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

In the News-Seen around the Web

Find out why it’s harder to swallow after the age of 50!

coffee

Nearly 40 percent of older Americans are living with a swallowing disorder known as dysphagia.

Although it is a major health problem associated with aging, it is unknown whether the condition is a natural part of healthy aging or if it is caused by an age-related disease that has yet to be diagnosed, such as Parkinson’s disease or amyotrophic lateral sclerosis (ALS).

Following a recent study, researchers at the University of Missouri have established a model that identifies aging as a key factor in the development of dysphagia, which may lead to new therapeutic treatments.

“As people age, and especially once they’re 50 and older, their ability to swallow quickly and safely deteriorates with each advancing decade,” says Teresa Lever, assistant professor of otolaryngology at the School of Medicine and lead author of the study.

“For years, we haven’t known why. Through our research with mice, we now know this disorder can occur naturally and independent of another disease.

“Our next step is to study this model to determine why age-related dysphagia, also called presbyphagia, occurs and identify ways to prevent it.”

Pneumonia Risk

Individuals with presbyphagia generally experience slow, delayed, and uncoordinated swallowing that compromises airway function. This puts older individuals at risk for developing life-threatening malnutrition and aspiration pneumonia, which is caused when food or saliva is breathed into the lungs or airways.

These risks are increased when an individual has an existing health condition, such as a neurodegenerative disease, head and neck cancer, or a major surgery.

Videofluoroscopy has long been the gold standard for diagnosing swallowing disorders in humans. A video fluoroscopic swallow study is a radiologic examination of an individual’s swallowing function that uses a special X-ray device called a fluoroscope.

The patient is observed swallowing various foods and liquids mixed with a contrast agent that can be seen by fluoroscopy in order to evaluate his or her ability to swallow safely and effectively.

Same Symptons in Mice

However, because a long-term study of the swallowing ability of an individual as he or she ages is unfeasible, Lever and her research team studied the swallowing function of healthy mice throughout their approximate two-year lifespan.

“We have a miniaturized fluoroscope and swallow test protocol that are unique to our lab that we can use to determine if a mouse has dysphagia,” Lever says. “By studying the swallowing function of healthy mice over their lifespan, we found they exhibit many of the same symptoms of dysphagia as healthy aging adults.”

15 Signs and Metrics

The researchers established 15 metrics that could be compared to human swallowing function. These metrics include functions such as swallow rate, pharyngeal transit time—the time it takes liquid to be swallowed through the pharynx , or throat, and into the esophagus, or food tube—and the number of ineffective swallows through the esophagus.

The researchers found that healthy aging mice develop symptoms of swallowing impairment that closely resemble the impairments seen in older adults: generally slowed swallowing function, impaired tongue function, larger size of the amount swallowed, and an increase in the time it takes liquid to travel through the throat to the stomach.

“We’re about to change the landscape of dysphagia intervention,” Lever says. “For years, we’ve only been able to treat the symptoms and have been unable to address the root causes of dysphagia.

“Though more research is needed, this knowledge sets the stage for us to study ways to prevent, delay or potentially reverse swallowing disorders using new therapies.”

The study was published online by the journal Dysphagia. Funding from the University of Missouri and the National Institutes of Health helped support the project.

Source: University of Missouri Republished from Futurity.org under Creative Commons License 4.0.

*Image of “coffee” via CIAT/Flickr

Source:  http://www.theepochtimes.com/n3/1315567-why-its-harder-to-swallow-after-age-50/

Dysphagia Tools

Here is a list of dysphagia tools that are commercially available.  Dysphagia Ramblings does not endorse any commercial tool for dysphagia.  

Thermal Stimulation

 

Vibration

 Z-Vibe

 

EMST

 

Modified Barium Swallow Chairs

 

MBSS

 Tims

 FEES

 NDOHD

 

Thickeners

 

MDTP

 Course

 

SwallowMist (Misting Device for NPO)

 

Measuring Outcomes

 SWAL-QOL and SWAL-CARE-email the author at colleen_mchorney@merck.com

 

Lingual Strengthening

 MOST

 

Modified Shaker**

 

Stimulation

 

Straws

 

Neuromuscular Electrical Stimulation**

 

Modified Utensils

 

 

Assessment Tools

 4″ by 4″ Gauze

 Handheld Mirror (I bought mine at Dollar General)

 Dum Dum Suckers

 Dysphagia Toolbox – Free assessment materials

 

Education

Research vs. Clinical skills

One thing that has become completely apparent through social media is that there seems to be a great divide amongst researchers and clinicians.  

There are the people that swear if one more person asks them to present the article providing the research to the technique they are recommending……….

The truth is we live in a world of Evidence-Based Practice (EBP).  Somewhere along the line, EBP became peer-reviewed research articles published in a relevant journal.  

ASHA defines EBP as:  

Evidence-Based Practice (EBP)

The goal of EBP is the integration of: (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve. Conceptually, the trilateral principles forming the bases for EBP can be represented through a simple figure: Read more about EBP.

EBP_Logo

We do need published research to support what we do.  The trouble is, techniques we try using our general knowledge and clinical expertise may be something we try during a session.  It may be something that comes to us as we sit and work with a patient or client, however we really don’t have the time to sit and wait for the research to be funded, proposed, completed, peer reviewed and published.

Listening to our patients can be very revealing in what works and doesn’t work for them.  Not sitting and listening to the patient and saying, “Well, the research said this would work.”  It may not work for the particular patient.

Honing in on our clinical skills is pertinent to our profession.  You may read an article and think, that might work for my patient if I change x, y, and or z factor.  

Research is a part of EBP.  The studies are great to have and the studies definitely support what we do as a Speech Language Pathologist (SLP).  I, personally, deeply admire those that complete research in our field.

One obstacle I find with research is that I can’t always exactly replicate a study.  Does that mean, if I use a substitution that I’m not following the peer-reviewed published research?

We need to let research guide us in our decision-making skills when assessing and formulating that ever-evolving treatment plan for a patient.  

We also need to use our hard-earned clinical skills that we all worked so hard to earn!

Failure or Success

drinking-glass

I failed the #thickenedliquidchallenge.  When I say failed, I mean 3 drinks in and I was done.  By drinks I don’t mean cups, I mean 3 swallows.  

The message from this:  Please, do not put me on honey thickliquids as I will only take 3 drinks.

In this failure, I did as I pledged.  I donated to the National Foundation of Swallowing Disorders (NFOSD).  I donated to fund a new future webinar because learning and education is so important!

So was my failure really a success?  It depends on your point of view.

Did you take the #thickenedliquidchallenge?  Were you able to drink honey thick liquids for 12 hours?  Did you donate to the NFOSD?

Gelmix Thickener

I was really excited to see Gelmix at the ASHA Convention this year.  I’ve heard a lot about Gelmix, but have never had the opportunity to try it until now!What is Gelmix?

Gelmix is a “healthy thickener” as it is USDA Organic.  Gelmix was formulated to thick breast milk, formula and other liquids.  Gelmix is also free from common allergens including:  gluten, corn, lactose, casein and soy.

Gelmix is made from Carob Bean Gum.  Carob Bean Gum is widely used for its gelling and thickening properties.  The other two ingredients in Gelmix are Organic Tapioca Maltodextrin and Calcium Carbonate.

Gelmix is activated in warm liquids, so you must warm the liquid prior to thickening it with Gelmix.

Gelmix can be used for term infants and children under 3 to thicken to a “light honey-thick consistency.”  For children over 3 and adults, Gelmix can be used to thicken liquids to a “spoon-thick consistency.”

Gelmix is contraindicated for infants under a gestational age of 42 weeks or under 6 pounds.  It also cannot be used with infants with suspected allergy to galactomannans.

Gelmix is available in an 8.8 oz jar (250 grams) which will thicken up to 624 fluid ounces for $29.99 or you can buy the “stick pack” which contain 5 stick, individual serving packets for $5.99.  Each stick will thicken 4 oz of liquid to nectar consistency.

The instructions for thickening with Gelmix:

  • Warm desired amount of liquid (between 100-120 degrees F for best results).
  • Sprinkle in Gelmix per usage instructions.
  • Mix well until Gelmix is completely dissolved.
  • Wait 5 minutes for the mixture to thicken and cool to a safe feeding temperature, mix again before serving.

Usage Instructions:

Infants and Children under 3:

  • Half Nectar:  Add 1 scoop for every 3-4 ounces of liquid.
  • Nectar-Thick:  Add 1 scoop for every 2 ounces of liquid.

(For infants and children under 3 years old, do not use more than one scoop Gelmix per 2 ounces of liquid.  To avoid gassiness, start with lowest concentration, particularly for infants 6-12 pounds.)

Adults and Children over 3:

  • Nectar-Thick:  Add 2 scoops per 4 ounces of liquid.
  • Honey-Thick:  Add 3-4 scoops per 4 ounces of liquid.
  • Spoon-Thick:  Add 4-5 scoops per 4 ounces of liquid.

Gelmix may gradually thicken over time.

Time for a Trial



Last night, I thought what a great time to try Gelmix and combine it with the #thickenedliquidchallenge.   I heated up my water and some milk.  I mixed the Gelmix in, per recommendations for honey thickened liquid.

 

I used a whisk to mix the thickener because when using a spoon, the water was extremely clumpy.  The milk actually became more of a pudding thick liquid.

The water was a little discolored, as with almost all thickened water.  The Gelmix really didn’t add a flavor to the water.

 

The milk was not discolored at all and had no added flavor.

The texture was another thing.  I am just not a honey-thickened liquid person.

I miserably failed the #thickenedliquidchallenge and will be donating to the National Foundation of Swallowing Disorders (NFOSD).

The Gelmix seems to be a good option for a more organic thickener, if you have access to heating your liquids.  It seems to be a great option for babies and would love to hear your thoughts on using Gelmix with babies!

The Dysphagia Buy-In: Selling Your Services

My colleague Jonathon Waller, over at the Dysphagia Cafe posted recently. I LOVE his post. If you haven’t read it yet, you definitely need to. Dysphagia Therapy: More Rehabilitation and Less Compensation.

I think the reason I love this post, and asked him if he minded if I expanded on it, was because THIS IS MY LIFE!

I have definitely had the buy-in aspect. I live and work in Smalltown, Nowhere. People typically have not heard about this “dis-fay-gee-ah” thing.

I go into a room to work with a patient or they come to see me as an outpatient and they have NO idea why they’re there. They swallow just fine and have no problem speaking. Even though they cough and choke with every sip of water.

I find the majority of my evaluation is getting the person to “buy-in” to therapy. They’re not going to continue to come in for therapy if they don’t know what I’m doing.

Let’s face it, we’ve given ourselves a bad name at times. Have you ever had that patient that actually comes to you from another SLP with a 10 page list of exercises that they need to complete 10 times each, 3 times a day, including, but not limited to: stick your tongue out, up, side to side, say every /k/ and /g/ word known to man, stick out your jaw and hold it tensed for 5 hours……you get the picture. Now ask these people why they do these exercises and they have no idea.

I explain the swallowing system to the patient. These are muscles that we work with and when we don’t use those muscles or don’t use them as we’re supposed to, we lose the ability for those muscles to perform the way they are meant.

I often teach my patients, it’s like when you hurt your leg or ankle and limp for several days. You then create other problems because you are walking in a manner you were not meant.

I then teach them how I’m going to help. There’s homework. You don’t do your homework, you may not get better. There’s work to be done in my room. However, I can’t fix this in one session. Much like you can’t expect to go to the gym and after one day of lifting weights look like Arnold Schwarzenegger from the 80’s.

I ask them to give me 4-8 weeks along with the home-exercise program.

We use NO compensation in the therapy room. By using those compensations 100% of the time, we’re not teaching them to swallow without and building pathways FOR those compensations. (After all, who wants to tuck their chin, stand on their head and count to 25 when they swallow).

My patients EAT and DRINK in my therapy room. They don’t stick out their tongue at me or say “cook” with an emphasized /k/ sound. They SWALLOW.

Happy Swallowing Rehabilitation. P.S. I’m all for Swallow Pathologists, Dysphagiologists, anything that distinguishes us by what we do!! Maybe Dysphagia Rehabologists?? I say we put it to a vote!