Course Alert-MBSImP

mbsimp

If you are a clinician working with patients with dysphagia, the Modified Barium Swallow Impairment Profile is an very thorough course.  The MBSImP targets modified barium swallow studies, however the anatomy learned through the course is amazing.

After taking the course, I wrote a review, which you can find here.

The MBSImP is taught by Dr. Bonnie Martin-Harris and available through Northern Speech Services.

The course seems a little costly, but at $600 for 2.1 CEUs it is a great value!

MBSImP

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.

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.