Don't be a sip, sip, DONE kind of SLP... A Compensatory Strategy Review for Swallowing Disorders.

Compensatory Strategy Review

I know I promised to write up my review of CTDM this weekend, but something a little more "critical" occured this week that I thought l should perhaps address. Just in case you're not privy to the poor state of affairs in dysphagia education in years past, we literally have some SLPs relying solely on Facebook University to get them through the work day. You may have been blessed with an amaaaazing dysphagia professor that made you build a larynx from scratch and print it with a 3D printer, or maybe you were stuck with the most craptastic lecturer that could lull a squirrel to sleep, or you were one of those that just knew you were going to work in the schools so you didn't really pay attention at all, but recently saw a PRN rate for $90/hr and now all of a sudden you're all like "OMG sign me up and tell me everything I need to know." 

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So you take your baller PRN job, and Tom, Dick, and Harry that work in administration believe that since you have an SLP license you have plenty of experience doing MBSS. You're trying to impress everyone because they're giving you their first born to work there, and you're trying to pretend that you're totally confident in your skills, and really "how hard can it be? Those C-arms are all over Instagram!"

So I was at a facility earlier this week and I saw in the chart that the patient just had a flouro in the hospital. Hey SLP? Yes? Gertrude just had an MBSS a week ago, why am I even here? Look at the report. Oooooooh. It was one of those took one sip of thin, she aspirated, I got scared and peed my pants, test is done, get this lady a PEG, and send her back to the nursing home with the shittiest report of life that isn't even worth the paper it's written on. 

After attending CTDM last weekend, reading Dr. Ianessa Humbert's article in the ASHA Leader this week, and listening to the latest "Down the Hatch" podcast (That's a whole lotta Ianessa all up in my head for one week!), we decided to call the SLP at the hospital to see what she was thinking. She admitted she wasn't.  The SNF SLP was extremely syrupy sweet and kindly asked the hospital SLP why she didn't trial more consistencies, or throw in a chin down posture, or perhaps well anything! The hospital SLP replied with a major truth bomb... "I don't know." "I didn't realize they would ask me to do these, the other SLP is out on maternity leave, and I don't even know where to start with the compensatory strategies."

Unfortunately, we hear this all. too. often. I figured if this person is out there doing this, then chances are we have others out there doing it (or not doing it) as well, (since it seemed to be a common theme in Dr. Humbert's ASHA Leader article). I do not mean to rag on people doing MBSS, as I know plenty of people out there doing FEES with a wing and a prayer as well, but bottom line is... patients, insurance, and facilities are paying GOOD money for these tests. We deserve to give them an instrumental assessment that is worth something. We have some excellent clinicians out there fighting the good fight for access to instrumentals and it only takes a few bad apples without proper training to ruin it for the good guys.

Another point I would like to add is that we are in the days where the MBSS or FEES report travels with the patient for-ev-errrrrrr... its like we've completely forgotten that a person's health is not static and is subject to change! I know we've all heard an MD say, "They had a swallow study 2 years ago, he doesn't need another." I've seen a bajillion SNF residents that were put on nectar thick liquids ions ago, but never were re-assessed since their acute care stay, their functioning is much improved, and they were able to be upgraded back to thin upon re-assessment. I always think to myself, "How long has this poor dude been miserable on nectar thick with the CNAs and dietary staff barking at him that he'll aspirate and die unless he drinks his thickened liquids?" I'm sure I don't want to know the answer.

So why do we ALWAYS seem go to the thickened liquids first? When have we gotten away from trialing compensatory strategies FIRST instead of going right to the thickened? The incredible Jeri Logemann (1993) suggested that we should trial a postural technique FIRST, and changes to the diet LAST. Trialing compensatory strategies does require the evaluating clinician to think critically and quickly, but wouldn't you rather try this first than significantly change your patients's diet? Did you know that Rasley and colleagues (1993) found that 77% of patients benefited from postural changes, and aspiration was ELIMINATED in 25% of these patients? For real, step away from the thickener as your first choice, my friends.

I also will add that it is important to trial various consistencies with AND without the compensatory strategies IF you suspect any type of cognitive deficit. Some SLPs get so crazy with chin down, head rotation to the left, stand on the right leg, when really Gertrude can't even remember what she had for breakfast this morning, let alone carry out 5 strategies per bite. I love the concept of mobile FEES and mobile MBSS because we're able to ask the treating SLP if the patient can independently perform the strategy for every single bolus. (This is very important to remember if you are seeing the patient at the hospital and sending them back to a SNF). Your report is WORTHLESS to the facility if the information can not be implemented. 

Conversely, if you're the one sending your patient for these sub-par studies, help to educate your colleague! There is nothing wrong with calling ahead of time and saying "Hey, I noticed in Gertrude's medical history that she has a paralyzed L vocal fold, I was thinking maybe a head rotation to the left may do her some good!" And hospital SLP may say "duh of course," but I'm sure she'll at least consider it! As the quote above says, "You don't know what you don't know until you know you don't know it," and if SLP #2 has no idea she's making your life hell, she won't know what she needs to improve upon! 

I encourage you all to review the strategies below, and get comfortable thinking on your feet with these. If this is all new to you, or you're feeling extra ballsy and want to send them to your colleague, please click the green box at the top and print out the "cheat sheet" to carry with you. 

So now we’re going to play a little game called, “If I see this (fluoroscopically, OR endoscopically), perhaps we should TRY this…”  (Newsflash! These are not one-size-fits-all, the anatomy, alignment, and swallow trigger in my turkey neck is a heck of a lot different than Gertrude's.) 

When you see: Poor bolus control, poor oral transport
You can try: Head tilt back to 60 degrees
Why? This allows gravity to slow down the bolus for oral transport to the pharynx. Ideal for oral cavity anatomical differences, post-op CA with intact swallow response. 

When you see: Poor oral containment
You can try: Chin down posture
Why? This keeps the bolus in the anterior oral cavity which helps to prevent premature spillage.

When you see: Poor tongue base retraction
You can try: Chin tuck or chin down posture
Why? This helps to reduce the distance between the tongue base and posterior pharyngeal wall.

When you see: Delayed swallow
You can try: Chin down posture
Why? This widens the valleculae to accommodate the bolus prior to the initiation of the swallow.

When you see: Vallecular residue
You can try: Chin tuck and/or effortful swallow  
Why? This helps to narrow the vallecular space and pharynx.

When you see: Unilateral pharyngeal paresis
You can try: Head rotation to the weak side, OR head tilt to the strong side
Why? The bolus is channeled down the stronger side using gravity, and by closing off the weaker side pyriform sinuses when using a head tilt.

When you see: Unilateral vocal fold paresis
You can try: Head rotation to the weak side
Why? Head rotation increases vocal fold closure through external pressure on the thyroid cartilage.

When you see: Pyriform sinus residue
You can try: Head rotation to the weak side
Why? This helps to increase UES opening and duration, and reduce UES resting pressure. This can decrease pyriform sinus stasis after the swallow.

When you see: Poor airway protection
You can try: Chin down posture OR breath hold and/or effortful swallow
Why? This can help flex the epiglottis into a more protective position and also narrow the laryngeal vestibule. The breath hold helps to increase medialization of the vocal folds. 

(Side note: Click that green box at the top to print out a PDF of these strategies in a pocket-sized chart that you can carry with you when you do your instrumentals… just remember... your patients deserve better than a sip, sip, DONE!

 

Resources:
Corbin-Lewis, K, Liss, J. M., & Sciortino, K. L., 2005, Clinical Anatomy & Physiology of the Swallow Mechanism, Thomson Delmar Learning, Clifton Park, NY

Logemann, J. A. (1993). The dysphagia diagnostic procedure as a treatment efficacy trial. Clinics in Communication Disorders, 3(4), 1-10.

Rasley, A., Logemann, J. A., Kahrilas, P. J., Rademaker, A. W., Pauloski, B. R. & Dodds, W. J. (1993). Prevention of barium aspiration during videofluoroscopic studies: Value of change in posture. American Journal of Roentology, 160, 1005-1009.

                            

Theresa Richard