Dysphagia Diagnosis
One of the greatest obstacles besides becoming comfortable with the anatomy during a Videofluoroscopy of VFFS is becoming familiar with that anatomy while moving during scanning and accepting different consistencies while also counting how many swallows it takes to get the bolus down. The only way to become proficient and eventually specialized is with study and practice. This comes with reviewing as many videos as possible. This includes normal swallows as well as disordered.
Becoming a reliable observer, learn how to interpret evidence, learning how to recognize and interpret anatomical and physiological differences will contribute to developing the swallowing specialists trained eye. Even if your hospital or practice has a machine where you can review the MBS at a later date as many times as you would like, you still need to have the ability to do all of the above during the immediate evaluation in case the patient or caregiver has any immediate questions, (and this is most likely that the patient comes from a Skilled Nursing Facility) you need to send them back with the report and recommendations immediately, (as transport usually does not like to wait long).
Provided from from the University of Minnesota in Duluth Department of Communications and Sciences Department albeit quick clips and difficult to interpret, but it's definitely a good start for students looking to study!
Becoming a reliable observer, learn how to interpret evidence, learning how to recognize and interpret anatomical and physiological differences will contribute to developing the swallowing specialists trained eye. Even if your hospital or practice has a machine where you can review the MBS at a later date as many times as you would like, you still need to have the ability to do all of the above during the immediate evaluation in case the patient or caregiver has any immediate questions, (and this is most likely that the patient comes from a Skilled Nursing Facility) you need to send them back with the report and recommendations immediately, (as transport usually does not like to wait long).
Provided from from the University of Minnesota in Duluth Department of Communications and Sciences Department albeit quick clips and difficult to interpret, but it's definitely a good start for students looking to study!
Remembering All Of Your Normative Data
To understand swallowing, be able to make a clear and accurate diagnosis and set appropriate effective goals for treatment, you must first understand what a normal swallow looks like. Looking for whether a patient has penetrated or aspirated is obviously vital but not the most important thing to note during an instrumental exam. Most clinicians and therefore patients misinterpret this as being a "PASS/FAIL" of the instrumental exam. A PASS being interpreted as NOT aspirating and a FAIL being interpreted as having aspirated. This is a tragic error on behalf of the clinician. The most important part of the instrumental exam is DESCRIBING the anatomical and physiological events that occur during the test. By describing the details of what you see, you will have an idea if the complications you see can lead to aspiration or penetration EVEN if the aspiration and/or penetration does not occur but most importantly, you will know what therapeutic strategies will have the least and most benefit to that patient specifically. As a clinician, you have the responsibility of finding the best most effective treatment plan for that patient. Your report should include the most descriptive and detailed, yet succinct information for your patients continuing care.
***This is not the place to show off and write in all fancy language. Keep it as simple and understandable as possible as if anyone without a specialized degree could understand it.
Examples of Normal Videoflouroscopy Studies
- Lateral View - 1/3 Tsp Honey http://www.d.umn.edu/csd/current/courses/swallowing/video/whole.mov
- Lateral View - 1/3 Tsp Ground Meat & 1/4 Cookie Oral Phase - http://www.d.umn.edu/csd/current/courses/swallowing/video/gb.mov Pharyngeal Phase - http://www.d.umn.edu/csd/current/courses/swallowing/video/gc.mov Dry Swallow to clear stasis - http://www.d.umn.edu/csd/current/courses/swallowing/video/gd.mov
- Lateral View - Clear Liquid -
Oral Phase - http://www.d.umn.edu/csd/current/courses/swallowing/video/nliqg.mov
Dysphagia Treatment Options
Once your Videofluoroscopy Exam is completed, your Speech Language Pathologist is then able to determine if there is a swallowing problem and exactly where the problem lies. Once a diagnosis of Dysphagia is confirmed, many different things can occur depending on the severity and location. Your Speech Language Pathologist should discuss their initial findings with you at the time of your examination however, you should make a follow up appointment to discuss your plans and their findings further.
Swallowing problems can occur for many different reasons. They don't necessarily mean a dysphagia diagnosis is imminent. However, once a diagnosis of dysphagia is given, it's important to note that dysphagia is not a disease but a symptom of an underlying disease/disorder. As your Speech Therapist decides on your dysphagia treatment course, identifying and understanding the underlying disorder is necessary in order to understand how the body will respond to treatment.
It is extremely important to follow the explicit directions of your Speech Language Pathologist, along with your Physician and if needed, a Nutritionist. Should you have concerns about this new lifestyle that you may have to become accustomed to, it is important to discuss them with your therapist so they can find ways to alternate your treatment plan to the best of their ability so as to keep you in the safest and least restrictive diet possible while also retaining your quality of life.
Depending on the severity of the Dysphagia, several recommendations for therapy, diet alterations, positioning, life style changes, may be made which can include any of the following:
Examples - National Dysphagia Diet (NDD)
2. Swallowing Therapy: Private swallowing therapy can include a variety of different things, again depending on the severity of your dysphagia and the site of your dysfunction.
Examples
There are a lot of new devices and treatment programs that have come to light in the last few years. Some are beginning to have supporting evidence, some no evidence to support, and some no evidence at all. In these cases, it's important to remember our training and the three fold that is EBP. As a clinician and a patient, we must read and practice as much as we can, be open to new ways of treating that may help our patients, however consider the outcomes (positive and negative), and come to our own conclusions based on EBP. Several of these devices look fancy to the patient who expects a device to do the work for them, yet, the device may be doing more damage than good. Logeman (2006) states there have been a number of experimental procedures described recently for improvement of motor control of swallow. None of these procedures has any experimental evidence to support its effectiveness. However, part of our ethical code and in our realm of practice is to incorporate not only case studies that have been published where we've seen evidence of these practices working, but to also consider our own experience as well. Therefore, if you're considering a treatment not widely used, you may want to consider asking such questions. Even if it is widely used, you want to consider these claims. Mainly because unfortunately not all SLP's keep up with their research practices and two they tend to use a lot of these experimental techniques as one fits all not understanding the real treatment rationales (why we treat certain Dysphagia's the way we do).
These procedures include using the following in places not meant for their for the use they were made for such as myofascial release, designed to release any scar tissue or connective tissue inhibiting movement of structures in the pharynx; neuromuscular electrical stimulation (NMES), designed to improve the strength of muscle contraction during swallow; and deep pharyngeal neuromuscular stimulation (DPNS), designed to utilize reflexive activity in the pharynx to improve swallow. The rationale for many of these procedures and their effectiveness are unclear. These types of procedures should be utilized with care until efficacy data are clearly identified. Humbert (2011) wrote the article Against E-Stim, however an opposing article For the use of E-Stim for Swallowing was in the same Journal of Perspectives. More recent research is examining the use of E-stim in conjunction with Dysphagia exercises.
For a detailed description of the various therapy techniques go to Dysphagia Treatment
Swallowing problems can occur for many different reasons. They don't necessarily mean a dysphagia diagnosis is imminent. However, once a diagnosis of dysphagia is given, it's important to note that dysphagia is not a disease but a symptom of an underlying disease/disorder. As your Speech Therapist decides on your dysphagia treatment course, identifying and understanding the underlying disorder is necessary in order to understand how the body will respond to treatment.
It is extremely important to follow the explicit directions of your Speech Language Pathologist, along with your Physician and if needed, a Nutritionist. Should you have concerns about this new lifestyle that you may have to become accustomed to, it is important to discuss them with your therapist so they can find ways to alternate your treatment plan to the best of their ability so as to keep you in the safest and least restrictive diet possible while also retaining your quality of life.
Depending on the severity of the Dysphagia, several recommendations for therapy, diet alterations, positioning, life style changes, may be made which can include any of the following:
- Diet restrictions: Diet restrictions can include a variety of different things which may include simple things from simply changing the temperature from which your food is served, to which the texture you may chew or not chew, to suggesting altering the volume to which swallow your food, as well as modifying your liquids.
Examples - National Dysphagia Diet (NDD)
- NDD Level 1: Dysphagia-Pureed (homogenous, very cohesive, pudding-like, requiring very little chewing ability).
- NDD Level 2: Dysphagia-Mechanical Altered (cohesive, moist, semisolid foods, requiring some chewing).
- NDD Level 3: Dysphagia-Advanced (soft foods that require more chewing ability).
- Regular (all foods allowed).
- Modified Regular Food Diet
- May note certain foods to avoid
- May restrict liquids completely
- May alter liquids to either Thicken liquids; nectar thick or honey thick or how they are swallowed (i.e., use of teaspoon).
- Parenteral and Enteral Nutrition
2. Swallowing Therapy: Private swallowing therapy can include a variety of different things, again depending on the severity of your dysphagia and the site of your dysfunction.
Examples
- Therapy can include various types of exercises and swallowing strategies taught during sessions which will then be able to be practiced and utilized at home.
- Exercises can include tongue strengthening and muscle strengthening
- Practices may be taught to modify swallow techniques referred to as compensatory strategies (ie., "chin tuck", "head turn", etc.) to assure safe swallow
- Some may call to use special techniques and devices such as Thermal Stimulation, Vital Stimulation, E-Stimulation, and/or use bio-feedback devices such as Surface Electromyography.
There are a lot of new devices and treatment programs that have come to light in the last few years. Some are beginning to have supporting evidence, some no evidence to support, and some no evidence at all. In these cases, it's important to remember our training and the three fold that is EBP. As a clinician and a patient, we must read and practice as much as we can, be open to new ways of treating that may help our patients, however consider the outcomes (positive and negative), and come to our own conclusions based on EBP. Several of these devices look fancy to the patient who expects a device to do the work for them, yet, the device may be doing more damage than good. Logeman (2006) states there have been a number of experimental procedures described recently for improvement of motor control of swallow. None of these procedures has any experimental evidence to support its effectiveness. However, part of our ethical code and in our realm of practice is to incorporate not only case studies that have been published where we've seen evidence of these practices working, but to also consider our own experience as well. Therefore, if you're considering a treatment not widely used, you may want to consider asking such questions. Even if it is widely used, you want to consider these claims. Mainly because unfortunately not all SLP's keep up with their research practices and two they tend to use a lot of these experimental techniques as one fits all not understanding the real treatment rationales (why we treat certain Dysphagia's the way we do).
These procedures include using the following in places not meant for their for the use they were made for such as myofascial release, designed to release any scar tissue or connective tissue inhibiting movement of structures in the pharynx; neuromuscular electrical stimulation (NMES), designed to improve the strength of muscle contraction during swallow; and deep pharyngeal neuromuscular stimulation (DPNS), designed to utilize reflexive activity in the pharynx to improve swallow. The rationale for many of these procedures and their effectiveness are unclear. These types of procedures should be utilized with care until efficacy data are clearly identified. Humbert (2011) wrote the article Against E-Stim, however an opposing article For the use of E-Stim for Swallowing was in the same Journal of Perspectives. More recent research is examining the use of E-stim in conjunction with Dysphagia exercises.
For a detailed description of the various therapy techniques go to Dysphagia Treatment