Why Won’t They Do What I Say??

I mean, let’s face it.  When we go through all that work of assessing a patient and making these phenomenal recommendations, we get a little testy when they are not followed by the patient, nursing staff or family.

Do we ever ask WHY these recommendations are not being followed?

Let’s face it.  We really don’t need a comprehensive study to determine that thickened liquids are not as tasty as regular liquids and pureed hot dogs just don’t cut it at a baseball game.

Colodny in 2005 found that 40% of patients with dysphagia that are capable of independent feeding choose to NOT follow the recommendations of the SLP.

Why would that even be a question?

Think about these factors:

  • Fear
  • Denial
  • Loss of independence
  • Loss of pleasure
  • Depression
  • Family pressure
  • Financial concerns
  • Lack of information
  • Religious/spiritual belief
  • Previous experience

These factors were all found to contribute to non-compliance.  How many patients or family members have ever said to you…..”I never knew that swallowing could be affected.”

There is such a lack of understanding of dysphagia, among the medical field, patients and lay people.

How do we bridge this gap?

Seriously, nursing staff should be compliant with my recommendations, right?

Not always.  And why would that be?

Another study by Colodny in 2001 looked at why nursing staff does not follow SLP recommendations.  Barriers to following recommendations:

  • Hassle
  • Knowledge
  • Disagreement

Nursing staff found that it was a hassle and time consuming to thicken liquids and to prepare food to meet patient needs.  They maybe lacked knowledge of feeding techniques, why the recommendations were made or even WHO needs to have the diet modifications.  Nursing staff also may disagree with our recommendations.  They may see Patient Joe that is chugging away at a glass of water.  He never coughs.  Nope, he’s a silent aspirator.  He won’t cough.   The problem is, the nurse doesn’t see any overt clinical symptoms that are expected with aspiration.

So, don’t go getting mad at your patients, families or staff.  Maybe they just don’t understand.  It’s amazing what a little education can do to bridge the gap.  Now, this isn’t always the case, but it’s always worth the effort.

  • Colodny, N. (2001). Construction and validation of the mealtime and dysphagia questionnaire: An instrument designed to assess nursing staff reasons for noncompliance with SLP dysphagia and feeding recommendations. Dysphagia16(4), 263-271.
  • Colodny, N. (2005). Dysphagic independent feeders’ justifications for noncompliance with recommendations by a speech-language pathologist. American Journal of Speech-Language Pathology14(1), 61-70.
  • King, J. M., & Ligman, K. (2011). Patient noncompliance with swallowing recommendations: reports from speech-language pathologists. Contemporary Issues in Communication Science and Disorders38, 53.
  • Morris, L. S., & Schulz, R. M. (1992). Patient compliance—an overview. Journal of clinical pharmacy and therapeutics17(5), 283-295.
  • Ekberg, O., Hamdy, S., Woisard, V., Wuttge–Hannig, A., & Ortega, P. (2002). Social and psychological burden of dysphagia: its impact on diagnosis and treatment. Dysphagia17(2), 139-146.

Myths in Dysphagia

Maybe you’ve heard of the Dysphagia Therapy Group Professional Edition on Facebook.  Maybe you’re even a member.  It’s definitely worth a look!

https://www.facebook.com/groups/343282762350392/permalink/973310226014306/?comment_id=973424432669552&offset=0&total_comments=25&notif_t=group_comment_mention

One of the  conversations started by a very active member and a friend, became a very hot topic.  Myths heard regarding dysphagia is a hot topic in the SLP world.  Below is a sample of some of the myths that were posted.

If a pt is having trouble swallowing, and SLP cannot eval until the afternoon or next day, put them on puree with nectar thickened liquids bc that’s the safest diet for everyone.”

“Thicker liquids are always safer than thins, so when in doubt, go thicker.”

“If a pt isn’t able to swallow, they should be referred for mbs or fees.”

“Straws are always a no-no.”

“Monitoring temperature for a spike a half hour eating will tell if pt has aspirated.”

“Monitoring O2 during PO intake will tell if pt has aspirated.”

“I had an slp say once that a trach pt can’t aspirate. .”

“A runny nose (absent of other s/sx [signs/symptoms]) indicates aspiration.”

“An NPO (nothing by mouth) recommendation is always a good choice for a pt who aspirates on everything.”

“ALL dementia and Alzheimer’s patients qualify for ST…”

“Chest xrays only show how a person breathes and nothing to do with aspiration”

1) The cuff should be inflated at all times to prevent aspiration. 2) The patient must tolerate cuff deflation for an accurate swallow eval. 3) a Gtube should be recommended if no consistencies are safely tolerated. 4) you should sign off the case if nobody is following your recommendations, 5) a waiver is a good idea when a patient is “noncompliant” so you CYA, 5) other professions should “automatically” understand SLP jargon and interpretations in eval and therapy notes.”

“People who aspirate are all doomed to death by aspiration pneumonia.”

“Patients with dysphagia should never be in reclined during PO”

“Any patient who has “aspiration pneumonia” in their diagnosis must have dysphagia.”

“AND.. Everyone who aspirates will develop pneumonia”

“I accidentally forgot to thicken the patient’s liquids…they didn’t aspirate though…they didn’t cough or anything. Ugh.”

“Any pt who requires pills crushed in purée really needs a swallow eval, even if they have no problem at meals.”

“6) an MBS is a pass/fail exam. 7) an slp can not/should not discuss end of life/hospice options with families, 8) when a patient demonstrates understanding it means they will carryover the strategies into dynamic mealtime behaviors.”

“A patient with no teeth or poor dentition is not capable of managing solid consistencies.”

“All patients could benefit from a chin tuck.”

9) patient advocacy ends with leaving a message for the doc (who never reciprocates communications). 10) irritable doctors should be avoided and communications abbreviated.”

“There is no need to refer a post op cervical surgery patient showing signs of dysphagia as he is definitely going to improve eventually”

“Piecemeal deglutition is abnormal.”

“Feeding tubes prevent aspiration pneumonia.”

“Penetration of barium on MBS is reason to downgrade liquids.”

All patient’s with dysphagia require a spouted beaker”

“When I worked in a SNF (skilled nursing facility), my favorite myth from CNAs was (when a pt was coughing during meals) “raise your arms!” Or “eat some bread” Really??”

“Well it’s not RLL (right lower lobe) pneumonia, so we know they didn’t aspirate.”

“If pt aspirated on all liquid textures, go with the thickest”.

Carbonated liquids are nectar-thickened liquids …”

“A cough always indicates aspiration”

“Alternating bites of food with sips of liquids to clear the oral cavity.”

“Absence of a gag reflex means someone can’t swallow anything safely …”

“Edentulous patients should be put on a puréed diet.”

“Penetration means downgrade. Stop the MBS if you see aspiration. If you have an NPO pt you should never use PO (oral) trials in therapy. MBS at every 30 days.”

“Don’t do a Modified if the family doesn’t want a PEG (feeding tube).”

“the patient is belching frequently, so the SLP should train the patient to not ‘gulp air while swallowing”

“They would swallow if you gave them food they liked better.”

“Straws can not be used with thickened liquids.”

“Thickened liquids at meals only”….

“Aspiration = pneumonia.”

“Objective studies are to see if patient is aspirating” (vs looking for dysfunctions and WHY)”

1) If a pt is on purée, they need their meds crushed.
2) A trache will ‘tether’ the larynx.
3) If a pt aspirates on pudding, don’t try anything else because pudding is the easiest.”

“I had a ‘dietary staff member’ tell my patients wife that whole milk is nectar thick so don’t add thickener.”

“Resident is NPO but it is “OK” to give medication by mouth (with water or food)”

“Lack of gag reflex alone indicates swallow eval when pt is otherwise okay with po intake.”

“Frazier water protocol won’t cause pneumonia. You can just hook them up to vitalstim without doing exercises and it’ll fix the swallow.”

There is a lot of education to provide!  Thanks everyone for your input and thanks Vince for letting me steal part of your idea!

The Swallow in Detail

The Swallow in Detail

 

Taken from: *Dysphagia Foundation, Theory and Practice by Julie Cicheroand Bruce Murdoch*

 

Hunger

Smell of food, empty stomach or electrolyte imbalance informs hypothalamus of the need to eat.

Brainstemactivates nucleii of CN VII and IX to promote secretion of salivary gland juices to prep for bolus

 

Chewing 

Bolus in mouth.  CN VII ensures good lip seal (orbicularisoris) while CN V relays sensory info to brainstem to constantly modify the fine motor control of bolus prep.

Motor activity to CN V, VII, IX, X, XII to create an enclosed environment within the mouth to prepare the bolus.

Cheeksprovide tone (buccinator CN VII).

Soft palate tense and drawn down towards tongue (tensor velipalatini CN V and palatopharyngeusCN IX)

Tongue is drawn up towards the soft palate (palatopharyngeusCN X, styloglossus CN XII).

Hyoidbone is stabilized (infrahyoid muscles CN XII and C1-C3) to allow movement of the mandible).

Bolus prepared by closing (temporalis, masseter, meial pterygoid,lateral pterygoid, CNV) and opening (mylohyoid and anterior belly of digastric CNV, geniohyoid CNXII &C1-C3.)

Bolus pushed around the mouth by actions of the tongue to create a consistent, homogenous texture (hypoglossus, genioglossus,styloglossus and 4 groups of intrinsic muscles of the tongue CN XII). Taste sensations (CN VII and IX) provide info to cortex to stimulate areas of brain required to coordinate the swallow (insulaand cingulatecortex).

 

Voluntary initiation

Once bolus is adequately prepared.

Soft palate elevates slightly (levator veli palatini and palatopharyngeusCN X).

Slight elevation of hyoid bone (suprahyoid muscles contracting on rigid mandible with slight relaxation of infrahyoid muscles.

Pharyngeal tube is elevated (stylopharyngeus CN IX, palatopharyngeusand salpingopharyngeus CN X).

Tongue delivers bolus to force bolus distally towards posterior wall of the pharynx in a “piston-like” manner using hard palate for resistance. Sensation by CN XI and by CN X (pharyngeal plexus).

 

Larngeal elevation

1st motion for tongue to propel bolus into oropharynx is elevated anterior direction toward roof of mouth (mylohyoid and anterior belly of digastric, CNV; stylohyoid and posterior belly of digastric CNVII; palatoplossusCN X; genioglossus, hyoglossus and styloglossusCN XII; geniohyoid CN XII and C1-C3) affects hyoid elevation in an anterior direction.

Soft palate seals off nasopharynx.

Superior constrictors begin medialization of the lateral walls.

Larynx elevated and moved anteriorly in relation to hyoid bone by thyrohyoid CNX.

 

Laryngeal closure

During laryngeal elevation-vestibule closes and rises relative to thyroid cartilage (cricothyroid and intrinsic laryngeal muscles CN X).

Opposition and elevation of arytenoid cartilages provide “medial curtains” of pyriform recesses (aryeppiglottic folds).

Pressure exerted on base of epiglottis causing it to tip and cover the laryngeal vestibule.

Medial constrictors (CN X) “strip” the pharynx by medialization following on from superior constrictors.

Palatedescends (palatopharyngeus CN X), constrictors “strip” and tongue moves posteriorly (styloglossus CN XII) to close oropharynx.

Once the bolus has reached pharyngeal areas innervated by the internal branch of the superior laryngeal nerve swallow reflexive and cannot be stopped.

Anterior and elevated movement of larynx allows cricopharyngeus to be stretched (UES) and opened.

Inferior constrictor finishes medialization and bolus in esophagus.

 
 

Resting state

CNX

Cricopharyngeus resumes tonic state.

Glotticopens and larynx lowers.

Ifbolus present should cough.

Tongue and hyoid and palate return to resting position.

**Oral phase for liquid boluses should take 1 second and the pharyngeal phase with all consistencies should take 1 second.**The ability to contain a bolus is prognostic.**The swallow is a positive pressure phenomena where the pressure is always on the tail of the bolus.

 
 

Triggering the pharyngeal swallow response:

 

        The bolus stimulates CN IX, X, XI in the medullary reticular formation

        (nucleus tractus solitarius) (NTS).

 

        Incoporates (NTS) input from V, VII, XII

 

        NTS signals motor nuclei in teh nucleus ambiguus to help fire IX, X,

        XI.

 

        Nucleus ambiguus innervates muscles of the velum, pharynx, larynx,

        and upper esophagus (IX, X, XI) producing the pharyngeal swallow

        response.

 

       Strongest ties to the NTS=anterior faucial arches, posterior tongue at

       the lower edge of the mandible, valleculae, pyriform sinuses and

       laryngeal aditus.

 

       The anterior faucial arches have a strong connection between the

       sensory receptors and NTS via afferent fibers of the glossopharyngeal

       nerve (IX) creating a trigger point for younger adults.  (Swallows in

       older adults may trigger lower.)

Dysphagia App

What’s changing on Dysphagia Ramblings??

NOTHING!!

I’m adding to enhance my blogging to include app reviews. Not only will I start reviewing apps (officially) on my blog for dysphagia apps, I will also include some cognitive, language, etc apps.

My first review? Of course it has to be Dysphagia by NSS

App: Dysphagia

What it is: A teaching tool that can be used for families, healthcare professionals, students and SLPs. This app can help as a visual tool in teaching the mechanics of the swallow.

Price: $9.99 ($3.99 for only the normal swallow version called Normal Swallow)

System: iOS (iPhone, iPod Touch and iPad)

Version: 1.3

This app is simple to use, offers amazing graphics and creates a new, animated teaching tool for SLPs educating others in dysphagia.

When you first open the app, you have a picture of the lateral view of the oropharyngeal region called Normal Swallow, Lateral View.

 

At the bottom of the screen is a play button (the little arrow pointing to the right by the white turning blue line). Above the line is a purple rectangle that tells you what percentage speed you are playing the video. You can touch that rectangle and change the speed of the app from 1% to 100% depending on how fast or slow you want the app to run.

 

At the top of the screen is a menu rectangular purple button. When you touch this button, it allows you view the menu of available swallows to watch. You have the option of:

Normal Swallow, Lateral View
Normal Swallow, AP View
Example of Penetration with Aspiration
Impairment of Bolus Transport
Impairment of Initiation of Pharyngeal Swallow
Impairment of Anterior Hyoid Excursion
Impairment of Laryngeal Vestibular Closure
Impairment of Pharyngeal Contraction
Impairment of PES Opening
Impairment of Tongue Base Retraction

 

Pros of this app:

It offers excellent graphics to teach a swallow and the components of the swallow. If you have taken the MBSImP course, you will recognize the animations.

It’s very easy to slow down or speed up the rate of the play of video to enhance learning for all viewers.

It’s easier to show patients and healthcare professionals the swallow process and easier than a traditional swallow study video to visualize the components of the swallow.

Cons of the app:

It is limited to a few swallow deficits. You can’t show your patient their true swallow using this app, however it would be impossible to have that function!!

This is an excellent app to add to your dysphagia technological toolbox!! It is excellent for students, patients, families, caregivers and SLPs that are not familiar with MBSS to demonstrate the function of the swallow.

My grade: A

The Dummies Guide to Dysphagia

A big shout-out to Tanya for the inspiration for this blog!!!

 Education is such an important part of not only the dysphagia eval, but also throughout therapy.  More than likely the patient/family will have no clue what dysphagia is or that such a condition even exists.  Swallowing is an event that you don’t think about.  Nobody swallows and analyzes their own swallow function (unless you’re an SLP of course).

 My first session with a patient is a large portion of education.  Whether I’m doing a swallow eval or a Modified Barium Swallow Study I’m continually educating.  I find that one of the easiest ways for me to educated patients/families is to explain each part of the eval and how it relates to swallowing.  If I’m checking for labial seal/strength I explain to the patient the purpose of the lips.  My new explanation for the tongue is that it’s like the quarterback of the team.  The tongue is the one that starts the play and makes it happen.  (The Colts have been doing well so everyone in Indiana loves football now.)  I not only educate on the structures and the means by which they function, I show pictures and try to demonstrate as best I can.

 When the patient understands the basics of such a complex and intricate system, they begin to understand how it could falter.  I always make sure that the patient understands that the swallow is something that we do so frequently we don’t even think about it.  I also let them know that the swallow involves a variety of closures, muscles, nerves and actions that all occur in 3-5 seconds.

 I typically have information available for the patient to take home with them.  I have brochures describing how speech therapy rehabs the swallow, information regarding swallowing and a self-test for dysphagia.  The self-test I use is found at  http://americandysphagianetwork.org.

 So, for all those that may read this and not understand dysphagia or know anything about the swallowing system:

 The lips are the first part of the swallowing system.  They have to close, and stay closed to help keep the food (the bolus) inside the mouth (the oral cavity).  The lip seal also helps create a pressure which helps to push the food (bolus) back and down the throat (the pharynx).  The tongue is the main player in the swallow.  The tongue is like the quarterback.  It is the first player to really receive the ball (the bolus), moves it around, getting it ready to “throw” down the line (the pharynx).  When the ball (bolus) is ready, the tongue takes it, throws it back (posterior propulsion) and launches the ball (bolus) down the pharynx.  Once the bolus starts down the pharynx, the airway has to move up and forward to close it off and you hold your breathe until the swallow is completed.  (I usually have the person swallow and feel their Adam’s Apple move up when they swallow.  If they can’t/don’t feel the laryngeal elevation, have them feel your throat.)  When the airway is closed, the food tube (esophagus) and lets the food go down.

 When we are not swallowing, our airway is open, allowing us to breathe and the esophagus is closed.  It switches for a split second when we swallow.  If any of these “tasks” don’t happen during the swallow or if they happen at the wrong time, that causes a problem with the swallow.

 Some of the problems that commonly occur with swallowing are lingual (tongue) weakness causing difficulty moving the bolus back in the mouth towards the pharynx (posterior propulsion), poor labial seal with food/drink falling out of the front of the mouth.  Pocketing is when food sticks in the mouth, usually between the cheeks and the gums.  If the airway doesn’t close off completely then food/liquids can start to go into the airway or go completely into the airway.  When the food/liquid goes into the airway, that is called aspiration and can lead to respiratory difficulties such as breathing difficulties, bronchitis, pneumonia or even death.

 Another problem that can occur in the pharynx is residue.  There are two pockets in your throat, one is called the valleculae and is located just above your airway.  The other is called the pyriform sinus and is above the esophagus.  If there is not enough pressure or force from the back of the tongue pushing the bolus down the throat and against the wall of the throat (posterior pharyngeal wall), the food can stick in these pockets after the swallow.  When food/drinks remain in the pharynx, the person may aspirate (the food/drink goes into the lungs) the residue once they breathe again.

 Another major part of the swallow that can “go wrong” is that the esophagus doesn’t open, or doesn’t open enough for the entire bolus to enter the esophagus.  The esophagus (upper esophageal sphincter-UES) is opened by the upward and forward movement of the airway (hyoid/larynx) and the pressure of the bolus.  Typically when the UES opening is compromised, the person will have pyriform residue, which may then be aspirated.

 There are many techniques/therapies to aid in rehabilitating the swallow mechanism.  Most commonly, people are placed on altered diets, or taught compensations such as chin tuck or head turn to stop aspiration/residue.  These alterations/compensations DO NOT improve the swallow, but may serve to eliminate the aspiration or risk of aspiration.  Swallowing is a muscle based system, powered by 6 cranial nerves.  We have to take an exercise physiology approach to rehabilitate dysphagia.  We can learn much from our physical and occupational therapy counterparts.  To train a person to walk, they have the person walk.  They may have them use a walker, but the ultimate goal is to have them walk without the walker or with independence.  The walker makes the person safe at the time, but does not “fix” the problem.  By the same token, we may put a person on an altered diet, or say, honey thick liquids.  This makes the person safe at the time, but does not “fix” the problem.  We work on strengthening those swallowing muscles to allow the person the opportunity to swallow with independence and to again swallow thin liquids.  Just as the physical therapist will work with the person walking without the walker in therapy, although outside of therapy the patient will probably still need to use the walker, we need to work with our dysphagia patient on swallowing thin liquids in therapy.  This may be a teaspoon of the liquid at a time.  By using the thin liquid, a little at a time, you are training the person to swallow.  You may use techniques such as the Mendelsohn or the effortful swallow to strengthen the muscles through resistance.

 I use VitalStim or neuromuscular electrical stimulation during swallowing therapy.  I place the electrodes so that they stimulate the impaired muscles during swallowing therapy.  If the person has decreased laryngeal elevation or the airway doesn’t close during the swallow, then I target the muscles that elevate the larynx.  The tongue is attached, via muscles, to the hyoid bone, which is part of laryngeal elevation.  So take the patient with decreased laryngeal elevation.  This person has aspiration with thin liquids but is safe with nectar thick liquids.  When using the Mendelsohn maneuver, the patient was able to safely swallow 5 ml of thin liquids.

 My therapy session would look like this:

At home, the person is drinking nectar thick liquids.  In therapy, I’m going to place the VitalStim electrodes on the laryngeal excursion muscles.  I like circuit therapy, I say it’s like Curves but for swallowing.  The patient will complete all exercises/swallows while the VitalStim is on.  We do lingual strengthening exercises using a tongue depressor (the patient pushes their tongue out, up and side to side against the tongue depressor), practice the Mendelsohn maneuver using dry swallows, when they are able to complete the Mendelsohn I would have them start using the Mendelsohn with 1ml water, working up to 5ml of water.  Therapy should always have many opportunities for swallowing (you can only exercise the swallowing system by swallowing).

 Vitalstim electrodes are attached to patient and VitalStim is turned on to a therapeutic level.

5 minutes of dry swallows using the Mendelsohn

4 minutes push your tongue out against the tongue depressor

5 minutes suck pudding through a straw (my FAVORITE exercise)

4 minutes push your tongue up against the tongue depressor

5 minutes pull your tongue back as far as it will go in your mouth, hold 5 seconds

4 minutes push your tongue to the right against the tongue depressor

5 minutes dry swallow using an effortful swallow

4 minutes push your tongue to the left against the tongue depressor

5 minutes pudding through the straw

5 minutes pretend to yawn and hold tongue back for a count to 5

5 minutes swallow pudding using an effortful swallow

 Now, keep in mind, the tongue is the quarterback of the swallow.  It is attached to the hyoid via muscles.  The person needs their larynx to elevate so I’m going to work on strengthening the tongue, to strengthen the hyolaryngeal excursion.  The Mendelsohn provides hyolaryngeal excursion through resistance of gravity.  The effortful swallow has been found to strengthen the overall swallow.  Tongue base retraction is part of the tongue which is going to aid in the hyolaryngeal excursion.  I like the pudding through the straw (I start with a regular straw and work to a coffee stirrer, my way of adding “weight” to the exercise) because it strengthens labial seal, the buccal (cheek) muscles, works on tongue base retraction, the person has a bolus to manipulate and then they have to swallow.  The pudding through a straw offers resistance to the oral phase of the swallow, by adding an effortful swallow, you add resistance to the pharyngeal phase as well.

 Keeping in mind the basic anatomy and physiology of the swallow, it just makes sense that exercise should offer resistance, making the task more difficult or require more effort.  Just as if you are trying to build up your arms to look good in your tank tops, you don’t start at 5 pounds and stay there.  You eventually add weight and keep working up.  Swallowing therapy should offer resistance, strengthening and endurance because you are working to improve the timing, speed and strength of the swallowing mechanism.

 

Journey to BRS-S

It’s official!  I finally did it and am so extremely happy and excited!!

 I finally, not only had my application accepted by the BRS-S (Board Recognized Specialty in Swallowing and Swallowing Disorders) and passed the exam.  I can officially put the title BRS-S after my credentials!

 I wish that I could say that it was an easy process, but it really wasn’t.  I will say though that I have learned so much along the way and have met so many new and wonderful process through this amazing journey.

 The main reason for writing this post is to, hopefully encourage others to do the same.  This was something to me that several years ago seemed completely unreachable.  I mean really, I’ll never compare to the Jeri Logemanns of the world!

 Many people have asked me about applying for and taking the exam for the BRS-S.  Here is post about my experience.

 I had went to many conferences and saw speakers with BRS-S after their names.  I went to the website, www.swallowingdisorders.org, and started looking into what it would take to become BRS-S.  WOW!  Not only do you have to prove that you have gone over and beyond in the area of swallowing and dysphagia, but you have to have 75 CEU’s in dysphagia, 3 years experience post graduation and letters of recommendation.

 The BRS-S does offer the opportunity to utilize a mentor during the entire process.  I decided that it wouldn’t hurt to look into a mentor to even see if this is something possible for me.  I actually did, 2 years ago, I applied for a mentor.  I ended up with Nancy Swigert, who I truly can never thank enough for not only giving me the courage and the confidence to believe that I could do this, but also endlessly reviewed and helped my revise my very very very long application.

 If you are looking into applying for BRS-S, the website has the following listed as requirements:

 

Requirements for all applicants      

 

 

1. ASHA Certification.

All applicants must currently hold the ASHA Certificate of Clinical Competence in Speech-Language Pathology (CCC/SLP).

 

2. Continuing Education.

All applicants must document receipt of at least 7.5 CEUs that relate to dysphagia within the last 3 years. A minimum of 4.5 of the CEUs need to be ASHA sponsored courses and up to 3.0 of the CEUs may be non-ASHA sponsored continuing education activities.

Individuals attending workshops which do not give ASHA CEUs may apply for independent study through ASHA to receive ASHA CEUs. Please provide evidence of attendance at other educational activities in closely related fields. Detailed descriptions of all non-ASHA sponsored CEU activities is required. Continuing education activities may include

  • Workshops, meetings or courses in swallowing and swallowing disorders, video and audio courses, telemedicine, and other electronic media)
  • Independent study (e.g., course development, research projects, publications, internships)
  • Self-study (e.g., videotapes, audiotapes, journals).

Continuing education courses must be directly related to dysphagia. If the title of the course is unclear (as it relates to dysphagia), an applicant should submit a program or brochure to provide substantiation for its inclusion.

When applying CEUs from the ASHA National convention or other multi-offering events, applicants must list specific course/workshop titles and corresponding CEUs in the application table. CEUs will be applied for only those courses/workshop relative to dysphagia.

College Courses.  If an applicant has completed a college level course in dysphagia, accrued credits can be applied to continuing education requirements. Graduate university coursework must be accompanied by a syllabus or transcript. One college credit is equivalent to 1 CEU (as it relates to application for BRS-S). The applicant must submit a transcript or other document verifying completion of those credits.

Instructor or Invited Lecturer. If an applicant teaches a dysphagia course at an approved university/college or provides dysphagia-related lectures at a conference which provides ASHA CEUs, a maximum of 3.5 CEUs may be applied to the 7.5 CEU requirement for BRS-S. One college credit is equivalent to 1 CEU. Each course may only be applied only one time within an application (even though the same course/conference may be taught several times during an academic year or in consecutive years). The applicant must submit appropriate evidence and documentation of the lectures that were related to dysphagia.

 
 

3. Post-Certification Clinical Experience.

All applicants must have completed a minimum of 3 years post certification (CCC/SLP) clinical work that has a focus in dysphagia. BRS-S has established two tracks to meet the diversity of clinical service environments for professionals at all levels of advancement within the profession:Clinical Track and Academic/Administrative Track.  The Clinical Track looks to identify professionals who demonstrate strong advanced clinical skills through direct provision of services to patients/clients. The Academic/Administrative Track looks to identify researchers, instructors and administrators who have advanced in different employment environments. These individuals maintain clinical skills through ongoing patient/client contact, while promoting improved patient care through research and teaching/training of clinicians within this specialized area of practice.

a. Clinical Track: a minimum of 350 clock hours of evaluation and/or treatment of swallowing disorders completed within a year for each of 3 years prior to applying for BRS-S. Supervision of speech-language pathology staff members and students providing evaluation and treatment to infants, children or adults with feeding and swallowing disorders can account for 100 of the required 350 hours/year. Supervisors must submit a statement affirming that all of the 100 hours of supervision were for dysphagia cases. The balance of the hours must be obtained from direct face-to-face clinical service to patients.

b. Academic/Administrative Track: a minimum of 100 clock hours of clinical evaluation and/or treatment of persons with swallowing disorders completed within a year for each of 3 years prior to applying for BRS-S. These hours must all be direct patient contact hours.

In place of the higher number of clock hours required of those in the Clinical track, applicants in the Academic/Administrative tract shall hold either:

a. an academic position in a degree-granting institution with a combination of teaching, and research, and academic advising with a focus on swallowing and swallowing disorders. Evidence of student advising, teaching, and research must be included in the narrative section of this application. Evidence of teaching should include a syllabus of the dysphagia course taught. Research must include clinical research in normal or disordered swallowing with direct contact with human subjects as part of the methodology. OR

b. an official administrative or supervisory position in a setting that provides clinical services to persons with swallowing disorders. Responsibilities will include training and supervision of clinical staff, program development, and leadership in the institution directly related to swallowing and swallowing disorders. Multiple examples and evidence of these areas of leadership must be included in the narrative section of the application (e.g. policy/protocol development regarding swallowing program, development and implementation of dysphagia quality improvement program).

 

4. Advanced Skill Documentation

Through the documentation of advanced level skills in swallowing and swallowing disorders, candidates must demonstrate that they have applied the highest level of ethical standards in their practice (i.e. service delivery and in the conduct of scholarship, research, and training). The expectation is that applicants can demonstrate “advanced” clinical and professional skills over the past 3 years. In other words, the applicant has achieved the highest standard of excellence, displays professionalism, is committed to continuous advanced learning, and displays characteristics that reflect achievements that go above and beyond expectations. Applicants may indicate a clinical preference or advanced level of experience in either pediatrics or adults but this is optional as applicants will have knowledge of swallowing and its disorders regardless of age.

There are distinctly different requirements for each track.

a. Applicants in the Clinical Track must evidence advanced skills either by satisfying at a minimum: two activity types within one category or one activity in two different category types. In other words, the applicant can choose to provide documentation in just one of 3 advanced areas.

b. Applicants in the Academic/Administrative Track must evidence advanced skills in at least two different category types.

 

 

       

 Yes, Yikes!!! I knew I had the ASHA credentials, I actually did have the continuing ed requirements, the hours of experience (thank you to all my SNF experience and the hospital). My area that I was lacking was my advanced experiences. Nancy gave me some wonderful ideas such as presenting poster presentations at my state convention, at ASHA, presenting within the community. I also added things like my Facebook groups, my Twitter experiences, online journal club. I live and work in a very rural area (25 bed hospital), so some of these advanced skills took some creativity. I also was very fortunate in that at the time I started my application process, I had the opportunity to supervise 2 CF’s and a student. Everything just seemed to come together at the perfect time!

I did end up doing a poster session at my state convention in 2011, then a poster presentation that same year at ASHA. I had the Facebook groups, CF supervision and several experiences with education of nursing staff etc. I felt that I was ready at that point. After sending in four copies of my very lengthy application, submitting my payment for application and several long weeks of waiting, I received a letter in the mail. I wasn’t accepted at that point.

The nicest part of the rejection letter, was that the board didn’t just tell me it wasn’t good enough at that point. They highlighted my areas of weakness and strength with suggestions for improving those weak areas and improving them for future application.

I’ll admit, that I spend a couple of days feeling sorry for myself. I cried a little. After encouragement and support from Nancy, my family and several friends, I decided to get back on it.

After another year of presenting to the community, speaking to a nursing class, reworking my application and basically doing all the things that were suggested by the board, i resubmitted my application. 4 more copies, $75 more, MANY revisions of the application, 4 letters of recommendation and letters from former patients.  After an agonizing 8 weeks, I was sitting on the couch one evening, checking my email. I had an email from the BRS-S. MY APPLICATION WAS ACCEPTED!!! I had to email and text everybody I knew!! It was like an absolute dream!

Then came the scary part. I had to pass the exam. What is on the exam?? That is what every person that has not taken the exam would like to know!!! There is a study guide that is submitted with your acceptance email, however, basically, you need to know a little bit of everything about swallowing and dysphagia. I have spent about the last month and a half studying everything I could get my hands on regarding swallowing and dysphagia, pediatrics, Dr. Logemann’s book, journal articles, everything!

I signed up to take my exam on Oct 2. I was a nervous wreck. I couldn’t eat and was just anxious. The time came to take the exam. I signed in (you have 2 hours to take the 110 question exam). I do remember several times thinking, why didn’t I study that more or what in the heck is that?? I actually finished the exam in less than an hour, thinking I would review my answers. I then decided that if I went back over my answers, I would change them and do worse.

I very quickly decided to then click on submit, which I did and waited. My score appeared within seconds, 92%!!!!! I needed an 80% to pass. I could barely believe that I passed!!! I actually obtained Board Recognized Specialty in Swallowing!!

I do believe that anyone who wants to achieve this great honor, should! It is a tough process, it is very taxing, but it is so very rewarding in the end. It is an amazing feeling to know that you have done something that very few people have accomplished at this point.

It is so important in the time of changing health care and the need to “prove” our services, that we have something that we can “prove” the worth of our services and that we are the ones that specialize in the area of swallowing!