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 dysfunction 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.

Where Can I Go for Questions Regarding Dysphagia?

You work with dysphagia everyday.  Well, maybe not everyday for some, but you work with patients with dysphagia at least some days.  You have the books, you have paper resources.  Does anyone else keep a binder with information for dysphagia??  I’m working on putting mine on Dropbox so that I can use mine on my iPad.  Where else can you go for information/help with dysphagia?

 First, there is a group on Facebook.  You may have seen it, may even be a member.  The Dysphagia Therapy group has grown more than I could have ever hoped.  This group has been such a great resource for swallowing specialists.  This group has served as a great place for professionals to ask and answer questions and to vent about issues we experience everyday.  We are also getting a number of students who utilize this forum as a means of gaining real world experience by asking professionals questions.  This has also been a great forum to share continuing education experiences, courses and information regarding dysphagia products.  You can join this group at our Facebook site.

 Twitter has become a great resource for all things SLP.  If you belong to Twitter, all you have to do is add the hashtag #dysphagia or #dysphagiapeeps.  Twitter has been such a great resource to ask/answer questions.

 There is a dysphagia maillist.  You email your questions/information to the listserv and will usually get at least one response if not more.  The only downside to this listserv is that it can, at times flood your email.   One complaint of this maillist is that often times the responses to questions can be very negative and often times you feel that you are being told what not to do, but never really what to do.  It also seems to be very heavily geared towards the pediatric population.

 By the same token, ASHA Special Interest Group (SIG) 13 for Swallowing and Swallowing Disorders also offers a mail listserv.  Again, the downside of this is flooding of your email and you have to be a member of SIG 13 (an extra $35 in addition to your dues for ASHA).  The good part of this listserv is the responses are often very positive and informative.  You also tend to hear from some of the “big names” in dysphagia such as James Coyle.  SIG 13 also has their own webpage on the ASHA site and with your membership, you get access to the Perspectives for Swallowing and Swallowing Disorders journal, which is a great resource.  You also, for a fee, can utilize this journal for CEU’s.

The National Foundation of Swallowing Disorders (NFOSD) provides free educational webinars as well as connects patients with qualified speech pathologists.  They publish articles on their site about patients with dysphagia.

 The Dysphagia Research Society is a great resource to therapists.  You can join via a research track or a clinical track.  There are three tracks of membership:  full member is $220 a year and you have to have published research; associate membership requires interest in deglutition and costs $170 a year, however you have full access to the Dysphagia journal; student/trainee membership is $50 a year and requires a letter from the head of the department.  In addition to their website, access to the Dysphagia journal, the DRS also has a conference once a year.  The 2012 conference will be held in Ontario Canada.  I believe that the conference is available for CEU’s.

 The VitalStim website offers great resources, whether you are a certified clinician or not.  The website offers resources, a list of VitalStim certified clinicians and free webinars.  Some of the webinars are for VitalStim certified clinicians only and some are free for all clinicians.

 That Mayo Clinic website offers resources for Dysphagia that would be more appropriate for families/patients.  This would be a great site for clinicians looking for resources for family/patient education handouts.  It might be good for students/new clinicians to start adding to their toolbox.  

 Clinicians that want to specialize in Dysphagia are encouraged to get their Board Recognized Specialty in Swallowing (BRS-S).  The BRS-S website offers CEU’s in Dysphagia.  You can also print the application to obtain your BRS-S with a list of the requirements.  You can obtain this via a research or clinical track.  The clinical track requires evidence of skills in Leadership, Education and Research, along with 75 hours of CE in Dysphagia courses within the last 3 years.  You also have to have 350 clinical hours within the last 3 years.  Once you submit your paperwork with $75 (you can request a mentor to assist you with your paperwork, help you determine if you are ready for BRS-S and set you on track to obtain your BRS-S within 3-5 years.) Once your application is accepted, you can take the examination for an additional $300.  You have 2 chances to take the test without having to pay again.  After the first 2 tries, you have to pay $75 per re-take and can only attempt to pass the exam for the next 12 months.

 The American Dysphagia Network offers CEU’s for clinicians, information on swallowing and swallowing disorders for clinicians and patients and a self-test for Dysphagia that can be completed online or printed and given to the public.  

 Swallow Safely is an amazing book written by Roya Sayadi, Ph.D., CCC-SLP and Joel Herskowitz, M.D. It is a great resource for family, patients, potential patients and clinicians. The book is easy to read, not terribly long and inexpensive. The book runs anywhere from $9.99 to $14.99. It is also available in ebook format, so it provides easy reading on your iPad or Nook.

 Last, but not least, if you own an iOS device (iPad, iPhone, iPod) or an Android system, there are apps available for you to use for Dysphagia therapy. There are not many yet mind you. If you own an Apple device, you can look for: Oral Motor from SmartyEars which is geared mainly towards pediatrics; Lingraphica offers an oral motor app geared more towards adults; Lingraphica also offers a Dysphagia app (Smalltalk) with icons which can be utilized by patients to “speak” words/phrases regarding their swallowing/dysphagia and also videos demonstrating maneuvers such as the supraglottic swallow; iSwallow offers a means of setting up a program for your patient, adding exercises, schedule, instructions and a journal for patients to use for their swallowing therapy; NeuroToolkit includes the NIH Stroke Scale, Coma Scales, SAH/AVM Scales, TIA/Stroke/ICH Scales, Anticonvulsants and Outcomes/UPDRS/Eye/EDSS/MIDAS. This is about it for the Dysphagia apps I have found for iOS. For Android, there are even less. Android offers the MiniMental app which may be helpful in determining cognitive status for you patient, Rancho Los Amigos app which basically just tells you what to expect at each level, and I sometimes use the stopwatch app for my assessment.

Lost Somewhere in a Pediatric World

Are there ever times you just question what you do in life?  There are times, I do.  Then I take a good look at what I do and realize, I don’t really want to be anywhere else.  I’ve worked in many different settings, with both peds and adults.  I LOVE my adults and LOVE working with people with swallowing difficulties.  To me, that is the most rewarding part of my job.

 I also sometimes feel alone in my world of medical adult therapy.  I get on the iPad looking for apps and almost everything is so pediatric based.  I do use my iPad in therapy with adults, but I am very picky on my apps.  I don’t like the “cartoony” apps for my adults.  There are therapists out there in the world that use pediatric resources for adults, however to me, I would not like an activity like that and will not subject my patients to that.  I often see it as demeaning and belittling, but maybe that’s just me.

 I get on Pinterest, with which I have a current obsession, and see all these cute, pediatric ideas.  There is an education category on Pinterest, but not a whole lot for medical.  I love getting ideas for Pinterest, however sometimes it’s a bit overwhelming with the amount of pediatric resources available and the lack of adult resources.

 Twitter is full of resources, but also seems to be very much pediatric based, which is probably the reason I spend most of my time on Facebook, where we have several adult-based groups, with adult-based therapists that share evidence-based practice ideas (and sometimes inaccurate opinions, but hey, it’s still nice to hear various sides and arguments which promote thinking.)

 I challenge all of you adult SLPs out there to help me in creating a larger basis for all of us adult, medical SLPs.  I applaude the efforts of Megan Sutton (Tactus Therapy Solutions) and Barbara Fernandes (Smarty Ears) for delving into the world of adult therapy on i devices (iPad, iPhone) and creating apps I can use in my therapy.   I am so looking forward to seeing more!!  (Or people that could help me turn my ideas into apps!  ;))

Modifieds……The Who, What, When, Why and How

I often feel I am very fortunate because I actually get to perform my own Modified Barium Swallow Studies (MBSS) or Rehab Swallow Study, Videofluoroscopic Swallow Study, Three Phase Esophagram…..whatever it may be called in your area.  I often wonder how clinicians work from some of the reports they receive.  I think back to the courses I’ve attended and the books I’ve read.  Dr. Logemann describes the MBSS as a procedure in which we find treatment strategies, compensations that help the patient swallow as safely as possible.  The main purpose of Dr. Martin Harris’ MBSImP is to discover the dysfunction causing the swallowing problem.  f

 We must always keep in mind that we don’t “treat” aspiration or penetration.  We treat the decreased hyolaryngeal excursion that causes the aspiration.

 There have been many times that I’m treating from a report another SLP had written.  I had no idea what direction to aim my therapy because the report merely stated aspiration.

 I’ve been reading questions from others, either from the Facebook groups or from the SIG 13 email forum.  There are always questions about modifieds, who’s appropriate, how to do it, what should be done.  Of course that triggers a blog post for me!!

 So, let’s begin with the who.  Who is appropriate for an MBSS?  When I am contemplating an MBSS for a patient I look at the following:

 1.  Are they appropriate for an MBSS??  They have to have some level of consciousness, it helps if the patient can follow simple directions (for chin tuck, swallow, etc) and it does help if they are able to sit up.  It is extremely difficult, though not impossible, to view what you need to view with someone that is constantly slumped over.

 2.  Will this MBSS change my plan of action?  If the MBSS will not change any part of the plan of treatment, it is probably unnecessary.  If I am looking at diet changes or most importantly, treatment planning and compensation assessment, then, yes, this person is in need of an MBSS.

 3.  To some degree we need to evaluate the physical status of the patient.  If you have had the luxury of looking at the fluoro machine, there is not a lot of space for the patient to sit in the machine.  Some people just don’t fit in the machine and if we squish them in the space, their shoulders hunch up to a point it’s difficult to examine the patient.  This problem can be overcome however with use of the C-arm, which is a large C shaped machine that ANY patient could sit inside.  The only reason that my x-ray techs and radiologists don’t like the C-arm is because it has increased fluoro exposure.

 What does an MBSS tell us?  An MBSS is used to tell us a large variety of information, not only to detect the presence or absence of aspiration.  When we are completing an MBSS, we should be looking at muscle movement throughout the swallow including pharyngeal stripping wave, tongue base retraction, hyolaryngeal excursion, etc.  With hyolaryngeal excursion, you are examining the movement of the arytenoids, the laryngeal closure and laryngeal excursion.  An MBSS tells us what physical aspects accompany a “silent” aspiration and what compensations may work for or worsen the swallow.  If you use a treatment approach such as McNeill Dysphagia Therapy Program (MDTP), you are also looking for your starting point for therapy.

 When is a patient appropriate for an MBSS?  As I’ve stated above, a patient needs to be able to have some ability to follow simple directions and should be able to sit upright, even if it is with support.  There are times with ICU patients, they are just not quite medically stable to be moved down to the x-ray suite and/or tolerate the procedure.  Also, consider, if the person has JUST had a stroke, they may need a day or 2 to recover prior to the MBSS.  If they’ve just had their trach pulled or have been extubated, they may need some recovery time prior to the MBSS.

 The where is the fluoroscopy suite.  If you’ve never been in one, you really need to make a visit.  The fluoro suite (any that I’ve been in) is somewhat small.  The patient is sat on a special chair (a Hausted chair for me) and is between the fluoro table and tube.  The radiologist will push the pedal/button to fluoro the patient and either an x-ray tech or the SLP will feed the patient the barium.

 Varibar is the barium most SLPs use as it is already the consistencies we use, thin, nectar, thin honey, thick honey and pudding.  Or, if you are unable to get your facility to purchase Varibar, you thicken the drinks the best you can!

The why of the MBSS, as I mentioned above, is to evaluate the swallow in ways we can’t do bedside.  We look at the muscle movement and function.  If you are an SLP and you complete your own MBSS, then I highly recommend looking into the Modified Barium Swallow Impairment Profile (MBSImP).  It is a long course if you attend the live session.  You also have to complete the online section to become registered and use the tools.  You can also only do the online section and skip the live.  This course teaches you how to evaluate and score the muscle movements of the swallow per MBSImP protocol.  Another added bonus is, it decreases the amount of fluoro time for you and your patient.

The how…..is variant.  Many people use a variety of techniques and consistencies for the MBSS.  This was part of the reason for the induction of the MBSImP, to standardize the MBSS.   Some people use every consistency they can find to feed the patient under fluoro, some use the Dr. Logemann set with 3 ml, 5 ml and 10ml liquids, etc.  Dr. Crary and Carnaby suggest using their protocol for MBSS.  You can find the Carnaby Videofluoroscopic Data Sheet at Dysphagia Toolbox.

Some important parts of the MBSS, whichever technique you employ is:

1.  Analyze the patient’s swallow.  Look at the muscle dysfunction and piece together the patient’s history, bedside eval, etc, to examine the entire picture of this patient.

2.  There is no need to assess full meals and every consistency or texture the person may ever eat.  If you look at the muscle function, this gives you a good picture of your patient.f

3.  Remember, although insurance will typically pay for an MBSS every 30 days, that does not mean that one is necessary every 30 days.

You can also watch a variety of MBSS videos on YouTube.

The McNeill Dysphagia Therapy Program

For those of you who haven’t heard of the McNeill Dysphagia Therapy Program or MDTP, you need to look it up.  You can Google search the supporting evidence of the program.



 I have been extremely excited about this course since I’ve heard about it 3 years ago.  The downfall, it’s only offered at certain times.  The limitation of the course prevented me from attending for a while, however this January, I had the opportunity to attend in Orlando.

 In 2010, I attended the ASHA convention in Philadelphia.  I went to a session by Dr. Carnaby and Dr. Crary talking about MDTP.  Of course, it was mostly discussing the research and success behind the technique.  It was interesting though to see that the results they found with this therapeutic technique indicated superior outcomes to traditional therapy alone.

 At first, I was a little uncertain why there was so much secret behind this therapy.  When you go to the course, you have to sign a contract that you won’t teach the technique to anyone else.  Also, to use this technique and call it MDTP, you must be certified.  If the therapy is so great and successful, why not share it with everyone??  In talking to the researchers, Dr. Carnaby and Dr. Crary, they want to make sure that SLPs are properly trained in this technique before going out and attempting it with their patients.  They want to train the SLPs in the technique.

 The technique makes sense.  In providing services for over 10 years, one thing has become very prevalent in our services.  We have increased our understanding for neuroplasticity and exercise-based therapy programs.  When we look at neuroplasticity, we must use specific tasks to increase the swallow.  If I want a person to run a marathon, they have to run.  Sitting on an exercise bike daily will not get them prepared for the marathon without actually practicing running.   If I want my patient to be really good at sticking out their tongue, that’s what I’ll have them do.  I want my patients to improve their swallowing, so that’s what I need to target with my patients.

 MDTP is a systematic exercise based program, focusing on swallowing using exercise principles.  While I am not allowed to teach the specifics, or include them in this post, the basics and concepts of this approach are freely available in the articles that can be accessed through Google.

 We can learn a lot through our PT/OT counterparts.  They work the muscle systems through exercise based therapy using weight and resistance to increase the motoric output of the muscular system.  This is what we should be doing.  While we can’t necessarily add weights to the swallowing muscles, we can use food and the bolus as resistance and weight.  We have the effortful swallow available using a higher resistive swallow with our patients.  sEMG can be utilized to get the patient to swallow harder and to monitor their swallows.

 So many of us have learned therapy the old way.  The stick out your tongue 10 times way.  That’s how I learned.  Naturally, there was little carry-over, little improvement and a lot of patients wondering what in the heck we were even doing.

 I have had my first new patient since learning MDTP.  This is an NPO patient with a feeding tube.  Traditional therapy to increase the muscles of the swallow has not worked.  Two MBSSs later, the patient is still NPO, with occasional ice chips and drinks of water.  During our first session, the patient went through the first 4 levels of MDTP.  NMES was introduced during the session, as patient had to swallow 5-6 times to clear the bolus.  NMES combined with MDTP reduced the number of swallows per bolus to 1-2, occasionally 3.

 MDTP finally focuses on swallowing as a whole.  It gives us a protocol with a food hierarchy, a specific swallow, a program to follow and a pass/fail criteria.  It forces us to look at the muscle function, how the muscles are made, what we can do to change the muscles, after all, we are rehabilitating our patients.

 I highly recommend this course to anyone and everyone treating patients with dysphagia.  The information regarding muscles, therapy and neuroplasticity is invaluable and great review if you are familiar with the content.  The technique is phenomenal with no materials, tools or expensive equipment to buy.  You can take the 1 day course and utilize it the next day.

 In our therapy world where outcome based therapy is becoming essential for reimbursement, MDTP gives us a way to measure outcomes for our patients.  More importantly, MDTP works.  Not for everyone, unfortunately there are those we just can’t help.  Our patients though deserve and expect the most recent, successful therapy processes we can provide.  Our patients success is why we do what we do.

 If you are interested in MDTP, course information is available at www.procourseceus.com.  Like ProCourse on Facebook and follow them on Twitter.