I’m guilty of assessing the swallow in 3 phases, please send me the PDF review of the 17 physiological impairments so I can write better reports!

 

 

 

I recently had the pleasure of attending the Florida Dysphagia Institute 2.0, and I’ve been mulling over something Dr. Bonnie Martin-Harris said for weeks now. In one of her talks, she described how “phases of the swallow” is just plain and simply not accurate anymore, and movements in swallowing are independent events.

Huh, I thought we all knew that by now. I guess not!

Then why the heck are we still referencing the swallow like it’s 3 separate phases when we’ve got research up the wazoo telling us we’ve got to swerve our thinking?!? If all we had to do was identify 3 phases and pick the impaired phase, and then do the same exercises to target that phase, I’m pretty sure we could train some monkeys to do that for us and then whomp, whomp — we’ve dried up our own profession.

This really got me wondering how long we’ve had this stuff documented and for some odd reason we’re still prehistoric in our thinking. I started investigating how far back we’ve known all this, and luckily, Dr. Brodsky was able to provide me with this paper in a jiffy, and viola, lo and behold, in 2005, Dr. Bonnie Martin-Harris, wrote about how there is a “significant overlap between the initiation of oral and pharyngeal components of swallowing and highlights the artificiality of separating the swallowing continuum into isolated phases.”

I feel like I try really, really freaking hard to keep up with the literature, and believe me, I get it, it’s so hard, and sometimes some things fall through the cracks. I think it’s even worse when we finally realize some of these papers have been around for 10+ years and we STILL are not using them correctly in our clinical practice! Major face palm!

I recently started working on a series of posts about various treatment strategies that target different physiological deficits, but then I thought woah! Hold up! Let’s get everyone on the same page with the physiology before we start throwing the kitchen sink at it.

I was fortunate enough to attend the MBSImP training many years ago, even before I was doing my own instrumental assessments, and that’s when the lightbulb went off in my head that maybe there’s a whole lot more to this dysphagia stuff than I really comprehended. As an SLP working full time in the SNFs with no access to instrumentation other than the crappiest of reports written from an MBSS that took 6 weeks to schedule, the MBSImP course really changed my thinking of the swallow to considering various physiological components as opposed to the 3 phases we learned about circa Jeri Logemann, 1998. I think the MBSImP is really when my brain made the switch to components, and when I really became much more critical of the reports I received and eventually wrote myself. But to think that Dr. Martin-Harris has been writing about this since 2005.. we’ve been under the rock for 12 years people!

I think its important to bring these papers back in to the light because we are in an interesting time in dysphagia research right now. We have a melting pot of clinicians, some who have graduated from top notch medical SLP programs and have dedicated their lives to studying and practicing evidence based treatment, and other clinicians who are now forced to learn about dysphagia on their own, because they happened to fall into a medical setting somewhere along the way. No biggie, we commend you for learning, but it’s crucial that in order to command evidenced based treatment strategies for our patients, we must bring the physiological components to light in our diagnostics and phase out the phases (pun intended!)

Fast forward to now I do FEES full time for a living, and it’s critical when we write our reports that we describe the various physiological components, and not just slap on a blanket phase deficit. We know waaaay more about the details about the swallow now than to just say 1 out of 3 phases are affected and call it a day. I know it’s easy if you haven’t been educated to claim that with FEES you cant see the oral phase or the esophageal phase, but when you say that we’re deduced to the pharyngeal phase and that FEES can only provide us with imaging of 1/3 of the swallow? Get the heck outta here dude, we know better than that now.

(And just for good measure, we are able to assess lip closure, premature spillage/posterior oral containment, swallow efficiency from the lingual base, timelines of initiation of the swallow, and oral residue with endoscopy, and we are also able to suspect esophageal dysfunction in which a referral to GI is made, same as with an MBSS that does an esophageal screen (Allen et al., 2002).

Like I said before, we’ve had this information out for well over 10 years now and it’s still not being used. I can’t tell you how many times, I go in to buildings that don’t have full time SLPs, and I have to report to the DOR about the patient’s swallowing functioning. “Ok well tell me what’s affected, the oral phase, or pharyngeal, or esophageal? Well I guess either pharyngeal or not since you can’t assess oral and esophageal on FEES.” <— True life quote from a DOR last week.

If we’re going to grow as a field, and be respected as THE dysphagia experts, we must be thorough in our instrumental evaluation reports, thorough in our explanations to our colleagues, and thorough in our prescribed evidenced based treatment strategies. Again, the DOR could’ve just called in the trained monkey to identify the phase and hand the patient the cookie cutter handout of exercises. Shoot, even Puxatawney Phil can decipher between the seasons! Surely he can tell us which phase of the swallow is impaired!

Sit down my friend, let me enlighten you. We assess a hell of a lot more than just 1, 2, or 3 phases, and we have specific evidence based treatments strategies for these documented deficits, a crap ton more than the throw bowl of spaghetti at the wall method and see what sticks.

“Recognition of the impaired physiologic component(s), in lieu of describing an “oral phase” or “pharyngeal phase” disorder, is essential for the application of the appropriate treatment strategies that effect improvement in the physiologic swallow component.”

In the quote above from Dr. Martin-Harris’s paper (2005), she describes 11 different physiological components, in the MBSImP which was published 3 years later, in 2008, she documents 17! In the SA Swallowing Services Advanced FEES course, they document 13 different components. Although that is not standardized, it at least gives us an idea that on our instrumental reports we CAN and SHOULD be documenting a heck of a lot more than 3 phases!

So I encourage the younger clinicians, or clinicians that are new to the medical side, or SLPs that have been practicing a long time but don’t perform instrumentals, and even the SLPs that do instrumentals but write craptastic reports to expand your horizons! Educate yourself on ALL of the different biomechanics of the swallow, because after you truly understand ALL of the various physiologies, then you can go and choose the proper evidence based treatment strategies for those deficits instead of running every Tom, Dick, and Harry through the same tongue wagging exercises hoping and praying that somehow it improves laryngeal vestibule closure.

But as I’ve said, and I’ll always say, you don’t know what you don’t know until you know you didn’t know it. So if you’re one of those that constantly refers to the swallow in 3 phases, please take some sort of instrumental course. Even if you have no access to FEES or VFSS yourself, seeing is believing and I guarantee it will help to train your brain to see the swallow in a little more detail than what our lab monkey or Groundhog Phil can show us.

So although Dr. Martin-Harris does break down the components in to 3 “domains,” the buck doesn’t stop there. The 3 domains include the 17 physiological components of the swallow that make up the MBSImP. Because I don’t believe in completely brain dumping on you, this will be just a little refresher that we will parlay in to the correlating treatment strategies (when I get around to that.)

So let’s talk about EACH physiological component of the MBSImP here and what it’s looking for, and the musculature and cranial nerve involvement. (We’re going with the MBSImP components #becausestandardized, it’s easily obtainable through Northern Speech Services, and most grad programs are requiring their students to complete it now (Hallelujah!!), so it’s basically the universal love language of physiological deficits of swallowing in relation to a VFSS. (Don’t think I’m leaving this earth until the FEESimp has been brought to life though ;)) HOWEVER, please do NOT take this and use it to score your VFSS exams “per the MBSImP”. You must take the course, and become an MBSImP certified clinician to learn the proper scoring protocol.

(If you’d like to see this version in a snazzy PDF chart sent right to your email, click the box at the top of the post to download the chart, you’re welcome.)

  1. Lip Closure – looking for any labial escape
    1. Muscle involvement: Orbiculoris Oris
    2. CN VII – Facial
  2. Tongue control during bolus hold – did they form a cohesive bolus or let any escape
    1. Muscle involvement: intrinsic tongue muscles, tensor veli palatini, and palatoglossus
    2. CNs V – trigeminal, X – vagus, XII – hypoglossus
  3. Bolus preparation/mastication – assessing chewing and mashing of bolus
    1. Muscle involvement: muscles of mastication, intrinsic tongue muscles
    2. CN V – trigeminal, VII – facial, XII – hypoglossal
  4. Bolus transport/lingual motion – speed and organization of tongue movement
    1. Muscle involvement: intrinsic tongue muscles
    2. CN XII – hypoglossal
  5. Oral Residue – able to clear it?
    1. Muscle involvement: intrinsic tongue muscles, buccinator
    2. CN XII – hypoglossal, CN VII – facial
  6. Initiation of pharyngeal swallow – location of bolus head when the swallow triggers
    1. Muscle involvement: Sensory only
    2. CN IX – glossopharyngeal and X – vagus
  7. Soft palate elevation – any bolus escape?
    1. Muscle involvement: levator veli palatini
    2. CN X – vagus
  8. Laryngeal elevation – assessing the movement of the hyoid cartilage with approximation of the arytenoid cartilages.
    1. Muscle involvement: longitudinal pharyngeal muscles, thyrohyoid
    2. CN IX – glossopharyngeal and X – vagus
  9. Anterior hyoid excursion – present or absent?
    1. Muscle involvement: geniohyoid
    2. Spinal nerve: C1
  10. Epiglottic Movement – yes or no?
    1. Muscle involvement: supra hyoids
    2. C1 and CN V – trigeminal
  11. Laryngeal vestibule closure – complete or incomplete?
    1. Muscle involvement: intrinsic laryngeal muscles, base of tongue muscles
    2. CN X – vagus, XII – hypoglossal
  12. Pharyngeal stripping wave – yay or nay?
    1. Muscle involvement: pharyngeal constrictors
    2. CN X – vagus
  13. Pharyngeal contraction (in A/P view) – unilateral or bilateral bulging?
    1. Muscle involvement: pharyngeal constrictors, longitudinal pharyngeal muscles
    2. CN IX – glossopharyngeal, X – vagus
  14. Pharyngoesophageal segment opening – any distention?
    1. Muscle involvement: cricopharyngeus
    2. CN X – vagus
  15. Tongue base retraction – any contrast between tongue base and pharyngeal wall?
    1. Muscle involvement: extrinsic tongue muscles
    2. CN X – vagus, XII – hypoglossal
  16. Pharyngeal residue – how much?
    1. Muscle involvement: cricopharyngeus, pharyngeal constrictors, base of tongue muscles
    2. CN X – vagus, XII – hypoglossal
  17. Esophageal clearance Upright Position – any retention?
    1. Muscle involvement: longitudinal and circular muscles of the esophagus
    2. CN X – vagus

Hopefully, now you will see that we are doing our profession AND our patients a GIGANTIC disservice when we just say, “They have an oral phase dysphagia,” and hand them a pre-made worksheet of tongue wagging and duck face exercises when we really should be doing our due diligence and getting to the root of the issue AKA an instrumental assessment! VERY rarely does a patient present with only an oral phase dysphagia, so hopefully you learned from this post, that the impairments are intertwined amongst the domains, your x-ray vision can’t decipher that, and they will require exercises that are form-specific to the function! (Don’t you worry, we’ll get in to all of that jargon in the next coming months, click the green box at the bottom to be updated on all of these treatment strategies posts!)

If all of this stuff sounds like total German, don’t fret. There’s plenty of great resources out there to help you right your ship. Check out the following courses:

Also, check out these books, for your viewing pleasure:

And of course, if you’d like to learn more about swallowing physiology via FEES, check out this page for all of the awesome basic FEES courses coming up for the rest of this year. Even if you don’t have access to endoscopy, it is still a great course to help you see what you’re treating!

If this entire post is completely greek to you, or if you would just like some additional support while trying to stay afloat on dysphagia island, please consider joining the MedSLP Newbies group on Facebook, listen to the Swallow Your Pride Podcast, or check out the all inclusive Medical SLP Solution. We provide brand new weekly resources in the form of handouts and videos, a panel of experts to answer ALL of your Medical SLP questions (anonymously, and not limited to dysphagia) and monthly webinars for ASHA CEUs.

Sign me up for these stellar blog post updates.

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Resources:
  • Allen, Jacqui & White, Cheryl & Leonard, Rebecca & C Belafsky, Peter. (2012). Comparison of Esophageal Screen Findings on Videofluoroscopy with Full Esophagram Results. Head & neck. 34. 264-9. 10.1002/hed.21727.
  • Logemann JA. Evaluation and treatment of swallowing disorders, 2nd ed. Austin, TX: Pro-ed, 1998.
  •  Martin-Harris, B., Brodsky, M.B., Michel, Y. et al. Dysphagia (2008) 23: 392
  • Martin-Harris, B., Michel, Y., & Castell, D. O. (2005). Physiologic model of oropharyngeal swallowing revisited. Otolaryngology – Head and Neck Surgery, 133(2), 234-240 
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