Dysphagia Evaluation: Ask Many Questions!
by Karen Sheffler, MS, CCC-SLP, BCS-S of SwallowStudy.com
This is Part 1 of a blog I created for MedbridgeEducation.com.
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An 85-year-old woman walks into a bar, and…
No, wait, wrong blog…
An 85-year-old woman walks into an outpatient swallowing clinic to get help for her difficulty swallowing. After her clinical dysphagia evaluation, she comes out with a folder full of dietary suggestions, swallow strategies, tongue exercises, and swallowing exercises. She faithfully performs her exercise drill every morning and evening, laughing at herself making faces in the mirror. She tries to hold her tongue out while she is effortfully swallowing saliva (i.e., Masako/Tongue-Hold, Fujiu, M., & Logemann, J. A., 1996). She can only do two repetitions as her mouth is so dry.
She wonders how these are going to help her swallow better. During meals, she does as she was told, tucking her chin and effortfully swallowing two times after every bite of food. However, she still is bothered by that lump-in-the-throat sensation and the feeling of food stuck. Liquid comes back up on her when she tries to wash foods down. She can only eat a small amount before the food feels like it is coming back up into her throat. Most concerning to her, she is still losing weight. She wonders: “What am I doing wrong?”
We need to ask: “What are WE doing wrong?”
We need to “have the right pile of background information,” and “start with a good and accurate diagnosis,” per Dr James Coyle, PhD, CCC-SLP, BCS-S (Coyle, 2014, April).
This case is a perfect example of why the swallowing specialist needs a complete understanding of a patient’s swallowing physiology before prescribing swallowing maneuvers and exercises.
If we miss the underlying cause for the difficulty swallowing, “we treat a symptom and not its cause,” per Coyle (2014, April).
This point was stressed multiple times at this year’s Dysphagia Research Society 23rd Annual Meeting, March 12-14, 2015, Chicago, IL (#DRS2015). Dysphagia is not a disease in-and-of-itself; dysphagia is a symptom of underlying problems across many systems. We, as deglutologists, need to find the underlying issues that cause the swallowing dysfunction. This requires a multidisciplinary approach. As stated by the 2014-2015 president of the Dysphagia Research Society, Dr Kulwinder Dua, MD, during the opening of our 2015 annual meeting, “If there is no cross-talk (among the subspecialties), we are working in isolation and that is a disaster.” 600,000 people die every year due to complications from dysphagia, per Dua; more than from liver disease, kidney disease and HIV combined, and similar to that of diabetes.
What can we do? Dr James Coyle’s shared this advice (2014, April):
- Do not treat a symptom in isolation without knowing WHY.
- Do not treat the barium. In other words, do not treat the bolus.
- Ask: What did the patient do to make the barium/bolus aspirate?
- Then: leave the aspiration issue to also manage a host of other risk factors. Pneumonia is multifactoral, and underlying causes of dysphagia are multifactoral.
As stated by Joan Arvedson, PhD, CCC-SLP, BCS-S, at the 2015 Dysphagia Research Society Meeting, we need to ask: “What else?” These are her favorite four-letter words!
Start with the Art of the Clinical Examination
Dr Dua started the March, 2015 Dysphagia Research Society’s Post-Graduate Course with a talk focused on integrating the art and science of swallowing with technology. Here are some important take-home messages:
- “If technology fails you, will you be lost?”
- Will you still have “good history taking and keen observation?”
- “Are we driving technology, or is it driving us?”
- Dr Dua added this quote by Sir William Osler: “The practice of medicine is an art, based on science.”
I found a few more gems by Osler:
“Medicine is a science of uncertainty and an art of probability,” and
“There is no more difficult art to acquire than the art of observation…”
The SLP, who specializes in swallowing, is a transdisciplinary deglutologist-artist. In this healthcare climate, we need the SLP to also be the traffic cop to help direct the dysphagia work-up in the most efficient and cost-effective way. A thorough clinical evaluation of dysphagia can help the clinician begin to establish a hypothesis and point the instrumental examinations in the right direction.
Our clinical dysphagia evaluation (aka, clinical bedside swallowing evaluation) is not a screen, in my opinion. (See my ASHAsphere blog from #ASHA14: Dishing on Dysphagia.) The SLP may be the only discipline who spends more than 5 minutes critically evaluating the person’s eating and swallowing. As a part of this valuable billable service, we gather crucial information by:
- Thoroughly reviewing of the medical record. (See my blog on digging through the medical record.)
- Thoroughly interviewing not only the patient, but also the medical team, nurses, family, and other caregivers,
- Making keen observations when the person is eating and swallowing,
- Comparing the patient’s current functional status to his/her baseline cognitive-linguistic and swallowing function,
- Initiating the rapport-building, education and counseling that will be necessary throughout the process, and
- Knowing the limitations of a clinical dysphagia evaluation and communicating this. Therefore, we can back-up our recommendations for further testing. For example, a therapist could cite the evidence of poor pharyngeal/laryngeal sensation in patients with Dementia or advanced Parkinson’s, and request instrumental examinations when necessary.
As summarized by Dr Stephen Leder (2015, March):
*We know that our clinical examination cannot comment on pharyngeal and laryngeal anatomy and physiology,
*We cannot describe bolus flow characteristics on the clinical examination alone,
*We cannot rule-out silent aspiration, and
*We cannot fully or confidently recommend a diet or other interventions to promote safe swallowing.
In my fictitious case above, without a thorough clinical dysphagia evaluation, the symptom of food getting stuck in the throat was mistaken for pharyngeal dysphagia. A thorough interview and medical record review should have at least casted doubt on the pharyngeal dysphagia hypothesis.
Certainly an instrumental exam would have helped to point the referrals and therapy in the right direction (See Part 2 of this blog, addressing instrumental exams and necessary referrals).
I purposely painted a picture of an esophageal dysmotility to show how the entire treatment course was pointed in the wrong direction. (See prior esophageal dysphagia blog.) Did the clinician use multidisciplinary collaboration or critical thinking? Why was an instrumental examination not performed? Tongue base exercises will do nothing for the smooth muscle in the distal 2/3rds of the esophagus. Even more detrimental, the act of rapidly double swallowing with a solid bolus will interfere with her esophageal peristalsis, by potentially disrupting her secondary clearing wave, which could make her symptoms worse.
Our Broad Scope of Practice:
See ASHA’s Scope of Practice for Speech-Language Pathologists and ASHA’s practice policy page on Knowledge and Skills Needed by Speech-Language Pathologists Performing Videofluoroscopic Swallowing Studies. Both documents refer to oral, pharyngeal and esophageal phases of swallowing.
It is in our scope of practice and appropriate to provide brief therapy to assist patients who have esophageal dysphagia, as long as you have the knowledge and skills to do so. We can provide a significant amount of education and training to improve the patient’s quality of life and intake by suggesting slight diet modifications, training effective strategies, eliminating maladaptive ones, and increasing safety by reducing supraesophageal reflux aspiration risks.
Similarly, it is in our scope of practice to evaluate and manage more than just the swallowing mechanics. Our comprehensive mealtime evaluation can look for many potentially exacerbating factors. (See blog about mealtime success.) For example, imagine if further investigation into our 85-year old woman’s case revealed that recently she started eating her main meal of the day at the senior center. She described eating quickly and talking while eating with friends. Additional questioning revealed that her dentures are worn-down and loose from her weight loss. A review of medications revealed her physician recently increased her Lasix (Furosemide), which may contribute to dry mouth.
We “weave together” information from the instrumental and clinical dysphagia evaluations, and we intervene in a multidisciplinary way to produce the best possible outcomes, per Coyle (2014, April).
Always ask: What else?
And check out Part 2 of Dysphagia Evaluations: Good Dysphagia Evaluation Guides Treatment (Part 2)
Coyle, J.L. (2014, April). IIS5: Dysphagia Interventions: Are We Treating the Bolus, the Patient, or Something Else? Seminar presented at the Healthcare & Business Institute of the American Speech-Language-Hearing Association, Las Vegas, NV.
Fujiu, M., & Logemann, J. A. (1996). Effect of a tongue-holding maneuver on posterior pharyngeal wall movement during deglutition. American Journal of Speech-Language Pathology, 5 (1), 23-30.
Leder, S. (2015, March). Session X: Clinical Conondrum: I Can Tell You About the Pharyngeal Swallow Without Looking. Session presented at the Dysphagia Research Society 23rd Annual Meeting, Chicago, IL.