3 Reasons You Should Never “Fake it Till You Make it” in Dysphagia

I really don’t know where the phrase “fake it till you make it” came but it’s one phrase that absolutely makes me cringe in relationship to dysphagia.

Don’t get me wrong.  You should always go in confident in your skills.  How can you possibly be confident though in skills you don’t possess?

The scary part is, with dysphagia, if we don’t know what we are doing, but go in to diagnose and treat on the “fake it till you make it approach” we can play a key role in the person’s death.

Not necessarily that the person even chokes on something.  When we change a patient’s liquids and thicken the liquids, the person can then experience dehydration, sepsis, UTI or a multitude of other effects.

So let’s get to it.  The THREE reasons why you should never fake it till you make it in dysphagia therapy.

Reason One

It’s actually against our code of ethics provided by ASHA.

“Individuals shall not misrepresent their credentials, competence, education, training, experience, and scholarly contributions.”

When we “fake it” we are actually telling patients that we are competent in an area that we may not have a clue and misleading that patient.   Ideally, we should help that patient find a competent clinician if you do not feel that you fit that bill.

Reason Two

How can you assess and diagnose what you don’t know?

Yes, we diagnose dysphagia.  This is the reason we are Speech Language Pathologists in the US.  We are able to diagnose a range of speech and swallowing related disorders.

If you don’t understand the normal swallowing process and know the deficits, how can you possibly diagnose dysphagia?  Did you know that when a diagnose is given to a patient, that diagnosis stays with the person.

Misdiagnosis often leads to inappropriate diet changes, unnecessary therapy services and possibly secondary issues that can arise from those inappropriate diet changes.

I mean, do you really know any person that has been excited about having thickened liquids?  Have you ever had a patient comment on the amazing taste of thickened liquids?

What if you are the person responsible for the Modified Barium Swallow Study (MBSS) or Flexible Endoscopic Evaluation of Swallowing (FEES)?  Do you know how to complete the test or interpret the test.  If the answer is no, then you’ve just wasted, money, time and effort.  Accurate completion and reporting of either of these assessments is vital in diagnosing, referring or providing treatment for dysphagia.

Reason Three

Just like you can’t assess and diagnose dysphagia, how can you possibly treat dysphagia when you don’t understand it.

I mean sure, you can throw a list of exercises at a patient, you can modify the diet, but what are you doing for the patient?   What are you actually accomplishing with this patient?

This patient is relying on you to be the expert, to be honest with them and to help them with an issue that is a major roadblock in their recovery.

What can you do?

Don’t turn to social media the night before an evaluation or treatment session knowing nothing about the disease process, the assessment or the treatment protocols.

If you are interested in dysphagia but don’t feel comfortable or confident in dysphagia, find a mentor, read journal articles, shadow, read textbooks.  Learn everything you possibly can about dysphagia.

Be honest with your patient.  I am terrible with fluency.  If I have a referral for a patient with dysfluency, I will more than likely refer them out to an SLP with more experience.  It’s the right thing to do.

Hold paramount your patient’s best interest and never, ever “fake it till you make it.”

  • Tanner, D. C. (2010). Lessons from nursing home dysphagia malpractice litigation. Journal of gerontological nursing36(3), 41-46.
  • American Speech-Language-Hearing Association. (2004). Knowledge and skills needed by speech-language pathologists performing videofluoroscopic swallowing studies.
  • American Speech-Language-Hearing Association. (2002). Knowledge and skills needed by speech-language pathologists providing services to individuals with swallowing and/or feeding disorders.
  • Boaden, E., Davies, S., Storey, L., & Watkins, C. (2006). Inter professional dysphagia framework. University of Central Lancashire, Preston.
  • McAllister, L., & Rose, M. (2000). Speech-language pathology students: Learning clinical reasoning. Clinical reasoning in the health professions, 205-213.
  • Kamal, R. M., Ward, E., & Cornwell, P. (2012). Dysphagia training for speech-language pathologists: Implications for clinical practice. International journal of speech-language pathology14(6), 569-576.
  • ASHA Code of Ethics www.asha.org

Be the Change

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Let’s face it, we’re not all leaders. Some of us are happy going to our jobs and just done at the end of the shift. Many of us tend to get on social media and complain about issues that we feel are out of our control.

The problem is that just voicing our concerns on social media does not solve the problems. We have to look beyond ASHA and our boss to make these changes.  Now don’t get me wrong, ASHA, management, your state association can be a great start.

You might be asking what are some of these gripes and complaints. Productivity is the big one. We are often asked to work billable time for the majority of our day not allowing us any break for consultation or paperwork that is required of us.  How many of us go in to work,  clock out to maintain our productivity while completing paperwork, making phone calls or some of the necessary but not billable time possible while maintaining 90% productivity or more.   Maybe the reason the productivity expectations exist and the reason that it keeps getting higher is because people are actually meeting these standards. When we give 100% the next expectation will be 110%.

So maybe we can sit and stew about the fact that I’m working on my own time or maybe I can join my state association or ASHA and help bring about change to that productivity.

Another frequent complaint is the lack of instrumental assessment.  Some facilities will not allow instrumental assessment,  however have you presented the cost associated with an pneumonia or with any re-hospitalization compared to the cost of an instrumental assessment?  How can you possibly build an accurate plan of care for your patient when you can’t assess your patient?

When we actually think outside the box that’s when we can get things done.

Continue to educated yourself.  Stop being so complacent with your job.  Stop using non-evidenced based practice and the same oral motor exercises that have been used for 25 years.  Keep up with new practices.  Be a champion and advocate for yourself and for the profession you hopefully love.

When you start standing up for yourself and demonstrating efficiency and competence in your job is when we can show other medical professionals the value in the Speech Language Pathologist in the area of dysphagia.

Stop just posting to gripe on social media and make a change!!

What is Dysphagia

What is dysphagia?

 Dysphagia is difficulty swallowing, which can affect any phase of the swallow.  The swallow is broken down into phases, including the oral anticipatory, oral pharyngeal and esophageal.

 How do I know if I have dysphagia?

 Dysphagia symptoms can vary from person to person.  You can have one or all symptoms of dysphagia.  Some people appear asymptomatic.  We typically associate coughing with aspiration (food/drink entering the lungs) however some people silently aspirate (no cough). Some symptoms/indicators of dysphagia include, but are not limited to:

  • Weight loss
  • Drooling or increased sensation of too much saliva
  • Coughing or choking during or after eating
  • Pocketing food
  • Pneumonia
  • Changes in diet-patient induced
  • Dehydration
  • Complaint of food sticking or “not going down”
  • Respiratory changes
    **NEVER assume a person does not have dysphagia because they are not coughing**

 

What should I do if I am having difficulty swallowing?

 If you are experiencing any of the symptoms above, you can fill out the self-evaluation for dysphagia.  Talk to your physician and request an evaluation from a Speech Language Pathologist.

 What is a Modified or Video Fluoroscopic Swallow Study?

 A Modified Barium Swallow Study, or Video Fluoroscopic Swallow Study is an exam that is completed in the radiology suite.  The Speech Language Pathologist (SLP) in conjunction with the radiologist will give the patient multiple consistencies of food/drinks mixed with barium.  While the patient swallows, the SLP and radiologist watches the swallowing structures on the monitor to determine dysfunction of the muscles of swallowing or swallowing structures.  The exam is typically recorded for review by the SLP.

 Did you know?????

 Approximately 300,000 to 600,000 people with neurogenic disorders are diagnosed with dysphagia.

 Swallowing involves the use of 6 cranial nerves.

 Approximately 40% of patients with dysphagia silently aspirate (food goes into the lungs without choking).

 Swallowing is one of the most complex body functions, yet in the normal adult, this process is automatic, effortless and efficient, occurring an average of 600 to 1200 times per day.

 There is evidence of dysphagia in 51% of patients with acute stroke.

 Parkinson’s dysphagia develops in approximately 50% of patients.

 Patients with multiple sclerosis, approximately 34% have dysphagia.

 Some medications, such as antidepressants can cause dysphagia.

 Swallowing is performed for management of secretions and to maintain nutrition and hydration.

 What kind of evaluation may the Speech Language Pathologist complete?

  •  Bedside or clinical assessments of dysphagia include, but are not limited to:
  • Cervical Auscultation-using a stethoscope to listen to the sounds of breathing and swallowing to determine   swallowing dysfunctions.
  •   Laryngeal elevation palpation-feeling the larynx for elevation and for hyoid anterior movement during the swallow.
  •    Monitor for signs or symptoms of aspiration-the SLP will review the patient chart and monitor during swallow trials for any of the signs/symptoms of dysphagia.
  •   Trial different consistencies-the SLP will present different food and liquid consistencies to test how the patient performs with the differing consistencies and to find which consistency is safest for the patient.
  •  Pulse oximetry-the SLP may monitor the patient’s oxygen saturation levels to determine if they dip during swallowing,  which may indicate aspiration.
  •  (Pulse oximetry is unreliable in predicting aspiration)
  •  Heart rate monitoring-the SLP may watch the patient’s heartrate for increase or decrease in rate of heartbeat  during the swallow.
  • Blue dye assessment-the SLP may add blue food coloring  to food and/or liquids of a patient with a trach.  If the trach is suctioned and blue is suctioned from the trach, this is an indication that the person is aspirating.
  •  (Blue dye assessment is rarely used in practice now and has been discontinued by many facilities as it is unreliable).
  •  Three ounce water test-3 ounces of water is given to the patient, who must then drink all 3 ounces at one time without stopping.  This test is completed on a pass/fail basis.
  •   Bolus manipulation task-this assessment monitors how well a patient manipulates a bolus (bite of food) within the mouth (oral cavity).  This can also be done by rotating a tongue depressor on each side of the oral cavity.
  •  Monitor vocal sounds-after swallows involving different consistencies of food or drink, the SLP will have the patient say “ah”, monitoring for vocal changes after the swallow.
 

Instrumental Assessments include:

  •  Modified Barium Swallow Study/Video Fluoroscopic Swallow Study
  • FEES
  •    Manometry
  •    Ultrasound
 

 What kind of therapy is available for dysphagia?

There are several different treatment techniques available for dysphagia therapy.  Not all therapists are trained in each technique and some techniques are controversial due to lack of research offered.

Deep Pharyngeal Neuromuscular Stimulation (DPNS) currenty has no published, peer-reviewed research to support its use or disuse.

Therapeutic Techniques that are evidence-based and have published peer-reviewed research:

  •   Thermal-tactile stimulation
  •    Myofascial release and manual techniques
  •    Lingual exercises with resistance
  •    Exercises with resistance
  •    Manometry
  •    Neuromuscular Electrical Stimulation (NMES) 
  •    Masako
  •    Mendelsohn
  •    Shaker
  •    Supraglottic Swallow
  •    Super-Supraglottic Swallow
  •    Effortful Swallow
  •    Back of Tongue Exercises:  Yawn, Gargle, Pull tongue straight back
  •    McNeil Dysphagia Therapy Program (MDTP)
  •    Expiratory Muscle Strength Training (EMST)

  I have been recommended to have thickened liquids. What are the differences?

 There are four different liquid consistencies, thin, nectar, honey and pudding.

 Thin liquids are regular liquids such as water, tea or milk.  They need no preparation.

 Nectar thick liquids are the same consistency as syrup.  There are naturally nectar thick liquids such as buttermilk, tomato juice and fruit nectars.  Other liquids need to have thickener added to increase the viscosity and make them safe for the patient to drink.

 Honey thick liquids are the same consistency as honey.  There are no naturally honey thick liquids.  All liquids need to be prepared with thickener to be safe for the patient to swallow.

 Pudding thick liquids are as thick as pudding.  They have to be mixed with thickener and have to be spooned to swallow.