Tagged "MBSS"


Deciphering Dysphagia

Posted by Deborah Grauzam on

by Colette Ellis M.Ed., CCC-SLP, BCS-S

Dysphagia, or having difficulty swallowing, can affect upwards of 15 million adults in the United States alone. Research has demonstrated that as many as 1 in 25 individuals will experience some form of dysphagia in their lifetime, including 22% of those 50 years of age and older (ASHA 2018; Bhattacharyya, 2014). In the elderly, these percentage may be as high as 30% receiving inpatient medical treatment (Lane, Losinski, Zenner, & Amet, 1989). 68% of residents in long-term care setting may experience dysphagia according to the National Institute on Deafness and Other Communication Disorders (NIDCD, n.d.; Steele, Greenwood, Ens, Robertson, & Seidman-Carlson, 1997). In the "healthy elderly," dysphagia may occur between 13-38% among those living independently.

Dysphagia does not discriminate, rich or poor, young or old. If a swallowing problem occurs in the teen population, it is typically a continuation of a feeding/swallowing problem which was present as a younger child, such as the growing child with cerebral palsy.  New onset dysphagia in teens or younger children may be related to specific choking episodes or a sudden onset such as a traumatic brain injury (TBI) (Swigert, NFOSD, 2015). Second only to children 0-4 years of age, teenagers and young adults ages 15-24 experience the most TBI injuries, which can also present with dysphagia (http://www.cdc.gov/traumaticbraininjury/data/). Dysphagia has been estimated to occur in 13% of those individuals suffering a TBI, with gunshot wounds that cause TBI, producing dysphagia upwards of 37% of the time.

This medical condition can often be neglected or misdiagnosed, despite the significand prevalence across all ages. Education and timely referrals are potential keys to successful recovery or management of dysphagia. Including the above, dysphagia can be a consequence of stroke, head and neck cancer, neurological disease onset, Alzheimer’s dementia and other dementias, Parkinson’s disease, and congenital onset conditions. Speech-language pathologists are highly trained in head and neck anatomy/physiology, and can, with collaboration with the patient’s physician, evaluate and treat many forms of swallowing disorders or dysphagia.

But what does all this mean? What are the consequences of dysphagia? In children, dysphagia can lead to failure to meet nutritional and hydration needs, including failure to thrive in infants (Vivanti, Cambell, Suiter, Hannen-Jones, Hulcomb, 2009; Hays & Roberts, 2006). Severe consequences of dysphagia can include asphyxiation and death across all ages (Berzlanovich, et al, 2005), depression and isolation with negative impact on social well-being (Ekberg, et. al, 2002), as well as potential delayed or disordered development of oral and communication skills (Barbosa, Vasquez, Parada, Carlos, Gonzalez, Jackson, 2009; Morris & Klein, 2000). Another obvious, or maybe not so obvious consequence of dysphagia is pneumonia.

In order to evaluate and treat dysphagia, the speech-language pathologist must know how, when and why the symptoms are occurring. After a thorough case history is reviewed, a clinical swallow examination would be in order; in other words, watch the infant, child or adult eat and drink, regardless of their physical setting. If choking or coughing symptoms are noted, along with other risk factors such as recent hospitalizations, poor weight gain, change in current function, pneumonia onset, dehydration with urinary tract infection (UTI), a swallow instrumentation study may be necessary. These studies (the modified barium swallow study MBSS or the fiberoptic endoscopic examination of swallowing, FEES) would identify the anatomy and physiology of that individual’s current status and swallow, while enabling the skilled SLP to trial maneuvers, compensation or exercise while the swallow is "in view," and aid in treatment planning.

If you or someone you care about has been experiencing swallowing problems, encourage them to relay this to their physician and seek an evaluation from a speech-language pathologist skilled in evaluating and treating swallowing disorders. Eating and drinking have many social significances and being deprived of this basic pleasure would be detrimental. Think of this the next time you take that big drink of cool, refreshing water.

***

Here are a few resources to get more information:

References

ASHA, (2002). Roles of Speech-Language Pathologists in Swallowing and Feeding Disorders, Position Statement

ASHA, End-of-Life Issues in Speech-Language Pathology, https://www.asha.org/slp/clinical/endoflife/

Barbosa,C., Vasquez, S., Parada, M.A., Carlos, Gonzalez, J.C., Jackson, C., Yanez, N.D., Gelaye, B., Fitzpatrick, A.L.(2009). The relationship of bottle feeding and other sucking behaviors with speech disorder in Patagonian preschoolers. BioMed Central Pediatrics, Oct 21;9:66. doi: 10.1186/1471-2431-9-66.

Berzlanovich, A.M., Fazeny-Dorner, B., Waldhoer, T., Fasching, P., Keil, W. (2005). Foreign body asphyxia: a preventable cause of death in the elderly, American Journal of Preventative Medicine, Jan;28(1):65-9.

Bhattacharyya, N. (2014). The prevalence of dysphagia among adults in the United States. Otolaryngology-Head and Neck Surgery, 151, 765-769.

Vivanti, Cambell, Suiter, Hannen-Jones, Hulcomb. (2009). Contribution of thickened drinks, food and enteral and parenteral fluids to fluid intake in hospitalized patients with dysphagia. Journal of Human Nutritional Diet, Apr 22 (2)148-155.

Layne, K., Losinski, D., Zenner, P., & Ament, J. (1989). Using the Fleming Index of Dysphagia to establish prevalence. Dysphagia, 2, 216-219.

Morrison, et al., (2004). Palliative Care, NEJM, 350:2582-2590

Steele, C., Greenwood, C., Ens, I., Robertson, C., & Seidman-Carlson, R. (1997). Mealtime difficulties in a home for the aged: not just dysphagia. Dysphagia, 12, 43-50.

Swallowing Disorders Foundation: http://swallowingdisorderfoundation.com/dysphagia-in-teens-adults/ published 03-29-2015.

http://www.cdc.gov/traumaticbraininjury/data/

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Performing a VFSS that Communicates Positive Results: Adult and Pediatric Patients

Posted by Deborah Grauzam on

We are delighted to share with you a description of TalkTools® Instructor Jennifer Jones's four-hour presentation at the annual MSHA Convention, March 3, 2016.

"Performing a VFSS that Communicates Positive Results: Adult and Pediatric Patients"

By Jennifer Jones, Ph.D., CCC-SLP, BCS-S, C/NDT

ABSTRACT

The VFSS is the standard for instrumental evaluation of swallowing disorders, but if clinicians don't communicate the appropriate results then the receiving therapist cannot properly treat the patient. Participants will watch many VFSS and identify abnormal and normal physiology utilizing interactive technology, discuss positive attributes of a disordered swallow and plan treatment.

OBJECTIVES

  1. Identify 2 disorders each that could occur before, during and after the swallow.
  2. List 3 normal and appropriate physiologic attributes of the VFSS viewed.
  3. Discuss positive attributes of disordered swallows and plan appropriate treatment.

As Clinicians, we are taught to find the things that are “wrong” with our patients. When we write a language and/or swallowing report we document all of the things that our patient cannot do.  We are trained to see what is disordered or abnormal and we document those findings. However, there are positive attributes that should be reported as well. We need to see the positives that our patients have to offer, either through language or swallowing.

This course is created based on research that shows the normal aging process with swallowing, which is coined Presbyphagia. Are our patients being diagnosed with moderate and severe dysphagia based on normal aging changes to the swallowing anatomy and physiology? Are there patients who are on limited diets based on normal aging difficulties with swallowing? This course will teach attendees about the normal aging process and how to discern normal from abnormal physiology in the aging population.

The Videofluoroscopic Swallow Study is a means to discover what our patients can eat and drink safely with minimal risk and minimal invasion to their quality of life.  In order to achieve this goal, we must be able to discern the positive aspects of a patient’s swallow so that we can build on it. A swallow study should not be considered complete until there is some consistency that a patient can eat or drink safely with minimal invasion.  If a therapist can focus more on the positive aspects of the swallow then designing a treatment plan utilizing those aspects would be less invasive.

This course involves utilizing an audience response system so that participants can be interactive with the speaker. The speaker will present greater than 15 VFSS (the # depends on allotted time) for interpretation.  The VFSS will be discussed and participants will be presented with a question and multiple answers.  The participants will be required to answer these questions using the audience response system, which will require them to commit to an answer.  When we perform the VFSS we commit to answers rather quickly, which is what changes our on-line modifications during the VFSS. The participants will be required to answer questions related to normal and abnormal physiology, positive attributes and planning treatment. Upon completion of this course, participants will have reviewed multiple swallow studies and observed that positive attributes should be utilized to plan treatment.

If you missed it, meet Jennifer Jones June 24-25 in San Juan, PR for her live workshop: "Pediatric Dysphagia: Interpreting the MBSS and Planning Treatment."

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Why Every SLP Needs to Understand Dysphagia

Posted by Deborah Grauzam on

by: Dr. Jennifer Jones, Ph.D., CCC-SLP, BCS-S


TalkTools | Dysphagia

As a Board Certified Swallowing Specialist,  I am asked on a regular basis about why other therapists, nurses, physicians and general population need to know more about dysphagia and the symptoms.

Dysphagia is a growing health problem in the United States and the prevalence will increase significantly over the next 50 years. According to the US Census Bureau, between 2012 and 2060, the U.S. population is projected to grow from 314 million to 420 million, an increase of 34 percent. The population is also expected to be older. People over the age of 65 experience age-related swallowing difficulties[1] and diseases that cause dysphagia.

By 2030, more than 20 percent of U.S. residents are projected to be aged 65 and over, compared with 13 percent in 2010.[2] The US Census Bureau indicates that in 2010, the population of persons above the age of 65 was 40 million. Taken together, this suggests that up to 6 million older adults could be considered at risk for dysphagia. This will mean that someone you know, either a family member or a patient, will most likely have dysphagia.

Any disruption in the swallowing process, from the mouth, pharynx, larynx, and into the esophagus, could be defined as dysphagia. [3] Most people who experience mild dysphagia symptoms create compensatory strategies that will allow them to continue to eat by mouth, like eating less or eating foods that are easier to chew. Many of these cases go undetected because the doctor is never contacted about the difficulties.

TalkTools | Dysphagia

However, despite using these self-designed strategies, dysphagia often contributes to increased risk of malnutrition and pneumonia. A referral to a trained Speech-Language Pathologist (SLP) to diagnose the specific cause of the dysphagia is paramount.  The training of the SLP is also very important, because not all SLPs are trained extensively in dysphagia. It is imperative that your patient or family member receives the best assessment possible for dysphagia to detect difficulties that could lead to pneumonia.

The prevalence of pneumonia in elderly adults is rising, with a greater risk of infection in those older than 75 years.[1] [2] In addition, deaths from pneumonitis due to aspiration of solids and liquids (e.g., aspiration pneumonia) are increasing and are currently ranked 15th on the CDC list of common causes of mortality.[3]

The elderly population is only part of the picture. We must also keep in mind that there are many infants and children who need dysphagia evaluation and therapy services. Infants with feeding and swallowing difficulties can begin to receive services through Early Intervention as soon as they are discharged from the hospital after birth.

The most recent studies in 2012 (NICHCY, 2012) stated that there were approximately 350,000 infants / toddlers receiving Early Intervention services in the United States, which would calculate to approximately 3.0% of the 11.5 million live births over a 3 year period.[4] Also, over that same 3-year period, about 3.4% of those infants born were less than 34 weeks gestation, which places them in a high-risk group for feeding and swallowing impairments.[5] These estimations don’t even include the high-risk populations such as craniofacial anomalies, congenital heart defects, tracheotomies, cerebral palsy and genetic syndromes that are seen in the toddler years.

Another population to consider, but definitely not the last population, is school-aged children. School-based speech-language pathologists previously believed that by working in the school setting that they did not need to understand feeding and swallowing difficulties to the level of the modified barium swallow study and other medical involvements. This is no longer the case.

The ASHA 2014 Schools Survey found that 14% of the school-based speech-language pathologists serve students who have dysphagia. The speech-language pathologist serving preschoolers reports that the dysphagia population is 25.2%, elementary students was 9.7% and 11% for secondary schools. The highest numbers were reported for special day and residential schools at 40.6%.[6]

Students with dysphagia have a wide variety of primary etiologies that contribute to dysphagia, which include developmental disabilities, neurological disorders, genetic syndromes, cleft lip and/or palate, traumatic brain injuries, and an array of other medical conditions. Manikam & Perman (2000) researched pediatric feeding disorders and found that feeding and swallowing disorders were also seen in typically developing children at a rate of approximately 25-45% due to causes such as medication side effects and/or behavioral or sensory issues.[1]

The scope and practice of evaluation and treatment of dysphagia falls within the role and responsibilities of the speech-language pathologist. Across most settings and age throughout the lifespan the speech-language pathologist serves as the lead on coordinating dysphagia therapy and care. However, most SLPs do not seek or receive enough training for treating clients with dysphagia.

None the less, the services must be performed, especially if the student has dysphagia services written into the Individualized Educational Plan (IEP). These services typically fall under Other Health Impairments (OHI) and would be mandated that they are performed during school hours. Eating and drinking are a part of every student’s day and contribute to their readiness to learn. Therefore, the school-based speech-language pathologist is in need of just as much dysphagia training as those who are medically-based.

Dysphagia ImageA dysphagia evaluation typically begins with a clinical assessment in the therapist’s office, patient’s home or bedside at the hospital. If there are concerns for pharyngeal difficulties then the patient will be referred for a radiologic imaging study called a Modified Barium Swallow Study (MBSS). The importance of the MBSS is primarily to view the activity of the pharynx before,during and after the swallow because the pharynx cannot be fully evaluated during the clinical assessment.

The SLP can only make assumptions about the integrity of the pharyngeal musculature based on symptoms that are observed.  Performing an MBSS is the only true way to diagnose the pharyngeal phase during the swallow.  Some therapists may perform a Flexible Endoscopic Evaluation of Swallowing (FEES) instead of the MBSS.  However, there is no way to observe the pharyngeal phase during the swallow because of the “white out” that occurs due to epiglottic inversion. During the MBSS, the trained SLP will observe the normal swallow with food and liquids and then implement different compensatory strategies to help the patient eat and drink safely.

These strategies are considered temporary and are intended to decrease residue and aspiration risks.[1]  Compensatory strategies may include postural adjustments, like a head turn or chin tuck, swallowing maneuvers, such as a Mendelsohn maneuver or supraglottic swallow and/or diet modifications.[2] It is imperative that these strategies are observed during the MBSS because they don’t always make the swallow better and can often times make the swallow more compromised. Therefore, it is not wise to recommend that a patient perform a compensatory strategy just because it worked with another patient with a similar impairment.

The speech-language pathologist performing the MBSS should write a thorough report with clear recommendations and expectations for improvement. Reports should be detailed when describing the impairments and therapy strategies.  It is preferred that the treating clinician view the MBSS. However, a detailed report can be used to help analyze what they are seeing and plan treatment based on the outcomes of the patients swallow. Otherwise, the treating speech-language pathologist is totally reliant on the recommendations in the written report whether they are providing decreased dysphagia symptoms or not.

Therefore, it is paramount that all speech-language pathologists take continuing education courses that focus on the ability to execute and interpret a Modified Barium Swallow Study and to plan treatment based on the outcome of the study.


Swallowing SpecialistDr. Jennifer Jones is an ASHA certified Speech-Language Pathologist and ACE recipient with over 20 years experience. She earned a Bachelor of Arts degree in Deaf Education and Elementary Education from Converse College in 1992, completed her Masters in Speech Pathology (M.S.P.) in 1996 and her Ph.D. in Speech-Language Pathology and Audiology in 2003 from the University of South Carolina. Dr. Jones earned Board Certification in Swallowing and Swallowing Disorders in 2008 through her extensive training and experience in the field of dysphagia.

[1] Rasley A, Logemann JA, Kahrilas PJ, Rademaker AW, Pauloski BR, Dodds WJ. Prevention of barium aspiration during videofluoroscopic swallowing studies: value of change in posture. American Journal of Roentgenol.1993;160:1005–1009.

[2] Groher ME, Crary MA. Dysphagia: Clinical Management in Adults and Children. Maryland Heights, MO: Mosby Elsevier; 2010.

[1] Manikam, R., & Perman, JA (2000). Pediatric feeding disorders. Journal of clinical gastroenterology, 30(1), 34-46.

[2] Hutchins, TL, Gerety, KW, & Mulligan, M. (2011). Dysphagia management: A survey of school0based speech-language pathologists in Vermont. Language, Speech, and Hearing Services in Schools, 42(2), 194-206.

[1] Kaplan V, Angus DC, Griffin MF, Clermont G, Scott Watson R, Linde-Zwirble WT. Hospitalized community-acquired pneumonia in the elderly: age- and sex-related patterns of care and outcome in the United States. Am J Respir Crit Care Med. 2002;165:766–772

[2] Marik PE, Kaplan D. Aspiration pneumonia and dysphagia in the elderly. Chest. 2003;124:328–336.

[3] Murphy S, Xu J, Kochanek KD. Deaths: Preliminary Data for 2010. National Vital Statistics Report: Center for Disease Control and Prevention. Jan 11, 2012.

[4] Hamilton, BE, Martin, JA, Osterman, MJK & Curtin, SC (2014). Births: Preliminary Data for 2013. National Vital Statistics Reports, 63(2), 1-34.

[5] Martin, JA, Hamilton, BE, Osterman, MJK & Matthews, TJ (2012). Births: Final Data for 2012. National Vital Statistic Reports, 62(9), 1-87.

[6] American Speech-Language Hearing Association. (2014). Schools survey report: SLP caseload characteristics. Available from http://www.asha.org/Research/memberdata/schoolssurvey/.

[1] Fucile S, Wright PM, Chan I, Yee S, Langlais ME, Gisel EG. Functional oral-motor skills: Do they change with age? Dysphagia. 1998;13:195–201.

[2] This report is based on projections for the years 2013 to 2060. The Census Bureau’s official population estimates are used for 2012. (U.S. Census Bureau, 2012b). When both population estimates and projections are available, as is the case for 2012, estimates are the preferred data. The population estimates are available at www.census.gov/popest>.

[3] Crary MA, Groher ME. Introduction to Adult Swallowing Disorders. Philadelphia, PA: Butterworth Heinemann; 2003.

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