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The Great Thickener Challenge

The Great Thickener Challenge

So maybe it’s not really great, but it was a challenge. So what in the heck am I talking about??

Have you ever looked at all those different brands of thickener? Sometimes you don’t know which will be the best for your patients. Between Thick-It, Simply Thick, Thick n Clear, ThickenUp it’s hard to decide which will be best for your patient. Maybe by best, we also need to think about the look, taste and consistency that will be the most palatable for your patient.

I think we’ve all had those patients that just won’t drink because you put “that stuff” in their drinks. Their family members say if they could just have a drink of something maybe they’ll feel better.

There is a very nice product out there called the Provale cup. By limiting the amount of liquid a patient receives, either 5cc or 10cc, the patient may then be able to safely drink thin liquids. The Provale cup is for another post.

Going to conferences, particularly, the ASHA Convention, there are samples of thickener to go around. Nestle Nutrition also provides samples of ThickenUp free of charge. I decided that one day I would mix these samples with water, using the same container and method to mix, the same water and thicken the water to nectar consistency, just to see the variation.

I used 4 ounces of water from our cooler, which is purified water. I put the 4 ounces in a shaker and shook the water mixed with the pre-measured packet of thickener for nectar consistency. I shook for 30 seconds and then poured the liquid in a small cup.

The liquids were allowed to sit our for 10 minutes then the taste test began.

The following are comments by patients, therapists and myself regarding each thickener, marked by number. I could only get 4 to sample the thickened drinks, which is not a significant number, but I’m not publishing this…..

1. Clear-bubbly
No added flavor
water with added flavor
no flavor
slightly sweet
tastes like water
looked good

Preferred by 4

2. Cloudy
Thick chalky tasting
left after taste
“looks thick”
thicker than #1
not bad
no flavor
very thick
looks terrible
tastes terrible
feels sticky
had to wait for sip

Preferred by 0

3. Cloudy
after taste
not palatable
tastes bad
thinner than 2
little thick
tastes-not too bad
looks bad

Preferred by 0

4. clear
slimy-coating after
flour taste
similar to #1
little thicker
looks good
too thick
after taste
sticking all over

Preferred by 0

5. clear
no over-powering flavor
no after taste
no flavor at all
looks ok
went down ok
no taste

Preferred by 0

6. cloudy
starchy taste
worst thing seen or tasted

Preferred by 0

7. cloudy
thick and clumpy
starchy taste
spit back out
too thick
tastes/looks terrible

Preferred by 0

There were many variations including the yield, the color varied from clear to cloudy. The consistency differed from a honey consistency to a slightly thicker than thin consistency.

The results:

#1 Simply Thick

#2 Thick It

#3 Thick It 2

#4 Thik and Clear

#5 Thicken Up Clear

#6 Thicken Up

#7 Thick and Easy

By a landslide, all 4 people chose Simply Thick as the best during this challenge.

Everyone should challenge themselves to get as many thickener samples as they can.  Try those thickeners and determine the quality of the thickeners so that you can make an educated recommendation for your patients to increase their willingness to comply with the liquids and to provide them with the best quality thickener available.

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Using your iPad in Dysphagia Therapy

Using Devices with Dysphagia

Let’s Get Techy

So many people are using iPads, iPhones and iPods in therapy. While there are many other devices out there, I’m focusing on the i devices because those are the devices that I know the best. It is very easy to find apps for pediatric speech therapy, even apps for adult language therapy. There are apps for language, articulation, AAC, voice, fluency, and a few for dysphagia, but not many. It seems that few therapists are using their devices for dysphagia therapy. In lieu of the small amount of apps available for those of us specializing in dysphagia therapy, we can very effectively use our devices for treatment.

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My "Unproductive" Day

In the world of productivity demands, RUG levels, Medicare reimbursement, we are often pressured to see as many people as we can, then go home.  Productivity demands become increasingly cumbersome for most of us and have become a great source of stress.

The thing is, productivity does not tell the real story of my day.  As I don’t work in a SNF, some days,  productivity can be difficult, but I leave my job exhausted.

Some days, I am running between floors trying to fit in both inpatients and outpatients.

Some days may look a little like this:

8:00 Arrive at work, open my office, put my bags away then walk to the front desk to check my schedule.

8:15 I have checked for new orders, I have 3.  2 of them are Modifieds.

8:20 Call xray to see if they received the orders.  No??  Ok, I’ll call third floor and have them put it in.  I finally get someone to answer on third floor, after the third attempt.  They’ll put the orders in right away.  I ask if they can have the patient ready in about 15 minutes.  No problem.

8:40 Grab my radiology bag from my room, run downstairs to 2nd floor to get ready for the modifieds.  I mix the barium for the studies.  The orders still have not arrived.  I go upstairs to help get the first patient because X-ray is short-staffed.  Patient 1 is not ready, student nurses are giving them a bath.  Patient 2 is not ready because they still need to get their meds.  The orders are not in yet.  Yes, they are order number XXXX.

9:00 Patient 1 is finally ready.  They need to be transferred per bed.  We push them down, get the Hausted chair ready, then call ER to help transfer the patient.

9:20 The patient is ready….

You get the idea.  Many of the things we can’t bill for ARE necessary to effectively treat and/or assess the patients that we do have.  The phone calls, the information sharing with the nurse, talking to other therapists about issues you feel will help enhance their session.  These are all very important, very much needed parts of our day that can take much of our time.

We live in a productivity-based world, but we have a non-productivity-based profession.

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As many of you know, if you follow me on Twitter or participate in the Facebook Dysphagia Therapy Group, I went to the MBSImP live conference this past weekend.  For those of you that don’t know what the heck the MBSImP is, it stands for the Modified Barium Swallow Impairment Profile.  What it is, an answer to everyone’s prayers to FINALLY have a standardized method for swallow studies.

This protocol for MBSS is based on more than 10 years of work and research.  A powerpoint presentation is available from Dr. Martin-Harris regarding the MBSImP.   Nancy Swigert also wrote a nice review of the MBSImP.  NSS-NRS is the company that provides the MBSImP training.

The course consists of a “live” course.  You go for a day and a half to learn about the MBSImP from Bonnie Martin-Harris.  The course entails comprehensive review of each physiologic function of the swallow, and goes over scoring for the MBSImP.  The MBSImP consists of 17 components from labial seal to esophageal clearance.  Each component is scored from 0 to either 3, 4 or 5, with the higher number indicating a worse impairment.  After you go to the live course, you have the option to proceed with the MBSImP training through an online module.  The cost of the live course is applied to the online module.

The nice part of the MBSImP is the training slides.  Each MBS frame has a corresponding animation making each component of the swallow easy to see for the training purposes.  The animations are used in the live course and the online module.  With the online module, you go through a training section, a practice section and then a test.  With the test, you have to have 80% reliability on your scoring.  Once you reach the 80% (you can take the test as many times as needed), you become a registered user and have access to a database.  This database allows you to input your patient information, which is de-identified to create a comprehensive report for each swallow study you complete.

Part of the live training is respiration and respiration in relation to swallowing.  One thing we learned is that most people will inhale and partially exhale before swallowing.  When the swallow is complete they will finish the exhalation.  It is important that we as therapists evaluate the respiratory pattern of the patient and take that into account.  One point that was emphasized was to teach an expiratory cough to clear and not cue the patient to inhale then cough.  Also to force “audible” vocal closure, or take a deep breath with an audible “huh”.

There is a complete outline including instruction to patient, what barium to present, when to present each consistency and how much to present.  This is done in a precise manner, however it was emphasized that you DO NOT HAVE TO FOLLOW THE PROTOCOL.  There will be times that you have to use your clinical judgement.  Now, with the database, Bonnie will have access to all of the inputed data, remember, it is de-identified.  To be a part of her collection of data, she needs to protocol to be standardized, but if it is not necessary or safe to standardize it for your patient, then you do it how you need to do it.

With the MBSImP, you score each component with the given scale.  You are working to capture IMPAIRMENT.  This is not focusing on aspiration, penetration or testing every consistency known to man.  This is focusing on the function of the swallow and the dysfunction to create an appropriate therapy plan to rehabilitate the swallow.

I plan to implement this in my practice, although I do to some extent already.  This gives me a standardized score for the swallow study.  This score allows me to demonstrate improvement and to focus on more than just penetration/aspiration, diet consistency, pooling, etc.  You focus more on the actual dysfunction.  The decreased TBR, the decreased pharyngeal stripping wave, they opening of the Pharyngeal Esophageal Segment (PES).  Dr. Martin-Harris uses PES rather than Upper Esophageal Sphincter (UES).

I think that this Profile came at the right time.  More than ever, we as SLP’s need to stand our ground and maintain our status as dysphagia experts.  We are the ones that study this mechanism.  We need to evaluate properly.  A modified should not be merely to determine aspiration or to see if the person if “safe” with thin liquids.  We need to determine dysfunction, rehabilitate the swallow system and re-evaluate to determine improvement of the function.  This will not only create a much nicer and less subjective study (really, what does mild, moderate and severe tell me?)

This brought back a lot of the information that I learned from Mary Simmons through CIAO Seminars.  We don’t treat aspiration, penetration or premature spillage. We treat the dysfunction, the decreased hyoid protraction, the decreased laryngeal elevation.

I think when we realize that dysphagia is muscle-based function of the body that works as a system, we can effectively diagnose and treat the dysphagia, the dyfunction instead of worrying so much about the actual aspiration or sticking our tongues out 10 times.  Then and only then can we call ourselves a dysphagia expert.

All-in-all I’m very excited about this protocol and the direction in which it takes our field.  I highly recommend it to all dysphagia therapists, whether you actually are responsible for MBSS or not, you can still learn quite a lot about the swallow function and I believe it will be much easier to interpret the results if you have a therapist that uses the protocol.

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Training other professionals in Dysphagia

As a dysphagia therapist, I am often asked to train or inservice other professionals in dysphagia.  This usually includes inservices for nursing staff, CNA’s, dietary and at times, other therapists.

I find that the best way to educate, is to let them “experience” dysphagia.  I will typically go over the basics of the swallow.  I will go over the oropharyngeal structures and their function in swallowing.  The lips help keep the food/drinks in the mouth, the tongue helps to move the food/drink around in the mouth and to push it back to the throat, the cheeks help keep food from pocketing between the gums and cheeks, the airway moves up and forward and the esophagus opens.  I find that if they understand that dysphagia involves more than just coughing with drinks or food.

I try to simulate dysphagia with my students.  I have been known to have them perform the Masako, put peanut butter on the floor of the mouth and have them keep their tongue in it then chew bread without moving their tongue.  I give them a whole medicine cup full of Tic Tacs and tell them to swallow them.  I have also blind-folded someone and then fed them pureed foods, in the same manner they feed the patients, large, over-flowing spoonfuls, one after another.

I also go over the signs and symptoms of dysphagia.  Certainly coughing/choking will indicate dysphagia, but also difficulty chewing, difficulty swallowing pills, complaint of food sticking in their throat, pain, weight loss, etc.  Most of the nursing staff I have encountered do not understand dysphagia nor do they understand how we treat it.

Always make sure and go over the treatment methods.  We use compensatory strategies for a reason, along with maneuvers, strengthening exercises, NMES, DPNS and thermal-tactile stimulation.  I don’t go into great detail about the treatment methods, however a little education can go a long way.  Once doctors and nurses understand what we are doing and that we can rehabilitate the swallow, they tend to recommend speech more for patients.

In previous posts, I have stressed the importance of educating the patient.  Our job is continual education.  I live in a very rural area, in fact I work in a 25 bed hospital.  Most people in our area do not know anything about dysphagia.  Education for the public and doctors and nursing is what has helped me to increase my referrals.  I started in the hospital in August of 2009 with maybe 3-4 patients a week.  I know regularly have 12 or more patients on my outpatient caseload and receive 2-4 inpatient referrals.

Once others understand what you are doing, they not only have more respect for your work, they will also tend to send you more appropriate referrals.

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Put Yourself in Their Shoes

Put Yourself in Their Shoes

My number one rule-of-thumb, especially when treating my patients with dysphagia is to put myself in their shoes.  I must consider their goals and wishes as well as their understanding of dysphagia and how that impacts their therapy.  Swallowing assessment and therapy is very much dependent on how well you can explain what you are doing with your patient.

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