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MBSS AND FEES. Why Not Both?

MBSS VS. FEES

Whenever you read the literature, you often see MBSS vs. FEES or a similar thought comparing the two tests, attempting to find the superior, gold standard assessment.

On social media, we seem to have 2 camps.   Team MBSS and Team FEES.   You can’t be friends and in separate camps!!  (Completely joking here!!!)

Many facilities choose one test or the other.   You can either request MBSS or FEES.  They’ll have a contract for Mobile MBSS or Mobile FEES.   In the hospital, it’s either/or.

What would happen if we try to change that thought.   What if, we changed from an either/or to a both.

What If…….

What if companies had the option of both.  Maybe the ability to do both tests at one time?  Even if they are completed at different times.  Both tests give you such a varied viewpoint of the swallow while often providing the same information regarding the swallow.

The literature says……

The majority of the research tells us that we see the same pharyngeal events with FEES that we see with MBSS including decreased back of tongue control/oral containment resulting in premature posterior loss of bolus, decreased hyolaryngeal excursion, decreased epiglottic introversion, decreased laryngeal closure resulting in penetration/aspiration or vallecular residue.   We may see decreased opening of the Pharyngoesophageal Sement (PES)/Upper Esophageal Sphincter (UES)  resulting in pyriform sinus residue and maybe aspiration.  We can see residue on the posterior pharyngeal wall due to decreased pharyngeal squeeze/stripping wave.

So, in fact, with either test we can see the physiological events of the swallow that lead us into a plan of treatment.

Much of the research states that residue, aspiration, etc are all rated as more severe when using FEES.

What about the doctors

Look at physicians.   they will often order a CT scan for a stroke patient.   When this doesn’t give them all the information needed, they often then order an MRI.   The CT and MRI do give different viewpoints and provide some different information and compliment each other very well.

Anecdotal thoughts.

In my experience, not just reading the research, when a patient had a FEES (performed by me) and later had an MBSS (performed by a colleague) the findings were exactly the same leading to identical recommendations.   In fact, I did not know until after the test that the patient was going to have an MBSS and the other SLP did not know until after the test, the results from the FEES.

Changing our thinking.

So let’s work on changing our thinking to BOTH tests, not just one or the other.  Let’s educate other medical professionals that we are looking for much more than just aspiration or penetration and that we can do so much more than just change a diet.

Let’s make a change!

References:

Aviv, J. E. (2000). Prospective, randomized outcome study of endoscopy versus modified barium swallow in patients with dysphagia. The Laryngoscope110(4), 563-574.

Schatz, K., Langmore, S. E., & Olson, N. (1991). Endoscopic and videofluoroscopic evaluations of swallowing and aspiration. Annals of Otology, Rhinology & Laryngology100(8), 678-681.

Brady, S., & Donzelli, J. (2013). The modified barium swallow and the functional endoscopic evaluation of swallowing. Otolaryngologic Clinics of North America46(6), 1009-1022.

Leder, S. B., Sasaki, C. T., & Burrell, M. I. (1998). Fiberoptic endoscopic evaluation of dysphagia to identify silent aspiration. Dysphagia13(1), 19-21.

Bastian, R. W. (1991). Videoendoscopic evaluation of patients with dysphagia: an adjunct to the modified barium swallow. Otolaryngology—Head and Neck Surgery104(3), 339-350.

Langmore, S. E. (2003). Evaluation of oropharyngeal dysphagia: which diagnostic tool is superior?. Current opinion in otolaryngology & head and neck surgery11(6), 485-489.

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Modified Barium Swallow Study: Gold Standard or Old News?

The Modified Barium Swallow Study, no matter what name is used, has been considered a gold standard for many years in the assessment of dysphagia.  

Recently there has been a lot of debate about whether the MBSS continues to be the gold standard or if FEES (Flexible Endoscopic Evaluation of Swallowing) has taken the place as the gold standard evaluation.

For some reason, it’s become an either/or world that you only get FEES or you only do MBSS.   This is just absurd!

Both tests can provide valuable information.

The MBSS can give you valuable information (FEES posts coming soon!)  You can visualize the oral cavity as the patient prepares to swallow the bolus.  You can visualize as the bolus passes through the pharynx and hopefully through the esophagus.

You can view the patient laterally, you can use an anterior-posterior view or even an oblique view as needed to gather as much information as possible regarding the swallow.

Communication is key.

As the treating SLP, it is so important to get information to the SLP completing the instrumental assessment regarding patient history, why you are ordering the study and possibly even some information about your tentative treatment plan, current diet level, etc.  Most patients are not able to relay the information the same way an SLP would, if at all.

Are there any strategies you think might be beneficial?

Are there any consistencies you want trialed?  Let the SLP know!!

The SLP completing the MBSS doesn’t quite get off the hook.

As the assessing SLP or the SLP completing the instrumental assessment, it is critical that the treating SLP receive a report they can use to build a treatment plan.  It is impossible to educate a patient on why they are on an altered diet or why they need to use such and such compensation when the SLP is unsure.  The report needs to include compensations trialed and effective or ineffective.  It’s also very difficult to know what consistencies, amounts, etc to use for therapeutic trials if the study was discontinued after one instance of aspiration on a teaspoon of thin.

Remember though, sometimes the report never gets to the treating SLP.   Sometimes they try like crazy to get it, but they are never able to do so.

Download your Communication Guide:

Untitled Design

You won’t get an instrumental assessment if you don’t request it.

Often instrumental assessments are not recommended for a variety of reasons.  Maybe you have sent multiple patients out for an MBSS and the report is not what you need to create a solid treatment protocol.  Maybe the patient refuses or the doctor refuses or the facility refuses.

It is time that we educate physicians, nurses and other medical professionals on the purpose of the MBSS.  Physicians often know or have a good idea that a patient had a stroke.  They still use the CT scan and/or MRI to determine size of stroke, location of stroke and whether the stroke is acute or an old infarct.

We need the same diligence in our field to assess dysphagia beyond just penetration/aspiration and diet selection.  Whether the physician orders the MBSS or the patient participates should be irrelevant to our recommendation for MBSS.  If we believe the MBSS is an important tool to our patient’s care, document and recommend.

Theresa Richard created a great guide for gaining access to instrumental assessment.   The Step-by-Step Guide to Advocating For Access to Instrumentation for Our Patients

 

 

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The Instrumental Guide to Compensatory Strategies and Maneuvers

When completing instrumental assessments, the easiest way to change the swallow is to change the diet consistency.

Dr. Jeri Logemann (1993) has suggested using compensatory strategies/maneuvers in the following order:

  1. Postural techniques
  2. Sensory techniques
  3. Maneuvers
  4. Diet changes

Remember we can often change the swallow through sensory techniques.   Steele and Miller 2010 concluded:  “Boluses of liquids and solids normally initiate pharyngeal swallowing using multiple modalities, including taste, water, touch, pressure, and possibly temperature to excite several types of sensory fibers of different diameters that innervate the receptors in the oropharyngeal mucosa. It appears that stimulation of a greater number of receptive fields and their individual sensory neurons induces a stronger reflex with greater muscle recruitment and force. ”

Do you want a guide to help you determine which compensatory strategy/maneuver may work best?  Click the picture below to download your guide.

The Instrumental Guide Dysphagia Ramblings

 

References:

Logemann, J. A. (1993). Manual for the videofluorographic study of swallowing (Vol. 2). Austin, TX: Pro-ed.

Logemann, J. A. (1998). The evaluation and treatment of swallowing disorders. Current Opinion in Otolaryngology & Head and Neck Surgery6(6), 395-400.

Steele, C. M., & Miller, A. J. (2010). Sensory input pathways and mechanisms in swallowing: a review. Dysphagia25(4), 323-333.

 

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Barium

So, you know all about MBSS, right? 

You’ve learned the MBSImP, you know all about consistencies, all about compensatory strategies.

What barium should you use?

We are often mixing the same barium used in other studies with food and liquid brought in from the kitchen.

At one point, there was a recipe available to make your own barium cookies.  You can also purchase these.

The thing is, when we use the same barium as used in the more in-depth esophageal tests they coat the structures.   That is what they were designed to do.   Sometimes that is all you can use because it’s all that’s available, but you have to remember there may be residue there, that wouldn’t normally be present.

The best option is to use Varibar, which was designed for the MBSS.  This is the same barium used in the MBSImP.

Not sure which compensatory strategies to use?  Read more by clicking on the picture!

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Maybe not sure about which consistencies you should trial?  Read more by clicking on the picture!

which consistencies do i trial

References:

https://imaging.bracco.com/us-en/products/fluoroscopy/varibar

Dantas, R. O., Dodds, W. J., Massey, B. T., & Kern, M. K. (1989). The effect of high-vs low-density barium preparations on the quantitative features of swallowing. American Journal of Roentgenology153(6), 1191-1195.

Logemann, J. A. (1993). Manual for the videofluorographic study of swallowing (Vol. 2). Austin, TX: Pro-ed.

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Which Consistencies Do I Trial?

A Moment in Time

Most people call the Modified Barium Swallow Study (MBSS) a “snapshot in time” or a “moment in time”.

You can’t possibly trial every single consistency the person may eat while under fluoro.  The radiation exposure would get to be ridiculous and the kitchen in your facility may not like you much if you do many modifieds in a week.

So what in the heck should you trial?

Well, if you follow the MBSImP, then you know that there is a standardized set of consistencies to trial (thin, nectar/mildly thick liquid, pureed and solid).  You can add to this if you need.  If you want to add a mixed consistency or need to try honey/moderately thick, then you can add that.

Basically, you want to answer the question, what is the physiology of the swallow?

Somewhere along the line, the MBSS became a test for determining if the patient is aspirating or not and what consistency we need to place the person on (or their diet sentence.)

Don’t forget, you are answering the questions:

  • What does the swallowing physiology look like?
  • How can I change the swallow to make it functional?

You are finding the information to develop that patient’s plan of care to make them as functional with swallowing as possible.

The best thing you can do is to test the consistencies that answer those questions.

Now remember, in the MBSImP course, you learn the nectar (mildly) thick liquids can change the swallowing physiology with increased movement of the pharyngeal structures.   You may recommend the patient stays on regular liquids, however you may use nectar (mildly) thick liquids to exercise the oropharyngeal musculature as an exercise.

References:

Martin-Harris, B., Logemann, J. A., McMahon, S., Schleicher, M., & Sandidge, J. (2000). Clinical utility of the modified barium swallow. Dysphagia15(3), 136-141.

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

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.

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.

Gibson, E., Phyland, D., & Marschner, I. (1995). Rater reliability of the modified barium swallow. Australian Journal of Human Communication Disorders23(2), 54-60.

Palmer, J. B., Kuhlemeier, K. V., Tippett, D. C., & Lynch, C. (1993). A protocol for the videofluorographic swallowing study. Dysphagia8(3), 209-214.

 

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Compensatory Techniques

Compensatory techniques are used to alter the swallow, however compensations may not create a lasting effect to the swallow.

Compensatory strategies may be short term or used more long-term, such as with patients with head and neck cancer.

Compensatory strategies can be used to alter posture, timing of the swallow, laryngeal closure.

While most compensatory strategies do not cause long-term effects to the swallowing system, some can be used as exercise to create a lasting effect to swallowing.

Any compensatory strategy should be viewed during instrumental assessment to determine the effectiveness and accuracy of completion.

Maneuvers: 

Supraglottic Swallow

  • To close vocal cords prior to the swallow.
  • Improves coordination of the swallow.  
  • Use when you see aspiration prior to or during the swallow.
  • Use with a delayed pharyngeal swallow.

Logemann recommends 10x/day x5 min with 5-6 swallows each time as exercise.  (Frymark et al 2009)

Super Supraglottic Swallow

  • For early closure at the entrance to the airway.
  • Facilitates timing and extent of laryngeal closure at specific levels of the larynx.
  • Use with penetration/aspiration prior to or during the swallow.
  • Use with a delayed pharyngeal swallow.

Mendelsohn Manevuer

  • To assist in laryngeal elevation.
  • Widens the valleculae.
  • Use for reduced laryngeal elevation.
  • Use for reduced PharyngoEsophageal (PES) opening.
  • Use for discoordianted swallow.

Effortful Swallow

  • Increase strength of the overall swallow.
  • Use with vallecular residue.
  • Use with reduced tongue base retraction.

Postures:

Chin Tuck

  • Widens valleculae.
  • Helps patient keep bolus in the oral cavity.
  • Narrows airway.
  • Use with oral containment issues (posterior loss of bolus resulting in aspiration).
  • Use with reduced airway closure.
  • Use with vallecular residue.

Head Turn (to weak side)

  • Closes the weak side of the swallow directing the bolus to the stronger side.
  • Use with unilateral pharyngeal paralysis or paresis.

Head Back

  • May assist patients with poor oral control or difficulty propelling the bolus.
  • Pharyngeal phase must be intact.
  • Use with patients with poor anterior-posterior propulsion of bolus such as with glossectomy.

Side Lying

  • To help clear pharyngeal residue by altering gravity.
  • Use with reduced pharyngeal contraction (pharyngeal residue, aspiration after swallow).

Changes in the bolus/Sensory

Texture-give a variety of textures.  Patient may be more successful with a bolus they have to chew.  (Don’t try one texture only!!)

Viscosity-May trial thicker consistencies to determine if there is an effect on the swallow.  (May help you determine if thick liquids could be used therapeutically during sessions, not necessarily for diet changes.)

Temperature-Patients may respond differently with a hot bolus vs. a cold bolus.

Sour-Try different tastes.  Sour has been known to stimulate a faster swallow.  Patients may respond to differing tastes.

Size-Patient may have difficulty with a small bolus vs. a large bolus or vice versa.   Some patients require a larger bolus to trigger the swallow.

Pressure-Patient may respond with a swallow given pressure from the spoon as presenting the bolus.

Diet Consistency Changes:

Remember, diet consistency changes should be considered as a last resort!  Do not immediately trial thickened liquids and change a diet without first trialing other strategies that may allow a patient to safely swallow thin liquids.

For more information on the new standardized diet consistency levels, visit the IDDSI website.

References:

Corbin-Lewis, K., & Liss, J. M. (2014). Clinical anatomy & physiology of the swallow mechanism. Nelson Education.

https://iddsi.org/

https://www.asha.org/PRPSpecificTOpic.aspx?folderid=8589942550&section=Treatment

Logemann, J. A. (1993). Manual for the videofluorographic study of swallowing (Vol. 2). Austin, TX: Pro-ed.

Langmore, S. E., Kenneth, S. M., & Olsen, N. (1988). Fiberoptic endoscopic examination of swallowing safety: a new procedure. Dysphagia2(4), 216-219.

McCauley, R. J., Strand, E., Lof, G. L., Schooling, T., & Frymark, T. (2009). Evidence-based systematic review: Effects of nonspeech oral motor exercises on speech. American Journal of Speech-Language Pathology.

Ashford, J., McCabe, D., Wheeler-Hegland, K., Frymark, T., Mullen, R., Musson, N., … & Hammond, C. S. (2009). Evidence-based systematic review: Oropharyngeal dysphagia behavioral treatments. Part III–impact of dysphagia treatments on populations with neurological disorders. Journal of Rehabilitation Research & Development46(2).

McCabe, D., Ashford, J., Wheeler-Hegland, K., Frymark, T., Mullen, R., Musson, N., … & Schooling, T. (2009). Evidence-based systematic review: Oropharyngeal dysphagia behavioral treatments. Part IV–impact of dysphagia treatment on individuals’ postcancer treatments. Journal of Rehabilitation Research & Development46(2).

Frymark, T., Schooling, T., Mullen, R., Wheeler-Hegland, K., Ashford, J., McCabe, D., … & Hammond, C. S. (2009). Evidence-based systematic review: Oropharyngeal dysphagia behavioral treatments. Part I–background and methodology. Journal of Rehabilitation Research & Development, 46(2).

Wheeler-Hegland, K., Frymark, T., Schooling, T., McCabe, D., Ashford, J., Mullen, R., … & Musson, N. (2009). Evidence-based systematic review: Oropharyngeal dysphagia behavioral treatments. Part V–Applications for clinicians and researchers. Journal of Rehabilitation Research & Development46(2).

Wheeler-Hegland, K., Ashford, J., Frymark, T., McCabe, D., Mullen, R., Musson, N., … & Schooling, T. (2009). Evidence-based systematic review: Oropharyngeal dysphagia behavioral treatments. Part II–impact of dysphagia treatment on normal swallow function. Journal of Rehabilitation Research & Development46(2).

McCoy, Y., & Wallace, T. (2018). The Adult Dysphagia Pocket Guide: Neuroanatomy to Clinical Practice. Plural Publishing.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Mobile MBSS

Did you know?  Have you heard?

Instrumental assessments come to you!!

Now, you can schedule mobile FEES AND mobile MBSS.

This cuts down the cost of transport and the various costs of instrumental in the hospital setting.

Do you need Mobile MBSS or FEES at your facility?  Chances are, there’s one in your area.

Do you own a Mobile MBSS or FEES company?  Post a link to your website in the comments!!

Locators:

https://www.mobiledysphagiadiagnostics.com/mobile-swallow-study-locator/

https://maphub.net/Flatlan…/mobile-fees-providers-04-30-2019

 

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What Good is the MBSS if the Report is Not so Good?

I think we all get it. 

You work in a facility or for a company that has to send patients our for modifieds or instrumentals of any sort.

It’s Never Easy

You go through the works.   You have to evaluate the patient and try to scour through their paperwork to find out if they’ve had an instrumental.   You talk to the nurses and the DON, the DOR, the doctor and have to jump through a million hurdles just to get the patient out for the instrumental.

You sometimes wait for weeks for your patient to be scheduled and then finally get in for the study.

The Wait is Over…..Or Is It?

The patient comes back to your facility and all they can tell you is they had 2 bites of food and 1 drink and they were told to thicken their drinks.

You get the report (if you’re lucky) and find out that your patient aspirated on thin but not nectar thick (mildly thick) but they did penetrate so they are now on pureed food and honey thick liquids.

Your first thought….What the hell!!  Did they try compensatory strategies?  Did they try to change the bolus size?  Did they try anything?

The Report

You don’t know because it’s not in the report.

You may also not know how they responded to the aspiration, when it happened or why it happened.

The report is everything in the Modified Barium Swallow Study (MBSS).  The report is how the treating SLP knows what is happening and how they build the patient’s treatment plan.

What Happens in the Fluoro Room, Goes in the Report

You see, much like the evaluation you write or the plan of care you carefully create and document, the MBSS report has to be thorough and complete.  If it’s not documented, it didn’t happen.

You complete the best MBSS you know how so make it count with a great report.

Dr. Logemann reported on using compensatory strategies, sensory techniques and multiple trials of a bolus to determine swallowing deficits and how to safely keep the patient eating by mouth if possible.

We may use a chin tuck, head back or head turn to change the physiology of the swallow to improve the patient’s ability to swallow a bolus or even a variety of bolus types.

We may use sensory techniques such as pressure on the tongue, change in size of bolus or change in temperature of bolus to change the swallow.

Let’s Be Honest

The fact of the matter is, if we don’t give the patient a chance to swallow in a variety of ways during the instrumental, we may be sentencing them to thickened liquids or altered food consistencies.  We may be sentencing that patient to dissatisfaction, decreased quality of life, dehydration, malnutrition or even pneumonia.

Who Writes the Report

Palmer et al indicated the report includes a summary of what was done (position of the patient, bolus types presented, strategies trialed), a description of significant structural abnormalities, a summary of the observation of swallowing including each functional component, a diagnostic assessment, and recommendations.   Now, keep in mind, Palmer suggested the physician write the bulk of the report, I think we can agree the SLP writes the entire report.

Utilizing the MBSImP report generator can save time and ensure that you are providing a complete report.   Following a protocol and a report generator can ensure that nothing is forgotten, plus, if you can provide the radiologist with the protocol, it can save that surprise when they don’t understand what you are doing with a patient, which can lead to a discussion in front of the patient/family.

How are the reports in your area?  Good, great, need a little work?  How are the reports you write?

References:

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

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

Martin-Harris, B., Logemann, J. A., McMahon, S., Schleicher, M., & Sandidge, J. (2000). Clinical utility of the modified barium swallow. Dysphagia15(3), 136-141.

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.

 

 

 

 

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What’s In A Name

Seriously, how many names can we have for one test?

We typically do the same thing…..assess swallowing function, so why a million different names?

In the early days, the swallowing assessment using x-ray was called a Cookie Swallow Test.

You can read more about the history of the MBSS:

untitled design-1

The same test is more recently called:

  • Modified Barium Swallow Study (MBSS)
  • Modified Barium Study (MBS)
  • Videofluoroscopic Swallow Study (VFSS)
  • Swallow Study
  • Rehab Swallow Study

No matter what it is called, the procedure should be the same.  A variety of consistencies will be presented with an SLP assessing the swallow.  Compensatory strategies may be trialed (more to come soon), various presentation methods may be trialed, sensory techniques may be trialed.

No matter what the name, the SLP will be assessing the physiology of the swallow so that an accurate treatment plan can be developed.

What other names have you heard that X-Ray swallow study called?

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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.