Exercise

Recent and some previous dysphagia literature emphasizes the use of exercise physiology. Researchers such Lazarus et. al, Robbins et.al, Burkhead et. al and Clark have published the need for incorporating exercise physiology into dysphagia therapy. They emphasize the need to understand the muscles involved in the swallowing mechanism, understand their function so that you can exercise those muscles in the manner in which they function for the swallow.

 The best way to work and improve the swallowing function is to swallow. Not only simply swallow, but push the swallow beyond it’s normal capacity. One way to incorporate increasing the load of the swallow is to use the effortful swallow, the masako or the Mendelsohn maneuver. The Shaker is a great load-resistant exercise to increase opening of the UES. These exercises have been researched and shown to be effective. Logmemann credits the research that has been established for the Shaker exercise and the lingual strengthening exercises from Robbins to increase lingual strength, with overall strengthening of the swallow.

 I’ve started an exercise approach to my dysphagia therapy. I started using almost like a “circuit” of swallowing training. I give the patient a list of exercises to complete while in therapy. Depending on what they need to focus their therapy, they complete a circuit of exercises. I use a variety of swallowing exercises including the Mendelsohn maneuver, effortful swallow, lingual resistance exercises, oral manipulation exercises. Most exercises include swallowing as part of the exericise. One of my favorite strengthening exercises is sucking pudding through a straw. I have the patient start with a regular drinking straw and work their way down to using a coffee stirrer. This not only strengthens the tongue, cheeks and lips, it also requires that they swallow. They spend x number of minutes of each exercise.

 Taking an exercise-based approach to swallowing is far superior to simply altering diet consistencies or adding compensatory strategies to each swallow. Rehabilitation should bring about a change to the swallow mechanism. I do not nor will I use compensations or altered diets in my therapy. I may put the patient on an altered diet, but I want to work the system naturally, not with a compensation if I can avoid it! Look to your PT and OT departments. They work the muscles to bring about change and we should be doing the same.

 Logemann, J.A. (2005). The Role of Exercise Programs for Dysphagia Patients. Dysphagia. 20: 139-140.

 Clark, H.M. (2005). Therapeutic exercise in dysphagic manamgent: Philosophies, practices and challenges. Perspectives in Swallowing and Swallowing Disorders, 24-27.

 Robbins, J.A, Butler, S.G, Daniels S.K., Diez Gross, R., Langmore, S., Lazarus C.L., et al (2008). Swallowing adn dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. Journal of Speech, Language and Hearing Research, 51: S276-S300.

 Burkhead, L.M., Sapienza, C.M., Rosenbek, J.C. (2007). Strength-training exercise in dysphagia rehabilitation: Principles, procedures and directions for future research. Dysphagia, 22:251-265.

 Clark, H.M. (2003). Neuromuscular treatments for speech and swallowing: A tutorial. American Journal of Speech-Language Pathology, 12: 400-415.

 Robbins, J.A., Gangnon, R.E., Theis, S.M., Kays, S.A., Hewitt, A.L. and Hind, J.A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatric Society, 52, 1483-1489.

 Lazarus, C., Logemann, J.A., Huang, C.F., and Rademaker, A.W. (2003). Effects of two types of tongue strengthening exercises in young normals. Folia Phoniatrice et Logopaedica, 55, 199-205.

The Dummies Guide to Dysphagia

A big shout-out to Tanya for the inspiration for this blog!!!

 Education is such an important part of not only the dysphagia eval, but also throughout therapy.  More than likely the patient/family will have no clue what dysphagia is or that such a condition even exists.  Swallowing is an event that you don’t think about.  Nobody swallows and analyzes their own swallow function (unless you’re an SLP of course).

 My first session with a patient is a large portion of education.  Whether I’m doing a swallow eval or a Modified Barium Swallow Study I’m continually educating.  I find that one of the easiest ways for me to educated patients/families is to explain each part of the eval and how it relates to swallowing.  If I’m checking for labial seal/strength I explain to the patient the purpose of the lips.  My new explanation for the tongue is that it’s like the quarterback of the team.  The tongue is the one that starts the play and makes it happen.  (The Colts have been doing well so everyone in Indiana loves football now.)  I not only educate on the structures and the means by which they function, I show pictures and try to demonstrate as best I can.

 When the patient understands the basics of such a complex and intricate system, they begin to understand how it could falter.  I always make sure that the patient understands that the swallow is something that we do so frequently we don’t even think about it.  I also let them know that the swallow involves a variety of closures, muscles, nerves and actions that all occur in 3-5 seconds.

 I typically have information available for the patient to take home with them.  I have brochures describing how speech therapy rehabs the swallow, information regarding swallowing and a self-test for dysphagia.  The self-test I use is found at  http://americandysphagianetwork.org.

 So, for all those that may read this and not understand dysphagia or know anything about the swallowing system:

 The lips are the first part of the swallowing system.  They have to close, and stay closed to help keep the food (the bolus) inside the mouth (the oral cavity).  The lip seal also helps create a pressure which helps to push the food (bolus) back and down the throat (the pharynx).  The tongue is the main player in the swallow.  The tongue is like the quarterback.  It is the first player to really receive the ball (the bolus), moves it around, getting it ready to “throw” down the line (the pharynx).  When the ball (bolus) is ready, the tongue takes it, throws it back (posterior propulsion) and launches the ball (bolus) down the pharynx.  Once the bolus starts down the pharynx, the airway has to move up and forward to close it off and you hold your breathe until the swallow is completed.  (I usually have the person swallow and feel their Adam’s Apple move up when they swallow.  If they can’t/don’t feel the laryngeal elevation, have them feel your throat.)  When the airway is closed, the food tube (esophagus) and lets the food go down.

 When we are not swallowing, our airway is open, allowing us to breathe and the esophagus is closed.  It switches for a split second when we swallow.  If any of these “tasks” don’t happen during the swallow or if they happen at the wrong time, that causes a problem with the swallow.

 Some of the problems that commonly occur with swallowing are lingual (tongue) weakness causing difficulty moving the bolus back in the mouth towards the pharynx (posterior propulsion), poor labial seal with food/drink falling out of the front of the mouth.  Pocketing is when food sticks in the mouth, usually between the cheeks and the gums.  If the airway doesn’t close off completely then food/liquids can start to go into the airway or go completely into the airway.  When the food/liquid goes into the airway, that is called aspiration and can lead to respiratory difficulties such as breathing difficulties, bronchitis, pneumonia or even death.

 Another problem that can occur in the pharynx is residue.  There are two pockets in your throat, one is called the valleculae and is located just above your airway.  The other is called the pyriform sinus and is above the esophagus.  If there is not enough pressure or force from the back of the tongue pushing the bolus down the throat and against the wall of the throat (posterior pharyngeal wall), the food can stick in these pockets after the swallow.  When food/drinks remain in the pharynx, the person may aspirate (the food/drink goes into the lungs) the residue once they breathe again.

 Another major part of the swallow that can “go wrong” is that the esophagus doesn’t open, or doesn’t open enough for the entire bolus to enter the esophagus.  The esophagus (upper esophageal sphincter-UES) is opened by the upward and forward movement of the airway (hyoid/larynx) and the pressure of the bolus.  Typically when the UES opening is compromised, the person will have pyriform residue, which may then be aspirated.

 There are many techniques/therapies to aid in rehabilitating the swallow mechanism.  Most commonly, people are placed on altered diets, or taught compensations such as chin tuck or head turn to stop aspiration/residue.  These alterations/compensations DO NOT improve the swallow, but may serve to eliminate the aspiration or risk of aspiration.  Swallowing is a muscle based system, powered by 6 cranial nerves.  We have to take an exercise physiology approach to rehabilitate dysphagia.  We can learn much from our physical and occupational therapy counterparts.  To train a person to walk, they have the person walk.  They may have them use a walker, but the ultimate goal is to have them walk without the walker or with independence.  The walker makes the person safe at the time, but does not “fix” the problem.  By the same token, we may put a person on an altered diet, or say, honey thick liquids.  This makes the person safe at the time, but does not “fix” the problem.  We work on strengthening those swallowing muscles to allow the person the opportunity to swallow with independence and to again swallow thin liquids.  Just as the physical therapist will work with the person walking without the walker in therapy, although outside of therapy the patient will probably still need to use the walker, we need to work with our dysphagia patient on swallowing thin liquids in therapy.  This may be a teaspoon of the liquid at a time.  By using the thin liquid, a little at a time, you are training the person to swallow.  You may use techniques such as the Mendelsohn or the effortful swallow to strengthen the muscles through resistance.

 I use VitalStim or neuromuscular electrical stimulation during swallowing therapy.  I place the electrodes so that they stimulate the impaired muscles during swallowing therapy.  If the person has decreased laryngeal elevation or the airway doesn’t close during the swallow, then I target the muscles that elevate the larynx.  The tongue is attached, via muscles, to the hyoid bone, which is part of laryngeal elevation.  So take the patient with decreased laryngeal elevation.  This person has aspiration with thin liquids but is safe with nectar thick liquids.  When using the Mendelsohn maneuver, the patient was able to safely swallow 5 ml of thin liquids.

 My therapy session would look like this:

At home, the person is drinking nectar thick liquids.  In therapy, I’m going to place the VitalStim electrodes on the laryngeal excursion muscles.  I like circuit therapy, I say it’s like Curves but for swallowing.  The patient will complete all exercises/swallows while the VitalStim is on.  We do lingual strengthening exercises using a tongue depressor (the patient pushes their tongue out, up and side to side against the tongue depressor), practice the Mendelsohn maneuver using dry swallows, when they are able to complete the Mendelsohn I would have them start using the Mendelsohn with 1ml water, working up to 5ml of water.  Therapy should always have many opportunities for swallowing (you can only exercise the swallowing system by swallowing).

 Vitalstim electrodes are attached to patient and VitalStim is turned on to a therapeutic level.

5 minutes of dry swallows using the Mendelsohn

4 minutes push your tongue out against the tongue depressor

5 minutes suck pudding through a straw (my FAVORITE exercise)

4 minutes push your tongue up against the tongue depressor

5 minutes pull your tongue back as far as it will go in your mouth, hold 5 seconds

4 minutes push your tongue to the right against the tongue depressor

5 minutes dry swallow using an effortful swallow

4 minutes push your tongue to the left against the tongue depressor

5 minutes pudding through the straw

5 minutes pretend to yawn and hold tongue back for a count to 5

5 minutes swallow pudding using an effortful swallow

 Now, keep in mind, the tongue is the quarterback of the swallow.  It is attached to the hyoid via muscles.  The person needs their larynx to elevate so I’m going to work on strengthening the tongue, to strengthen the hyolaryngeal excursion.  The Mendelsohn provides hyolaryngeal excursion through resistance of gravity.  The effortful swallow has been found to strengthen the overall swallow.  Tongue base retraction is part of the tongue which is going to aid in the hyolaryngeal excursion.  I like the pudding through the straw (I start with a regular straw and work to a coffee stirrer, my way of adding “weight” to the exercise) because it strengthens labial seal, the buccal (cheek) muscles, works on tongue base retraction, the person has a bolus to manipulate and then they have to swallow.  The pudding through a straw offers resistance to the oral phase of the swallow, by adding an effortful swallow, you add resistance to the pharyngeal phase as well.

 Keeping in mind the basic anatomy and physiology of the swallow, it just makes sense that exercise should offer resistance, making the task more difficult or require more effort.  Just as if you are trying to build up your arms to look good in your tank tops, you don’t start at 5 pounds and stay there.  You eventually add weight and keep working up.  Swallowing therapy should offer resistance, strengthening and endurance because you are working to improve the timing, speed and strength of the swallowing mechanism.

 

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.

My Patient had Their Modified, Now What Do I Do?

Once upon a time, I worked in a setting and had to send my patients out for the MBSS. Now, I am able to complete my own MBSS. One thing I take into account when I am doing an MBSS for another SLP is making sure they get a complete study. I have actually gone to several CE courses regarding MBSS in the last 2 years. When I say a complete MBSS, I don’t mean that I test 15 different foods using every strategy known to man per spoon, cup, straw, syringe or whatever else I can think of to feed the patient. When I say complete, I mean that I try to find the dysfunction, the abnormality of the swallowing mechanism. I used to get those reports that stated patient so and so aspirated thin liquids with non-functional cough, chin tuck did not eliminate, blah blah blah. That doesn’t tell me WHY the patient is aspirating and what I need to focus my therapy on to STOP the aspiration.

 If you are one of those clinicians that have to send your patient out and rely on another clinician to complete your MBSS there are ways to interpret what the therapist is writing into muscle dysfunction.

 First, let’s look at the oral phase. You have to look at lip closure. You know that if the person drools or has anterior spillage of the bolus, there are probably some labial seal issues, so you are going to work some on that orbiularis oris and labial seal with resistive labial exercises. The tongue has to move the bolus from side to side, recollect the bolus on the tongue and push it back, pushing up against the palate to create pressure to push the bolus. If the patient has poor bolus formation, residue in the sulci, premature spillage, they are probably not getting good bolus formation, they probably have a weak tongue. If there is reported residue on the tongue and/or palate, they probably are not getting enough tongue-palate contact. You are going to work on resistive lingual exercises. Pocketing in the lateral sulci will indicate poor buccal strength, decreased tension. Resistive cheek exercises are a must.

 Premature spillage can indicate that back of the tongue is weak and the tongue is weak and not holding the bolus in a cohesive manner. Again, resistive lingual exercises, Masako, effortful swallow will all focus on the back of the tongue. Pharyngeal residue will always indicate decreased tongue base retraction and may indicate decreased pharyngeal stripping wave. Again, to strengthen that part of the swallow, I use the effortful swallow, large, thick bolus swallows. Penetration/Aspiration is going to indicate poor hyolaryngeal excursion, which can be any of the three areas including anterior motion of the hyoid, laryngeal elevation and hyoid/thyroid approximation or laryngeal closure. There is really quite a bit of information needed here, how long does the closure last, when are they aspirating. However, if all you get is penetration and/or aspiration you know you need to work on airway protection through the effortful swallow, lingual strengthening (it is attached to the hyoid, which is part of the excursion), Mendelsohn Maneuver. You will also have evidence of decreased airway protection through evidence of decreased epiglottic inversion. If you get a report of pyriform sinus residue, there is possibly an issue with Pharyngeal Esophageal Segment (PES/UES) opening. Now, the PES is opened through Hyolaryngeal excursion and the force of the bolus. The bolus is pushed through the oropharyngeal region by pressure of the tongue, so for PES opening issues, I work on lingual strengthening, Shaker, Mendelsohn, effortful swallow and change the bolus size and consistency.

 Many times, I have observed therapists altering patient diets, teaching chin tuck, double swallow, etc. While I agree that we have those patients that diet alterations, compensations are appropriate, we also have those patients that have the potential for rehabilitation that don’t want to look at their lap every time they swallow. I know I wouldn’t want that.

 As therapists, we have to become better at not only investigating and determining the dysfunction of the swallow, but at writing the report so that other clinicians can TREAT the dysphagia. We don’t treat symptoms. I can’t treat aspiration. In fact, many people CAN, in fact have dysphagia without aspiration or penetration. Think of how short a time we have the patient in radiology. Who knows that they weren’t going to aspirate the next bite that we never gave. We can, however, determine that the patient has decreased laryngeal elevation, with or without penetration/aspiration and TREAT that. We can determine that the patient has decreased lingual strength, (which will probably affect a huge portion of the swallow) and TREAT that.

 My modifieds have changed drastically. I don’t test every consistency. I test thin, nectar, honey-if absolutely necessary, pudding and cookie. I’m not looking for every consistency and what they do with it. I’m looking at the dysfunction of the swallowing mechanism. Once we start doing that, we become competent in what we do.

Journey to BRS-S

It’s official!  I finally did it and am so extremely happy and excited!!

 I finally, not only had my application accepted by the BRS-S (Board Recognized Specialty in Swallowing and Swallowing Disorders) and passed the exam.  I can officially put the title BRS-S after my credentials!

 I wish that I could say that it was an easy process, but it really wasn’t.  I will say though that I have learned so much along the way and have met so many new and wonderful process through this amazing journey.

 The main reason for writing this post is to, hopefully encourage others to do the same.  This was something to me that several years ago seemed completely unreachable.  I mean really, I’ll never compare to the Jeri Logemanns of the world!

 Many people have asked me about applying for and taking the exam for the BRS-S.  Here is post about my experience.

 I had went to many conferences and saw speakers with BRS-S after their names.  I went to the website, www.swallowingdisorders.org, and started looking into what it would take to become BRS-S.  WOW!  Not only do you have to prove that you have gone over and beyond in the area of swallowing and dysphagia, but you have to have 75 CEU’s in dysphagia, 3 years experience post graduation and letters of recommendation.

 The BRS-S does offer the opportunity to utilize a mentor during the entire process.  I decided that it wouldn’t hurt to look into a mentor to even see if this is something possible for me.  I actually did, 2 years ago, I applied for a mentor.  I ended up with Nancy Swigert, who I truly can never thank enough for not only giving me the courage and the confidence to believe that I could do this, but also endlessly reviewed and helped my revise my very very very long application.

 If you are looking into applying for BRS-S, the website has the following listed as requirements:

 

Requirements for all applicants      

 

 

1. ASHA Certification.

All applicants must currently hold the ASHA Certificate of Clinical Competence in Speech-Language Pathology (CCC/SLP).

 

2. Continuing Education.

All applicants must document receipt of at least 7.5 CEUs that relate to dysphagia within the last 3 years. A minimum of 4.5 of the CEUs need to be ASHA sponsored courses and up to 3.0 of the CEUs may be non-ASHA sponsored continuing education activities.

Individuals attending workshops which do not give ASHA CEUs may apply for independent study through ASHA to receive ASHA CEUs. Please provide evidence of attendance at other educational activities in closely related fields. Detailed descriptions of all non-ASHA sponsored CEU activities is required. Continuing education activities may include

  • Workshops, meetings or courses in swallowing and swallowing disorders, video and audio courses, telemedicine, and other electronic media)
  • Independent study (e.g., course development, research projects, publications, internships)
  • Self-study (e.g., videotapes, audiotapes, journals).

Continuing education courses must be directly related to dysphagia. If the title of the course is unclear (as it relates to dysphagia), an applicant should submit a program or brochure to provide substantiation for its inclusion.

When applying CEUs from the ASHA National convention or other multi-offering events, applicants must list specific course/workshop titles and corresponding CEUs in the application table. CEUs will be applied for only those courses/workshop relative to dysphagia.

College Courses.  If an applicant has completed a college level course in dysphagia, accrued credits can be applied to continuing education requirements. Graduate university coursework must be accompanied by a syllabus or transcript. One college credit is equivalent to 1 CEU (as it relates to application for BRS-S). The applicant must submit a transcript or other document verifying completion of those credits.

Instructor or Invited Lecturer. If an applicant teaches a dysphagia course at an approved university/college or provides dysphagia-related lectures at a conference which provides ASHA CEUs, a maximum of 3.5 CEUs may be applied to the 7.5 CEU requirement for BRS-S. One college credit is equivalent to 1 CEU. Each course may only be applied only one time within an application (even though the same course/conference may be taught several times during an academic year or in consecutive years). The applicant must submit appropriate evidence and documentation of the lectures that were related to dysphagia.

 
 

3. Post-Certification Clinical Experience.

All applicants must have completed a minimum of 3 years post certification (CCC/SLP) clinical work that has a focus in dysphagia. BRS-S has established two tracks to meet the diversity of clinical service environments for professionals at all levels of advancement within the profession:Clinical Track and Academic/Administrative Track.  The Clinical Track looks to identify professionals who demonstrate strong advanced clinical skills through direct provision of services to patients/clients. The Academic/Administrative Track looks to identify researchers, instructors and administrators who have advanced in different employment environments. These individuals maintain clinical skills through ongoing patient/client contact, while promoting improved patient care through research and teaching/training of clinicians within this specialized area of practice.

a. Clinical Track: a minimum of 350 clock hours of evaluation and/or treatment of swallowing disorders completed within a year for each of 3 years prior to applying for BRS-S. Supervision of speech-language pathology staff members and students providing evaluation and treatment to infants, children or adults with feeding and swallowing disorders can account for 100 of the required 350 hours/year. Supervisors must submit a statement affirming that all of the 100 hours of supervision were for dysphagia cases. The balance of the hours must be obtained from direct face-to-face clinical service to patients.

b. Academic/Administrative Track: a minimum of 100 clock hours of clinical evaluation and/or treatment of persons with swallowing disorders completed within a year for each of 3 years prior to applying for BRS-S. These hours must all be direct patient contact hours.

In place of the higher number of clock hours required of those in the Clinical track, applicants in the Academic/Administrative tract shall hold either:

a. an academic position in a degree-granting institution with a combination of teaching, and research, and academic advising with a focus on swallowing and swallowing disorders. Evidence of student advising, teaching, and research must be included in the narrative section of this application. Evidence of teaching should include a syllabus of the dysphagia course taught. Research must include clinical research in normal or disordered swallowing with direct contact with human subjects as part of the methodology. OR

b. an official administrative or supervisory position in a setting that provides clinical services to persons with swallowing disorders. Responsibilities will include training and supervision of clinical staff, program development, and leadership in the institution directly related to swallowing and swallowing disorders. Multiple examples and evidence of these areas of leadership must be included in the narrative section of the application (e.g. policy/protocol development regarding swallowing program, development and implementation of dysphagia quality improvement program).

 

4. Advanced Skill Documentation

Through the documentation of advanced level skills in swallowing and swallowing disorders, candidates must demonstrate that they have applied the highest level of ethical standards in their practice (i.e. service delivery and in the conduct of scholarship, research, and training). The expectation is that applicants can demonstrate “advanced” clinical and professional skills over the past 3 years. In other words, the applicant has achieved the highest standard of excellence, displays professionalism, is committed to continuous advanced learning, and displays characteristics that reflect achievements that go above and beyond expectations. Applicants may indicate a clinical preference or advanced level of experience in either pediatrics or adults but this is optional as applicants will have knowledge of swallowing and its disorders regardless of age.

There are distinctly different requirements for each track.

a. Applicants in the Clinical Track must evidence advanced skills either by satisfying at a minimum: two activity types within one category or one activity in two different category types. In other words, the applicant can choose to provide documentation in just one of 3 advanced areas.

b. Applicants in the Academic/Administrative Track must evidence advanced skills in at least two different category types.

 

 

       

 Yes, Yikes!!! I knew I had the ASHA credentials, I actually did have the continuing ed requirements, the hours of experience (thank you to all my SNF experience and the hospital). My area that I was lacking was my advanced experiences. Nancy gave me some wonderful ideas such as presenting poster presentations at my state convention, at ASHA, presenting within the community. I also added things like my Facebook groups, my Twitter experiences, online journal club. I live and work in a very rural area (25 bed hospital), so some of these advanced skills took some creativity. I also was very fortunate in that at the time I started my application process, I had the opportunity to supervise 2 CF’s and a student. Everything just seemed to come together at the perfect time!

I did end up doing a poster session at my state convention in 2011, then a poster presentation that same year at ASHA. I had the Facebook groups, CF supervision and several experiences with education of nursing staff etc. I felt that I was ready at that point. After sending in four copies of my very lengthy application, submitting my payment for application and several long weeks of waiting, I received a letter in the mail. I wasn’t accepted at that point.

The nicest part of the rejection letter, was that the board didn’t just tell me it wasn’t good enough at that point. They highlighted my areas of weakness and strength with suggestions for improving those weak areas and improving them for future application.

I’ll admit, that I spend a couple of days feeling sorry for myself. I cried a little. After encouragement and support from Nancy, my family and several friends, I decided to get back on it.

After another year of presenting to the community, speaking to a nursing class, reworking my application and basically doing all the things that were suggested by the board, i resubmitted my application. 4 more copies, $75 more, MANY revisions of the application, 4 letters of recommendation and letters from former patients.  After an agonizing 8 weeks, I was sitting on the couch one evening, checking my email. I had an email from the BRS-S. MY APPLICATION WAS ACCEPTED!!! I had to email and text everybody I knew!! It was like an absolute dream!

Then came the scary part. I had to pass the exam. What is on the exam?? That is what every person that has not taken the exam would like to know!!! There is a study guide that is submitted with your acceptance email, however, basically, you need to know a little bit of everything about swallowing and dysphagia. I have spent about the last month and a half studying everything I could get my hands on regarding swallowing and dysphagia, pediatrics, Dr. Logemann’s book, journal articles, everything!

I signed up to take my exam on Oct 2. I was a nervous wreck. I couldn’t eat and was just anxious. The time came to take the exam. I signed in (you have 2 hours to take the 110 question exam). I do remember several times thinking, why didn’t I study that more or what in the heck is that?? I actually finished the exam in less than an hour, thinking I would review my answers. I then decided that if I went back over my answers, I would change them and do worse.

I very quickly decided to then click on submit, which I did and waited. My score appeared within seconds, 92%!!!!! I needed an 80% to pass. I could barely believe that I passed!!! I actually obtained Board Recognized Specialty in Swallowing!!

I do believe that anyone who wants to achieve this great honor, should! It is a tough process, it is very taxing, but it is so very rewarding in the end. It is an amazing feeling to know that you have done something that very few people have accomplished at this point.

It is so important in the time of changing health care and the need to “prove” our services, that we have something that we can “prove” the worth of our services and that we are the ones that specialize in the area of swallowing!

Modified Barium Swallow Study……Part 2

I was recently directed to a blog post by Clinical Colleagues Confidential. regarding Modified Barium Swallow Studies (MBSS).

 The title of the blog post is:

 I have all the answers but nobody is asking me any questions

The original blog post can be found at:  http://cccslp.net/whats-the-frequency-3/

 This is part 2, because I recently wrote a post about MBSS.

 Being an SLP that actually completes MBSS, I felt I needed to address some of these issues comments.

1) I stopped the MBS because I was afraid the patient would aspirate.  Patients aspirate……it happens.  They have probably been aspirating for a long time prior to your study.  If you are afraid of aspiration, how can you assess the patient’s true swallow function?

2) The patient was coughing so I changed him to pudding at bedside.  Patients cough.  You need to check the patient’s meds (some actually cause a cough) and trial a consistency more than once to determine if the consistency is causing the cough.  It is also helpful if you use an instrumental exam such as FEES or MBSS to determine the physiology of the swallow.

3) I didn’t try thin during the MBS because at the nursing home he was already on nectar so I started there.  I use the protocol employed by the MBSImP.  Thin is tested.  I don’t stray from my consistencies.  I use thin, nectar, pureed and cookie with every patient (unless there is a very valid reason to not do a certain consistency).

There are many pieces of information you can use when you assess thin that you don’t get from nectar.  That’s why I don’t skip it.

4) There’s no speech at nursing homes so I put her on the safest diet; puree and pudding thick.  Who says that pureed and pudding thick is the safest.  Sometimes thick is not necessarily better.  Many people eat safely, millions in fact without the presence of speech.  You should not punish your patient because of lack of SLP.

5) A suspected timing delay of the epiglottis might be present and could lead to aspiration even though none was apparent on the MBS but to be safe I recommend nectar thick liquids.  If you did the MBSS, you should know if there is a delay of the epiglottis or not.  You SHOULD be assessing the epiglottis.  You should also know that epiglottic movement is indicative of hyolaryngeal excursion.  Sometimes you don’t see aspiration on the MBSS but you should be looking at airway protection and hyolaryngeal excursion which is an indicator.

 6) I didn’t want to recommend something they might aspirate and get sued.

I wish there was no number 6. Sadly, I think it is the driving force behind many of the recommendations. But, I would spread some words of caution to my peers, especially the younger ones. The only thing that avoids litigation is luck. The thing that wins litigation is expertise and documentation.

If you make a swallowing recommendation in isolation of the needs of whole patient to save him from aspiration pneumonia and he goes into renal failure…that’s a big problem.  I agree….documentation is key.  If you document that the patient appears safe, that is your finding.  You should be confident in your skills and you should be effective in your skills in completing MBSS.  This is not an area we can make a mistake because that can put your patient at high risk for pneumonia, respiratory issues, maybe death.  You recommend what’s appropriate for that patient without worry about litigation.

We seriously need to take a look at our profession.  WE are the experts in dysphagia.  We need to demonstrate our skills as experts.  Dysphagia is not an area we can “tinker” in.  

I highly recommend that any SLP completing MBSS that has made any of the above statements, take the Modified Barium Swallow Impairment Profile (MBSImP) by Bonnie Martin Harris.  This is becoming the gold standard for standardization of modifieds.  

Our responsibility as SLPs completing MBSS is to determine the physiology and etiology of the swallow/dysphagia.  We need to determine what is functioning and what is not functioning in the oropharyngeal mechanism.  Our job is not to state aspiration or penetration or….I coulnd’t do that because I was scared of this.  Our job is to state epiglottic dysfunction, lingual dysfunction, decreased laryngeal elevation, decreased arytenoid movement, and so on.  

SLPs need to take a stand and become experts in the area of dysphagia.

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.