Dysphagia Assessment

So many people assess dysphagia in the same manner, at least from my observations. Sit with them while they eat a meal, feel laryngeal elevation and trial diet modifications. I have rarely seen people do a thorough dysphagia bedside evaluation.

 I’m trying to standardize the manner in which I complete my bedside evaluation. I have started using the SOPE, the MASA and the Sage during every assessment, along with a thorough chart review and assessing aspiration risk factors. I can complete a fairly thorough assessment. The SOPE assesses cranial nerves, taste buds and some muscle function. The Sage assesses oral cleanliness and need for oral care. The MASA has been a fairly accurate indicator of dysphagia from my standpoint. I also do the traditional feel for laryngeal elevation, but I also feel for hyoid protraction. I have started assessing with water and graham crackers. If I need to, I will thicken the liquids, but usually wait for an instrumental assessment. I also have started using the 3 ounce water swallow challenge, which has been a good indicator for aspiration from what I have done so far.

 It is important to assess cranial nerves and to understand the cranial nerves. For instance CN XII, the hypoglossal nerve has no sensory pathways, only motor. This definitely affects the means by which you will treat. Another point that has been drilled into my head is that sensory input drives motor output. If you can increase the sensory input a person receives you can increase the amount of output in the muscle functions. Cranial nerve assessment is vital in understanding dysphagia. Sensory input such as olfactory and optical help to prepare the person for the swallow by increasing saliva and telling the body that it is going to masticate and swallow food/drink. Sensory input can also be established through tactile, thermal, or NMES input. In fact, Vitalstim placement 1 has the highest sensory input of all the Vitalstim placements. DPNS is highly driven by sensory input to the cranial nerves through use of frozen lemon swabs, along with thermal, tactile stimulation (TTS).

 You can actually tell a lot about a person by their oral hygiene. You can tell who will qualify for Frazier Water Protocol. Also, by oral hygiene, you can make an assumption that the person is at higher risk for aspiration pneumonia because of the poor hygiene of the oral cavity. It is important to let nursing and nursing staff know how often to complete oral cavity for patients that are unable to complete this task with independence.

 It is vital to assess motoric function. You treat the motor dysfunction, not the symptoms, i.e. aspiration. If you assess a person and can only tell that they are aspirating, but not WHY they are aspirating, you are no better off than you were before the assessment. There are many areas of function that are vital to swallowing, labial closure, lingual to palate contact, bolus management and propulsion (lingual strength), velar elevation, tongue base retraction, pharyngeal sqeeze, hyolaryngeal excursion (laryngeal elevation, hyoid protraction and hyoid thyroid approximation) and UES opening. I am extremely excited about the MBSImP which will be published next year with certification courses to follow!!

 The 3 ounce water swallow challenge is fairly new. It is an indicator of aspiration as it is believed, people that silently aspirate small amounts of liquid will choke with larger volumes. 3 ounces of water is enough to make a person choke, as it is stated per this protocol that silent aspiration is volume dependent. With this challenge, the person is given 3 ounces of water, either by straw or cup sip. They drink the water continuously. Any coughing, throat clearing or inability to drink all 3 ounces at one time is considered a fail. If the person can continuously drink the water and not cough during or for a minute after the challenge, they pass. Those that fail are then assessed instrumentally.

 Watching a person eat is also very critical to the evaluation. One predictor of aspiration is inability to self-feed. Medication can often affect a person’s ability to swallow, affect amount of saliva a person has to help break-down the food orally or affect the person’s alertness.

 A thorough dysphagia exam is vital and necessary for treatment. A good bedside examination with instrumental assessment will aid you in accurate assessment for thorough and appropriate treatment for dysphagia.

Put Yourself in Their Shoes

My number one rule-of-thumb, especially when treating my dysphagic patients is to put myself in their shoes.

 First, I need to make this patient and their family member understand just what is going on. No, I don’t explain dysphagia in medical terms, but it is easy to put into layman’s terms when you understand the swallowing process. The patient needs to understand dysphagia, what is compromising their swallowing function and understand how and why dysphagia treatment will make them better and safer. Patients need to understand that this can be a life-threatening dysfunction but that it can be improved through therapy, diet modifications, compensations, etc.

 I also have to remember that one of the joys in life is eating. We all go through our day eating and drinking. It’s how we socialize, what we do at holidays. Our patients do not want to continue on a pureed diet with honey thick liquids when there is therapy available to possibly get them to a higher level. I’ve seen too many people discharged from therapy on an altered diet because the therapist has no idea what to do with them. I’ve also seen patients upgraded before they even really have therapy. Upgraded three days after the MBSS with severe dysphagia and aspiration is not an appropriate upgrade.

 Remember that our job as dysphagia therapists is to rehabilitate, or bring about change to the swallowing system and the musculature of the swallowing system. We cannot bring about change by sitting with a patient during lunch and reminding them to tuck their chin. We cannot bring about a change by having them stick out their tongue 30 times a day and think that’s going to improve the swallow. The only true exercise for the swallowing system is swallowing and challenging the patient with the swallow.

Exercise

Recent and some previous dysphagia literature emphasizes the use of exercise physiology. Researchers such Lazarus et. al, Robbins et.al, Burkhead et. al and Clark have published the need for incorporating exercise physiology into dysphagia therapy. They emphasize the need to understand the muscles involved in the swallowing mechanism, understand their function so that you can exercise those muscles in the manner in which they function for the swallow.

 The best way to work and improve the swallowing function is to swallow. Not only simply swallow, but push the swallow beyond it’s normal capacity. One way to incorporate increasing the load of the swallow is to use the effortful swallow, the masako or the Mendelsohn maneuver. The Shaker is a great load-resistant exercise to increase opening of the UES. These exercises have been researched and shown to be effective. Logmemann credits the research that has been established for the Shaker exercise and the lingual strengthening exercises from Robbins to increase lingual strength, with overall strengthening of the swallow.

 I’ve started an exercise approach to my dysphagia therapy. I started using almost like a “circuit” of swallowing training. I give the patient a list of exercises to complete while in therapy. Depending on what they need to focus their therapy, they complete a circuit of exercises. I use a variety of swallowing exercises including the Mendelsohn maneuver, effortful swallow, lingual resistance exercises, oral manipulation exercises. Most exercises include swallowing as part of the exericise. One of my favorite strengthening exercises is sucking pudding through a straw. I have the patient start with a regular drinking straw and work their way down to using a coffee stirrer. This not only strengthens the tongue, cheeks and lips, it also requires that they swallow. They spend x number of minutes of each exercise.

 Taking an exercise-based approach to swallowing is far superior to simply altering diet consistencies or adding compensatory strategies to each swallow. Rehabilitation should bring about a change to the swallow mechanism. I do not nor will I use compensations or altered diets in my therapy. I may put the patient on an altered diet, but I want to work the system naturally, not with a compensation if I can avoid it! Look to your PT and OT departments. They work the muscles to bring about change and we should be doing the same.

 Logemann, J.A. (2005). The Role of Exercise Programs for Dysphagia Patients. Dysphagia. 20: 139-140.

 Clark, H.M. (2005). Therapeutic exercise in dysphagic manamgent: Philosophies, practices and challenges. Perspectives in Swallowing and Swallowing Disorders, 24-27.

 Robbins, J.A, Butler, S.G, Daniels S.K., Diez Gross, R., Langmore, S., Lazarus C.L., et al (2008). Swallowing adn dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. Journal of Speech, Language and Hearing Research, 51: S276-S300.

 Burkhead, L.M., Sapienza, C.M., Rosenbek, J.C. (2007). Strength-training exercise in dysphagia rehabilitation: Principles, procedures and directions for future research. Dysphagia, 22:251-265.

 Clark, H.M. (2003). Neuromuscular treatments for speech and swallowing: A tutorial. American Journal of Speech-Language Pathology, 12: 400-415.

 Robbins, J.A., Gangnon, R.E., Theis, S.M., Kays, S.A., Hewitt, A.L. and Hind, J.A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatric Society, 52, 1483-1489.

 Lazarus, C., Logemann, J.A., Huang, C.F., and Rademaker, A.W. (2003). Effects of two types of tongue strengthening exercises in young normals. Folia Phoniatrice et Logopaedica, 55, 199-205.

Dysphagia2Go-Revolutionizing the Dysphagia App World

Call me a little partial, but I LOVE this app.  Dysphagia2Go has given me a new way to utilize my iPad in my dysphagia therapy.  I also can use it with the confidence that it is HIPAA compliant.  Yes, I am one of the authors, but this app was created out of the need to complete a quick and simple Clinical Dysphagia Evaluation.  This app was created to assist clinicians in assessing all areas for dysphagia and to complete a chart review that is as thorough as possible.

 

When you open the app, you will first begin by adding your patient information.  You can save patients or you can bring up previous patient information.  When adding a new patient, you will be prompted to input a Patient ID, Patient first name, Patient last name, Patient Date of Birth and Physician’s Name.  If you are not comfortable adding a patient name, you can assign each patient a number or simply use initials.

 

One thing you will want to make sure to do is go under settings and add your therapist and institution information.  Turn the information on to add it to your reports.

 

Once you have added that patient, you can either view a saved report, or you can add a new evaluation.  To begin the evaluation, you will select the chart review tab.  The chart review will prompt you to input the reason for referral, physician order (yes or no), diagnosis, current method of nutrition, respiratory status, etc.  There is also a text box that you can input any other pertinent information from your chart review.  Don’t worry, new sections are being added to complete a more thorough chart review.

 

Once the chart review is completed, you can go assess the patient and begin to start the Oral Mech Exam.  This will prompt you to input information regarding all the oral and pharyngeal areas that we assess, including the tongue, teeth, lips, etc.

 

Upon completion of the Oral Mech Exam, you will be able to assess trials.  Either use the consistencies provided or skip the consistencies not used.   For each consistency, you will be able to assess oral control of the bolus, pharyngeal stage of the swallow and add any comments needed.

The final section is the Recommendations section.  You will be able to recommend compensatory strategies, exercises, MBSS, FEES, therapy, no therapy, or referrals.

 

Once the evaluation is complete, you can download the report and either print it wirelessly or email it to yourself and print it.  You also have the option to email it to yourself and cut and paste into your computer-generated report if your facility has a report that is required to be completed.

 

A few tips to remember with this app, first and foremost, please make sure to lock your iPad with a passcode.  This helps to ensure the privacy of the information that has been saved on your app and also helps to protect your valuable information that is stored on your iPad, should someone “borrow” it.  Also, please remember that this is a work in progress.  This app will continue to have new feature added.  One feature that will soon be added is the cranial nerve assessment section.   Please write a review of the app.  This is how we as the authors and Smarty Ears will know how to improve the app so that it can be useful for everyone.

 

We hope you enjoy Dysphagia2Go!!

 

Dysphagia2Go can be found on the app store for iPad at: http://itunes.apple.com/us/app/dysphagia2go/id469925526?mt=8

 

Dysphagia2Go is a revolutionary app connecting the dysphagia assessment world to technology. Dysphagia2Go offers an easy to use, HIPPA compliant** resource to complement your Clinical Dysphagia Evaluation. Dysphagia2Go guides you through the evaluation process with reminders to assess medications, cranial nerves and all the areas on which any good dysphagia evaluation should focus. This app provides a thorough evaluation report template developed by speech pathologists who have drawn upon their experience in varied settings to provide extensive opportunities to record chart reviews, assessment data, and recommendations in a single document, which can then be printed or e-mailed directly from the user’s iPad.

 

Dysphagia2Go allows for easy, single touch evaluation results with an easy-to-print report. If you don’t find what you need on the app or have other comments that should be added, Dysphagia2Go offers comment boxes throughout to add your own evaluation information.

 

Drop the pen and paper during your dysphagia app and use Dysphagia2Go for a quick and easy, complete Clinical Dysphagia Evaluation. While Dysphagia2Go provides an excellent resource for reporting data for swallowing assessments performed by a speech and language pathologist, it is NOT intended to replace an SLP’s clinical expertise or consultation. This app is not a replacement for clinical training and should not be used by individuals who are not experienced licensed speech and language pathologists.

 

* Dysphagia2Go relies on security measures that are built-in on the iPad.

** The app can only comply with HIPAA standards if user is protecting iPad data using iPad’s password protection.

*** Smarty Ears, LLC is not responsible for maintaining the confidential information that users have entered in to, or sent from the Dysphagia2Go app.

**** Smarty Ears, LLC does not recommend that the information entered in the application be e-mailed over a non-secure connection.

 
 

Electrodes…..Are they really all the same??

One of the biggest controversies in dysphagia therapy has to be NMES or Neuromuscular Electrical Stimulation, to use it or to not use it.  It has been extensively researched, although results of the research vary.

Whether you believe in NMES for dysphagia or use NMES, you need to understand the facts between the electrodes.  It’s not just about cost, the construct, impedance and versatility are also important.

One important thing to remember is that if the electrodes pull away from the patient, not only can it be uncomfortable for the patient but can interfere with your treatment.

VitalStim is the only company I’m aware that will only sell their electrodes given a certified clinician number, meaning that you HAVE to be certified in the modality to purchase the equipment.

The only training I have attended is VitalStim, which was worth every penny.  Whether you use the modality or not, the training is priceless with all the valuable information you gain.

One thing to remember is that NMES is not a cure.  Slapping the electrodes on a patient and turning on the machine will not make them swallow.  It is a modality, meaning that it may help improve the swallow when paired with swallowing exercises.

NMES stimulates Type II muscles, those fast twitch muscles predominant in the pharynx.  These are also the muscles that fatigue at a faster rate.

I have compiled information from websites (as available) regarding each of the electrodes available (of which I’m aware) for dysphagia therapy.

I do not endorse any of the electrodes.

Freedom Electrodes

Freedom Electrodes are distributed by North Coast Medical.  These electrodes are very much comparable to the VitalStim electrodes and work with the VitalStim and Guardian units.  


The tape holding the electrodes feels much like the VitalStim tape and the build of the electrode is much the same.


My patient who has used the eSwallow, VitalStim and Freedom electrodes stated that the Freedom Electrodes feel much like the VS electrodes.

The uniform current eliminates hot spots and provides maximum treatment across the entire electrode surface.

  • Freedom Stim™ Dysphagia Electrodes work with existing NMES devices for the treatment of dysphagia.
  • Silver (Ag) coated carbon film for reduced impedance, greater conductivity and uniform current dispersion.
  • Higher posts allow better adherence to the lead wires during treatment.
  • High quality, dual layer of gel formulated will adhere better during treatment.
  • Gel does not separate from carbon.
  • Latex Free.

Each kit contains:

  • (2) Tan Foam 2″ x 3.5″ (5cm x 9cm) Butterfly w/Snap Electrode.
  • (3) Skin-Barrier Wipes.
  • (3) Lotion Packets.

Freedom Stim™ 

Dysphagia Electrodes

 

 

Why Choose 

Freedom Stim™ Electrodes

 
  • Silver (Ag) Coated Carbon Film for Reduced Impedance,

    Greater Conductivity and Uniform Current Dispersion.

  • Extra Long 6” Pure Copper Lead Wires with Dispersive Heads.

    Helps to Prevent Wire Pull-Out from Body of Electrode.

  • High Quality Gel for Optimal Skin Adhesion.
  • Gel Does Not Separate from Carbon.
  • Excellent Customer Support.
  • Prompt Turnaround Time on Orders.
  • Competitive Pricing.
 
 
 

Freedom Stim™ Electrode Conduction

 

 
 

 

Freedom Stim™ Electrode Current Dispersion

 
    • The unique manufacturing processes and material used in Freedom Stim™ electrodes provide a uniform current dispersion throughout the desired treatment site of each electrode. This uniform current dispersion eliminates “hot spots” and provides the maximum treatment to the entire electrode surface.
 
    • A leading brand electrode and a Freedom Stim™ electrode are placed on a “Current Dispersion Meter”. An electrical current is passed through each electrode for a period of 60 seconds. The electrical voltage output is identical for each electrode. Results are shown at right.
 
  • The Freedom Stim™ electrode displays optimal current dispersion while the leading brand treats less than 50% of the surface, mainly where the wire is placed.
 
 

The difference is clear…

 

Current is concentrated in a small area, creating a “hot spot” that is less effective.

 
 

Freedom Stim™ electrodes are able to fully disperse the electrical current throughout the entire surface of the electrode.
The cost:  12 electrodes for $159 or $13.25/each

30 electrodes for $379.95 or $12.65/each

50 electrodes for $595.00 or $11.90/each

VitalStim Electrodes
From personal experience, I have to wrap the VS electrodes or whenever the patient moves, they do tend to pull away from the skin.


The VitalStim electrodes are designed for single use. 


VitalStim virtually pioneered the NMES drive for dysphagia therapy.  It’s become the branded name, not unlike Kleenex or Coke.  


When ordering VS electrodes, you have to have a VS number to order, preventing untrained clinicians from ordering supplies.

From the electrode fact sheet:

The VitalStim electrode was specifically engineered to cope with this challenge of the

dysphagia therapy environment.
The conductive carbon film is covered by a layer of silver to decrease impedance. The snap is

secured to the carbon by a patented conductive bond tape. This assembly is

covered by the foam cover and finally the tape patch that connects the electrode pair.

Impedance
To ensure low impedance, an extra layer of silver was added between the carbon and the

gel. In addition, a special gel was used that could withstand a full 60 minutes of current

flow. The gel was later improved to provide better adhesion. This construction results in a

consistent impedance rating of 30 Ohms or less (excellent).
The impedance (resistance to current flow) of an electrode increases with the amount of

current that flows through it.   Each square inch of the VitalStim electrode is exposed to a current load that is 20 x higher than an electrode that is used during a typical NMES protocol. In other words, only after 20

typical NMES treatment sessions will the typical NMES electrode have been exposed to

the same amount of current concentration as what the VitalStim electrode withstands

during a single session. The electrode used during VitalStim Therapy must therefore be

one that is able to carry this current load without increasing in impedance.
The cost:    12 for $209.00 or $17.42/each

30 for $450.00 or $15.00/each

50 for $675.00 or $13.50/each

100 for $1300.00 or $13.00/each

Alternative Electrodes

I have not personally had the opportunity to use these electrodes.  


There is not a lot of information on the website, so I hope to soon receive a sample pack to try the electrodes.  On myself, not my patients!

All shipments are in bags that contain ten 4-packs, or 40 individual electrodes. These are reusable electrodes (on the same patient).

All electrode orders include paper tape.  Skin prep pads are included with snap electrodes only.  Additional tape and pads are available if needed.

Save money on shipping by ordering more than one bag.  Shipping and handling is $8.95 per order (regardless of the size of your order). Shipments are made by Fed-X or UPS Ground (no PO Boxes please). Shipments are usually made within 24 hours of receipt of your order, depending on inventory.

Overnight shipping is available upon special request at $35.00 per order.

1.   .8″ round electrode with mini-snap connector            $98.50 per bag*
2.   1″ round electrode with mini-snap connector             $102.50 per bag*

3.    Butterfly electrode with min-snap connector              $108.50 per bag*

4.    .8″ round electrode with pigtail connector                   $72.50 per bag*
5.   1″ round electrode with pigtail connector                     $75.00 per bag*

 

* each bag contains ten 4-packs, or a total of 40 electrodes

 

 

Quality Construction

                       
             AlternativeElectrodes          Most competitive electrodes

Many electrode manufacturers sacrifice quality for economy – not us.  All electrodes supplied by AlternativeElectrodes use a high-performance, specially applied layer of pure silver inside our electrodes. This highly-conductive layer of pure silver disperses the electrical signal quickly and evenly over the entire surface of the electrode resulting in a more comfortable and more effective treatment for the patient.

 
 

The tape material holding the ESwallow electrodes is thin and a bit more flexible, however I still had to wrap the neck to ensure that the material did not pull away from the patient as they moved and ate.

 

With the thinner tape holding the electrodes, the actual electrode pulled away from the tape upon removal of the electrode after the session was over.

 

The ELI Premium Ag+ has a bold new look and even better performance.  The newly re-formulated electrode may be used for up to 3 treatment sessions on an individual patient.  The extremely low impedance electrode features total surface dispursion.  This makes the ELI Premium Ag+ the most advanced electrode on the market, delivering improved therapeutic results and greater patient comfort.  2 electrodes are conveniently pre-positioned on each butterfly shaped electrode patch.


The solitary plus electrode kit features the same, high performance electrode used in the ELI Premium Ag+. But, each electrode resides on it’s own self-adhesive patch.  This allows the SLP to have maximum control over the exact placement of the electrodes. 


The ELI Premium Ag+ is manufactured from an advanced silver – carbon – silver film.  A layer of carbon is sandwiched between two layers of silver chloride for complete dispersion of current.  A high quality 35 mil gel (compared to competition’s 25 mil gel) ensures maximum conductivity between the electrode and target muscle.  The result is an electrode with extremely low impedance.  Lower impedance means improved therapeutic results and greater patient comfort.


Ampcare

This is a newer company to me.  I first learned of this company on Twitter.  I went to their website, which gave me virtually no information.  This company has designed an NMES system that conducts stim to the submental muscles.  They offer a protocol called ESP (Effective Swallowing Protocol).
I could only find one piece of information on ESP through a Google search.  In this slide show which was presented, the “RX3ESP utilized a portable muscle stimulator using pulsed electrical current to depolarize nerve endings and produce a muscle contractions.”  5 patients were studied using this protocol.  Sessions were 30 minutes using 3 exercises 10 minutes each:  a modified Shaker using their posture device, the Mendelsohn Maneuver for 4 seconds followed by a swallow and the Effortful Swallow.  Of the 5 patients, 2 patients returned to full oral diet.
I have contacted the company multiple times with no response to date.  There is no information on the site regarding construct of the electrodes nor can I find any efficacy for use of this system.

**UPDATE:

Ampcare responded!

Unfortunately, they do no provide samples of their product.  You can receive their products when you attend the training.

Ampcare “utilizes any portable powered muscle stimulator that will house our parameters, Ampcare’s patented E-series FDA cleared pie shaped electrodes and a neuro-orthosis to address posture and add a resistive load to the exercise program.”

Ampcare began research in the US in 1997 with completion of a controlled trial in 2007.

The Ampcare electrodes are made to:

  •   Specifically designed to match the curvature of the jaw line.
  •   Made with a unique composition and highest quality materials.
  •   Extremely low impedance (10 Ohms) with total surface dispersion.
  •   Reusable, pre –gelled, self adhering, single patient use electrodes.
  •   Latex free, ISO Certified, made in the USA and up to 5 times cost
    savings.

Ampcare also offers a Restorative Posture Device (RPD)

AMPCARE Restorative Posture Device (RPD) – is indicated for patients that present with poor neck posture. This includes any individual with a:

  •   Head and neck alignment issue causing increased swallowing difficulty.
  •   Forward head on neck posture resulting in decreased range of motion.
  •   Weakness in their neck musculature.

Guardian
The Guardian electrodes, are made much the same as the other electrodes (Eswallow, VitalStim, Freedom) with a flexible tape, which still requires wrapping to ensure that the electrodes stick through movement.  


One difference with Guardian is that they advertise the electrodes as reusable.


The electrodes come in a variety of sizes as does Eswallow and Alternative electrodes.

     
     
     



        


Which electrodes do you believe work the best??

Modified Barium Swallow Study……Part 2

I was recently directed to a blog post by Clinical Colleagues Confidential. regarding Modified Barium Swallow Studies (MBSS).

 The title of the blog post is:

 I have all the answers but nobody is asking me any questions

The original blog post can be found at:  http://cccslp.net/whats-the-frequency-3/

 This is part 2, because I recently wrote a post about MBSS.

 Being an SLP that actually completes MBSS, I felt I needed to address some of these issues comments.

1) I stopped the MBS because I was afraid the patient would aspirate.  Patients aspirate……it happens.  They have probably been aspirating for a long time prior to your study.  If you are afraid of aspiration, how can you assess the patient’s true swallow function?

2) The patient was coughing so I changed him to pudding at bedside.  Patients cough.  You need to check the patient’s meds (some actually cause a cough) and trial a consistency more than once to determine if the consistency is causing the cough.  It is also helpful if you use an instrumental exam such as FEES or MBSS to determine the physiology of the swallow.

3) I didn’t try thin during the MBS because at the nursing home he was already on nectar so I started there.  I use the protocol employed by the MBSImP.  Thin is tested.  I don’t stray from my consistencies.  I use thin, nectar, pureed and cookie with every patient (unless there is a very valid reason to not do a certain consistency).

There are many pieces of information you can use when you assess thin that you don’t get from nectar.  That’s why I don’t skip it.

4) There’s no speech at nursing homes so I put her on the safest diet; puree and pudding thick.  Who says that pureed and pudding thick is the safest.  Sometimes thick is not necessarily better.  Many people eat safely, millions in fact without the presence of speech.  You should not punish your patient because of lack of SLP.

5) A suspected timing delay of the epiglottis might be present and could lead to aspiration even though none was apparent on the MBS but to be safe I recommend nectar thick liquids.  If you did the MBSS, you should know if there is a delay of the epiglottis or not.  You SHOULD be assessing the epiglottis.  You should also know that epiglottic movement is indicative of hyolaryngeal excursion.  Sometimes you don’t see aspiration on the MBSS but you should be looking at airway protection and hyolaryngeal excursion which is an indicator.

 6) I didn’t want to recommend something they might aspirate and get sued.

I wish there was no number 6. Sadly, I think it is the driving force behind many of the recommendations. But, I would spread some words of caution to my peers, especially the younger ones. The only thing that avoids litigation is luck. The thing that wins litigation is expertise and documentation.

If you make a swallowing recommendation in isolation of the needs of whole patient to save him from aspiration pneumonia and he goes into renal failure…that’s a big problem.  I agree….documentation is key.  If you document that the patient appears safe, that is your finding.  You should be confident in your skills and you should be effective in your skills in completing MBSS.  This is not an area we can make a mistake because that can put your patient at high risk for pneumonia, respiratory issues, maybe death.  You recommend what’s appropriate for that patient without worry about litigation.

We seriously need to take a look at our profession.  WE are the experts in dysphagia.  We need to demonstrate our skills as experts.  Dysphagia is not an area we can “tinker” in.  

I highly recommend that any SLP completing MBSS that has made any of the above statements, take the Modified Barium Swallow Impairment Profile (MBSImP) by Bonnie Martin Harris.  This is becoming the gold standard for standardization of modifieds.  

Our responsibility as SLPs completing MBSS is to determine the physiology and etiology of the swallow/dysphagia.  We need to determine what is functioning and what is not functioning in the oropharyngeal mechanism.  Our job is not to state aspiration or penetration or….I coulnd’t do that because I was scared of this.  Our job is to state epiglottic dysfunction, lingual dysfunction, decreased laryngeal elevation, decreased arytenoid movement, and so on.  

SLPs need to take a stand and become experts in the area of dysphagia.