, “The modified barium swallow permits direct observatino of oropharyngeal behavior and bolus transit from the oral cavity through the cervical esophagus during swallowing.”  (Robbins, Jo Anne, et al. “A modification of the modified barium swallow.” Dysphagia 2.2 (1987): 83-86.)

The Modified Barium Swallow Impairment Profile (MBSImP) defines 17 components of the swallow as listed below.  The protocol includes trials of thin liquids, nectar thick liquids (via tsp, cup and/or straw with a cued swallow and spontaneous swallow), pudding and cookie/cracker.  You can test other consistencies but it was determined through research that these consistencies may be enough for most patients.  Nectar thick liquids are assessed even in the absence of penetration/aspiration of thin liquids as the structural movements may increase with the thicker consistency liquid.  (Martin-Harris, Bonnie, et al. “MBS measurement tool for swallow impairment—MBSImp: establishing a standard.” Dysphagia 23.4 (2008): 392-405.)

17 Components of the Swallow:

1. Lip Closure

2. Tongue Control During Bolus Hold

3. Bolus Preparation/Mastication

4. Bolus Transport/Lingual Motion

5. Oral Residue

6. Initiation of the pharyngeal swallow

7. Soft Palate Elevation

8. Laryngeal Elevation

9. Anterior Hyoid Excursion

10. Epiglottic Movement

11. Laryngeal Vestibular Closure

12. Pharyngeal Stripping Wave

13. Pharyngeal Contraction

14. Pharyngoesophageal Segment (PES) Opening

15. Tongue Base Retraction

16. Pharyngeal Residue

17. Esophageal Clearance

Please don’t stop with aspiration.

Often MBS Studies are discontinued because the patient aspirates.  This should be the time you trial compensations and strategies to stop aspiration.  This study probably isn’t the first time the patient aspirated.  They are coming in for a swallow study aren’t they?  It is your job to determine why they are aspirating and how to stop it.

Communication is key.

As the treating SLP, it is so important to get information to the SLP completing the instrumental assessment regarding patient history, why you are ordering the study and possibly even some information about your tentative treatment plan, current diet level, etc.  Most patients are not able to relay the information the same way an SLP would, if at all.

As the assessing SLP or the SLP completing the instrumental assessment, it is critical that the treating SLP receive a report they can use to build a treatment plan.  It is impossible to educate a patient on why they are on an altered diet or why they need to use such and such compensation when the SLP is unsure.  The report needs to include compensations trialed and effective or ineffective.  It’s also very difficult to know what consistencies, amounts, etc to use for therapeutic trials if the study was discontinued after one instance of aspiration on a teaspoon of thin.

You won’t get an instrumental assessment if you don’t request it.

Often instrumental assessments are not recommended for a variety of reasons.  Maybe you have sent multiple patients out for an MBSS and the report is not what you need to create a solid treatment protocol.  Maybe the patient refuses or the doctor refuses or the facility refuses.

It is time that we educate physicians, nurses and other medical professionals on the purpose of the MBSS.  Physicians often know or have a good idea that a patient had a stroke.  They still use the CT scan and/or MRI to determine size of stroke, location of stroke and whether the stroke is acute or an old infarct.  We need the same diligence in our field to assess dysphagia beyond just penetration/aspiration and diet selection.  Whether the physician orders the MBSS or the patient participates should be irrelevant to our recommendation for MBSS.  If we believe the MBSS is an important tool to our patient’s care, document and recommend.