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.

Course Alert-Evidence Based Practice

critical_thinking_skills

Image from:http://thecollaboratory.wdfiles.com/local–files/philosophy-of-thought-and-logic-2011-2012/critical_thinking_skills.jpg

Northern Speech Services has a new course called:  Evidence-Based Practice In Adult Dysphagia Management: What The Evidence Says About Commonly Selected Rehabilitation Interventions.  This is a webinar by Ianessa Humbert, Catriona Steele and Phoebe Macrae.

I took this course over the weekend.  It was GREAT!  It starts with approximately 35 minutes of review of the anatomy and physiology by Dr. Humbert.  The second section is close to 2 hours and discusses 4 compensations/exercises including:  chin tuck, Mendelsohn Maneuver, Shaker and the Effortful Swallow.  Evidence for each of the 4 techniques is discussed and a look at critically appraising techniques/exercises for dysphagia.  A case study is provided for each.

This course only looks at 4 exercises/compensations, however it also breaks down the critical assessment for each, allowing the viewer to apply the same principle to any exercise/compensation.

I would definitely recommend this course to anyone working with patients with dysphagia.

Carbonated Beverages

carbonated

Carbonated beverages have hit the dysphagia world by storm.  Much of the recent dysphagia research has focused on the sensory portion of the swallow and how sensory drives the swallowing process.  Part of the sensory process is carbonated beverages.  One of the common misconceptions at this time is that carbonated beverages act as a nectar thick liquid.

Carbonation is a sensory option for dysphagia rehabilitation.   It’s effective through a process called chemesthesis, where the “bubbly” or “fizzy” of the carbonated beverage acts as a Trigeminal irritant.  The Trigeminal Nerve or Cranial Nerve V is one of the major swallowing nerves.  The Trigeminal Nerve has bare nerve endings making it more susceptible to sensory or afferent input.

Rather than acting as a nectar thick liquid, the carbonated beverage actually increases the sensory stimulation for the swallow.  Sensory input (afferent drive) drives the motoric output (efferent drive).

Research of carbonated beverages shows:

No significant effect on oral transit time, pharyngeal transit time, initiation of pharyngeal swallow or pharyngeal retention.  Carbonated beverages sis however decrease penetration/aspiraiton with 5 & 10 ml swallows.  (Saravou & Walshe).

Carbonated thin liquid significantly decreased the incidence of spillover, delayed pharyngeal response and laryngeal penetration compared to non-carbonated thin liquids.  (Newman et al).

Drinks containing chemical ingredients that activate sour and heat receptors alter swallowing physiology greater than water.  (Krival & Bates).

It is likely that sour and carbonated beverages reflect a more organized activation of the submental muscles because of more effective afferent input to the Nucleus Tractus Solitarius.  (Miura, et al).

One of the important issues to consider when looking at research involving carbonated beverages is that the researchers in these studies do not use Coke, Pepsi or Sprite.  They use Ginger Brew, Club Soda or carbonated citrus.

It is vital, as with any other compensation or technique to view the effects of carbonated beverages.  As with other strategies, you may not see the same effect in every patient and sometimes, the strategy you choose may make the swallow worse.

Krival K, Bates C. Effects of Club Soda and Ginger Brew on Linguapalatal Pressures in Healthy Swallowing. Dysphagia (2012). 27: 228-239.

Newman, et al. Carbonated Thin Liquid Significantly Decreases the Incidence of Spillover, Delayed Pharyngeal Response and Laryngeal Penetration Compared to Non-Carbonated Thin Liquids. Dysphagia 2001: 16: 146-150.

Saravou K, Walshe M. Effects of Carbonated Liquids on Oropharyngeal Swallowing Measures in People with Neurogenic Dysphagia. Dysphagia(2012) 27: 240-250.

Miura, Yutaka, et al. “Effects of taste solutions, carbonation, and cold stimulus on the power frequency content of swallowing submental surface electromyography.” Chemical senses 34.4 (2009): 325-331.

Books to Read-Clinical Anatomy and Physiology of the Swallow Mechanism

swallowing mechanism

This book is a great read to help understand the anatomy and physiology of the swallowing system.  It breaks the information down into an easy-to-read format.  This is a book that I used extensively when studying for for BCS-S exam and still have the book to reference when I question anatomy or physiology.  Definitely worth the money (although you may want to look for it used).

Clinical Anatomy and Physiology of the Swallow Mechanism by Kim Corbin-Lewis, Julie M. Liss and Kellie L. Sciortino

Upcoming Articles!!

One thing I love about the Dysphagia journal, is not only the great research it provides me 4 times a year.  I love the abstracts for the upcoming (now past) Dysphagia Research Society (DRS) conference.  

This year was no exception for exciting new research to come!

Some titles that I am very excited to look into:

  • The Effects of Taste Concentration on SEMG in Swallowing-(Spoiler:  High concentraion sour stimuli elicit higher amplitudes and longer durations on SEMG).  
  • Esophageal Screening as an Adjunct to the Videofluoroscopic Study of Swallowing.  
  • Sour Bolus Facilitates Spontaneous Swallow in Parkinson’s Disease
  • Effects of Age and Sensation on the Anticipatory Stage of Swallowing
  • Physiological Factors Related to Aspiration Risk:  A Systematic Review
  • Pharyngeal Tactile Stimulation Using A Nylon Thread for Enhancing Pharyngeal Sensory Perception

These are just a few of the exciting titles that have caught my attention.  

If you are interested in the Dysphagia journal or the Dysphagia Research Society conference at a discount, make sure to join the Dysphagia Research Society!

books

Course Alert-Head and Neck Cancer

head and neck cancder

Northern Speech Services is offering a new course on head and neck cancer entitled:  Head and Neck Cancer Across the Continuum of Care: Addressing Swallowing Challenges.  The course is taught by Paula Sullivan who is an expert in dysphagia in the cancer population.

Per the NSS website:

This comprehensive online course will provide the participant an in-depth examination of head and neck cancer, its presentation, functional sequelae, evaluation approaches, treatment options, and provide an evidence-based approach of optimal patterns of care for head and neck patients with swallowing dysfunction.  Types of treatment for head and neck cancer and their impact on swallowing and communication function will be described, including both surgical and organ preservation. 

Assessment and evidence-based practice relevant to the head and neck cancer population will provide support for the practitioner in developing a holistic approach to rehabilitation which will optimize functional outcomes and, most importantly, quality-of-life.  Video presentation will be an integral part of this course.  By the completion of this course, the participant will possess a comprehensive understanding of dysphagia management in this challenging and rewarding population. Offered for 0.9 ASHA CEUs – 9 contact hours. 

This is definitely a course on my to-take list!

Has anyone taken this course yet?  If so, let us know what you thought!