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

The Modified Barium Swallow Study

The Modified Barium Swallow Study or MBSS is an assessment to determine the physiology of the swallow.   

The MBSS is often ordered to “determine what consistency is the safest” or to “rule out aspiration” however there is so much more we can discover with the MBSS.

The MBSS is to confirm the diagnosis of dysphagia.  Not only to confirm the dysphagia but to also determine the cause of the dysphagia.

Do you often wish you had a nickel for every time you suspected a dysphagia and it was really something else?  Or that you suspected a normal swallow that was actually a dysphagia?   I would be retired by now!

The thing is, we can’t do instrumentals on absolutely every person that we see.   It would be nice, but it’s not always reasonable.

We have to determine when instrumental is important.

The Who 

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), but they don’t HAVE to be able to follow directions.  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 may be unnecessary.  If I am looking at treatment planning and compensation/maneuver 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 some x-ray techs and radiologists don’t like the C-arm is because it has increased fluoro exposure and can be difficult to move.

The What 

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.

The When 

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 (even as simple as open your mouth) 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, however that is very much dependent on each patient.

The Where  

The where is the fluoroscopy suite, if you are in a hospital setting.  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.

More recently, mobile MBSS vans are becoming increasingly more available.   This means the patient may be taken out into the parking lot at a SNF, ALF, etc and straight into the van for the test.   Some mobile units also use a C-arm that goes into the patient room.

The Why

The why of the MBSS, as I mentioned above, is to evaluate the swallow in ways we can’t do bedside.  At bedside, we can’t SEE the pharyngeal phase of the swallow.  We are taking a variety of symptoms and inferring what we think may be happening in the pharynx. 

We look at the muscle movement and function.   We look at compensatory strategies, maneuvers or sensory strategies that may improve the swallow.   We look to confirm or to rule out the diagnosis of dysphagia, because how can we be certain when we are just staring at a throat?

The How

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.  

If you are an SLP and you complete your own MBSS, then I highly recommend looking into the Modified Barium Swallow Impairment Profile (MBSImP).  This is a standardized protocol for MBSS.

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.

3.  Remember, an MBSS can be completed to answer questions and can be completed when the patient has a change in status whether that means an improvement or a decline.  

The Take-Away

No matter if you are a clinician completing the MBSS or the clinician treating the patient after the MBSS, it’s important to understand the MBSS.  Even if you never complete an MBSS, if you treat dysphagia, you should be able to interpret the MBSS.

You must be a competent dysphagia clinician to treat patients with dysphagia and you must understand the swallowing system in its entirety.

References:

The Step-by-Step Guide to Advocating For Access to Instrumentation for Our Patients

Attrill, S., White, S., Murray, J., Hammond, S., & Doeltgen, S. (2018). Impact of oropharyngeal dysphagia on healthcare cost and length of stay in hospital: a systematic review. BMC health services research18(1), 594.

Bonilha, H. S., Simpson, A. N., Ellis, C., Mauldin, P., Martin-Harris, B., & Simpson, K. (2014). The one-year attributable cost of post-stroke dysphagia. Dysphagia29(5), 545-552.

Bours, G. J., Speyer, R., Lemmens, J., Limburg, M., & De Wit, R. (2009). Bedside screening tests vs. videofluoroscopy or fibreoptic endoscopic evaluation of swallowing to detect dysphagia in patients with neurological disorders: systematic review. Journal of advanced nursing, 65(3), 477-493.

Ekberg, O., Hamdy, S., Woisard, V., Wuttge–Hannig, A., & Ortega, P. (2002). Social and psychological burden of dysphagia: its impact on diagnosis and treatment. Dysphagia, 17(2), 139-146.

Linden PL, Siebens AA: Dysphagia: predicting laryngeal penetration. Arch Phys Med Rehab 64:281-284, 1983.

Linden P: Videofluoroscopy in the rehabilitation of swallowing dysfunction. Dysphagia 3:189-191, 1989.

Logemann, J. A. (1997). Role of the modified barium swallow in management of patients with dysphagia. Otolaryngology–Head and Neck Surgery116(3), 335-338.

Logemann JA. Manual for the videofluorographic study of swallowing. 2nd ed. ProEd; Austin, TX: 1993.

Logemann JA. Evaluation and treatment of swallowing disorders. ProEd; Austin, TX: 1998.

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. Dysphagia23(4), 392-405.

Martin-Harris, B., Logemann, J. A., McMahon, S., Schleicher, M., & Sandidge, J. (2000). Clinical utility of the modified barium swallow. Dysphagia, 15(3), 136-141.

Palmer, J. B., Kuhlemeier, K. V., Tippett, D. C., & Lynch, C. (1993). A protocol for the videofluorographic swallowing study. Dysphagia8(3), 209-2

Patel, D. A., Krishnaswami, S., Steger, E., Conover, E., Vaezi, M. F., Ciucci, M. R., & Francis, D. O. (2017). Economic and survival burden of dysphagia among inpatients in the United States. Diseases of the Esophagus, 31(1), dox131.

Siebens AA, Linden PL: Dynamic imaging for swallowing reeducation. GastrointestRadio110:251-253, 1985.

Sura L, Madhavan A, Carnaby G, Crary MA. Dysphagia in the elderly: management and nutritional considerations. Clinical Interventions in Aging. 2012;7:287-298. doi:10.2147/CIA.S23404.

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MBSImP

MBSImP

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.

Where Can I Find MBSImP

This protocol for MBSS is based on more than 10 years of work and research.    Northern Speech Services is the company that provides the MBSImP training which can be taken wholly or partially online.

The 17 Components

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.  

The Training 

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 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”.

How In the Heck Do You Even Administer This Protocol? 

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.

Scoring the MBSImP

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.

This gives you a standardized score for the swallow study by entering all MBSS information and findings into a database, which creates your report.  This score allows you 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 tongue base retraction (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).

Thoughts on the MBSImP 

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?)

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 still very excited about this protocol and the direction in which it takes our field.  I have been using this protocol since 2010 and I highly recommend it to all SLPs treating dysphagia, 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.

References:

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. Dysphagia23(4), 392-405.

Sandidge, J. (2009). The Modified Barium Swallow Impairment Profile (MBSImP): a new standard physiologic approach to swallowing assessment and targeted treatment. Perspectives on Swallowing and Swallowing Disorders (Dysphagia)18(4), 117-122.

Gullung, J. L., Hill, E. G., Castell, D. O., & Martin-Harris, B. (2012). Oropharyngeal and Esophageal Swallowing Impairments: their association and the predictive value of the modified barium swallow impairment profile and combined multichannel intraluminal impedance—esophageal manometry. Annals of Otology, Rhinology & Laryngology121(11), 738-745.

Martin-Harris, B., Humphries, K., & Garand, K. L. (2017). The Modified Barium Swallow Impairment Profile (MBSImP™©)–Innovation, Dissemination and Implementation. Perspectives of the ASHA Special Interest Groups2(13), 129-138.

Martin-Harris, B. (2017). MBSImP™ Web Based Learning Module. Northern Speech Services.

Tran, T. T. A., Martin Harris, B., & Pearson Jr, W. G. (2018). Improvements resulting from respiratory-swallow phase training visualized in patient-specific computational analysis of swallowing mechanics. Computer Methods in Biomechanics and Biomedical Engineering: Imaging & Visualization6(5), 532-538.