Standardizing Dysphagia Practice In Patient-Centered Care · – Hypertension – Arthritis •...

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Bonnie Martin-Harris, PhD, CCC-SLP, BRS-S, ASHA Fellow

Professor, Dept. of Otolaryngology-Head & Neck Surgery

Professor, Dept. of Health Sciences & Research

Director, Evelyn Trammell Institute for Voice & Swallowing

Director, PhD Program in Health & Rehabilitation Science

Clinical Scientist, Ralph H. Johnson VA Medical Center

[email protected]

Standardizing Dysphagia Practice

In Patient-Centered Care

• NIH/NIDCD K24, Research and Mentoring on Swallowing Impairment and Respiratory-Swallow

Coordination, 2013-2018

• NIH/NIDCD R01, Standardization of Swallowing Assessment in Bottle-fed Children, 2010-2015

• NIH/NICDC R21, Respiratory Phase Training in Head and Neck Cancer, 2009 ─ 2012

• VA RR&D, Respiratory Phase Training in Dysphagic Veterans with Oropharyngeal Cancer, 2010 ─

2013

• VA RR&D, SPiRE, 2013-2015

• NIH/NIDCD K23, Standardiza<on of Swallowing Assessment, 2003 ─ 2009

• NIH/NIDCD R03, Respiratory and Laryngeal Dynamics During Swallow, 2000 ─ 2003

• Mark and Evelyn Trammell Trust, 1993 ─ 2019

• Bracco Diagnos<cs, Inc., 2009 ─ 2012

• Northern Speech Services, 2010 ─ present

• Given, Imaging, 2013- present

Support and Disclosures

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Standardized Assessment &

Essential for Translation

Guided Intervention

Swallowing Specialist

“A clinician who specializes in the neural control, function, impairment and restoration of the swallowing mechanism in dysphagic patients.”

~ Bonnie Martin-Harris, PhD

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• EVIDENCE, rather than opinion, should guide clinical

decision-making

• BROADER RANGE OF PATIENT OUTCOMES needs to be

measured in order to understand the true benefits and

risks of health care interventions

• RESEARCH PRIORITIES should be guided in part by public

HEALTH NEEDS

WHY Standardized Measurement?

WHAT Should Be Standardized?

• The INSTRUMENT – Contents and format

• DATA COLLECTION Protocol – Approach and method

• ANALYSES – Minimize variation in scoring and interpretation

• REPORTING – Well-tested approaches to presenting results

TRANSLATING RESEARCH INTO PRACTICE (TRIP)-II.

FACT SHEET, AHRQ PUBLICATION No. 01-P017.

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Modified Barium Swallow Study

Brief History

• Martin Donner

– 1965 used cine fluoroscopy for

diagnosis of neurologic dysphagia

• Jeri Logemann

– 1970’s MBSS for assessment of patients

with head and neck cancer.

Videofluoroscopic Imaging

Identify and distinguish :

• Type and severity of

impairment

• Sensorimotor function

• Cause of airway invasion

• Physiologic targets for treatment


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GOALS:

• Valid

• Reliable

• Physiologic vs. symptom based

• Clinically practical

• Linked to clinical action

– Targeted therapy


STANDARDIZEDMBS Measurement Tool

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Physiologic Components of Swallowing

1. Lip Closure

2. Tongue Control

3. Bolus Preparation/Mastication

4. Bolus Transport/Lingual Motion

5. Oral Residue

6. Initiation of Pharyngeal Response

7. Soft Palate Elevation

8. Laryngeal Elevation

9. Anterior Hyoid Excursion

10. Epiglottic Movement

11. Laryngeal Vestibular Closure

12. Pharyngeal Stripping Wave

13. Pharyngeal Contraction

1. Pharyngoesophageal Segment

Opening

2. Tongue Base Retraction

3. Pharyngeal Residue

4. Esophageal Clearance

Functional Targets

MBSImP™©: Standardized Protocol

ORALORAL PHARYNGEALPHARYNGEAL ESOPHAGEALESOPHAGEAL

© 2008 & © 2011 Medical University of South Carolina

Targeted Treatment of thePhysiologic Mechanism

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BiofeedbackIsometric/Isotonic

VoiceSwallowing

Sensation

• Tactile

• Auditory

• Visual

Targeted InterventionMulti-modality Dysphagia Treatment

What type of intervention is necessary?

– Compensation

• Postural techniques

• Sensory techniques

• Bolus modification

• Intraoral Prosthetics

Treatment Planning

- Exercise

• Direct

• Indirect

• Isotonic

• Isometric

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• Use it or loose it

• Use it and improve it

• Plasticity is experience specific

• Repetition matters

• Intensity matters

• Time matters

• Salience matters

• Specificity matters

• Age matters

• Compensation

• Restitution

• Self-regulation

Principles of Activity-dependent Neuroplasticity (Cortical Reorganization)

Training Paradigms

Case Study

• History of Present Illness:

– 54 year old male

– T4 N0 Mx SCCa right floor of mouth/oral tongue

– Status post right floor of mouth resection, right glossectomy, bilateral neck dissection, tracheostomy, PEG

• Past Medical History:

– Hypertension

– Arthritis

• Past Surgical History:

– Tonsillectomy

– L5 fusion

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Pre-Treatment MBS

Pre-Treatment MBSImP Scores

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PAS Scores

• Thin – 8: material enters airway, passes the vocal

folds, no effort to eject

– Occurred after the swallow only; 2° pharyngeal residue

• Nectar – 2: material enters airway, remains above the

vocal folds, ejected from airway

• Honey – 2: material enters airway, remains above the


0 = Cohesive bolus between tongue to palatal seal

1 = Escape to lateral buccal cavity and/or floor of mouth

3 = Posterior escape of greater than half of bolus

Targeted InterventionComponent 2: Bolus Hold

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• Compensation

- Modify bolus volume

- Modify bolus texture

• Sensory

- Stereognosis

• Motor

- Tongue to palatal seal

(anterior, lateral, posterior)


Tongue Exercise

• Improved tongue strength in healthy young and old (isometric

tongue strengthening exercises – resistance exercise)

- Lazarus et al., 2003; Hind & Robbins, 2004; Robbins et al., 2005 & 2008

• And in patients with CVA – improved maximum

isometric tongue pressures, maximum swallow

pressures, PA Scale

- Kays et al., 2004


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SwallowSTRONG

• Facilitates increased pressures generated by tongue and other

oropharyngeal musculature through progressive resistance isometric

exercise

- Measures pressure generation

- 4 sensor custom fit mouthpiece

- Auto calculates exercise targets

- Provides knowledge of results to user

- Transfers from non-swallowing practice to swallowing behavior

• U.S. patent # 6702765 FDA Registered

• http://www.swallowsolutions.com/Swallow_Solu

tions_LLC/Home.html


EXERCISE

• Resistive tongue exercise– SwallowSTRONG© device

COMPENSATION


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0 = Timely and efficient chewing and mashing

1 = Slow prolonged chewing/mashing with complete re-collection

2 = Disorganized chewing/mashing with solid pieces of bolus unchewed

3 = Minimal chewing/mashing with majority of bolus unchewed

Targeted InterventionComponent 3: Bolus Prep

• Compensation



- Optimize intra-oral placement

• Sensory

- Stereognosis

• Motor

- Tongue strengthening (resistive) exercise

- Tongue flexibility (range of motion) exercise

- Mandibular strengthening (resistive) exercise

- Mandibular flexibility (range of motion) exercise

Targeted InterventionComponent 3: Bolus Prep

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EXERCISE


• ROM exercise

COMPENSATION

Treatment PlanningComponent 3: Bolus Prep

0 = Brisk tongue motion

1 = Delayed initiation of tongue motion

2 = Slowed tongue motion

3 = Repetitive/disorganized tongue motion

Targeted InterventionComponent 4: Bolus Transport

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• Compensation

• Modify bolus volume

• Modify bolus texture

• Optimize intra-oral placement

• Sensory

• Stereognosis

• Motor

• Tongue strengthening (resistive) exercise

• Tongue flexibility (range of motion) exercise

• Suck-swallow and squeeze

Targeted InterventionComponent 4: Bolus Transport

EXERCISE


• ROM exercise

• Suck-swallow exercise

COMPENSATION

• Syringe

• Suck-swallow maneuver

Treatment PlanningComponent 4: Bolus Transport

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0 = Complete oral clearance

1 = Trace residue lining oral structures

2 = Residue collection on oral structures

4 = Minimal to no clearance

Targeted InterventionComponent 5: Oral Residue

• Compensation



• Optimize intra-oral placement

• Sensory

• Stereognosis

• Motor


• Tongue flexibility (range of motion) exercise

• Suck-swallow and squeeze

Targeted InterventionComponent 5: Oral Residue

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EXERCISE


• ROM exercise


COMPENSATION

• Syringe


Treatment PlanningComponent 5: Oral Residue

0 = Bolus head at posterior angle of ramus

1 = Bolus head in valleculae

2 = Bolus head at posterior laryngeal surface of epiglottis

4 = No visible initiation at any location

Targeted InterventionComponent 6: Initiation

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• Compensation



• Postural adjustment (chin tuck)

• Sensory

• Bolus Hold: Tongue to palatal seal (anterior, lateral,

posterior)

• Oropharyngeal stimulation followed by productive

tongue movement

• Taste manipulation

• Motor


• Tongue flexibility (range of motion)


Chin Tuck

• Delayed initiation of the

pharyngeal swallow

• Widens valleculae (timing)

• Improves vestibular closure

• Brings pharyngeal wall closer

to tongue base


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Motor

• Pharyngeal shortening - falsetto


EXERCISE


• ROM exercise


• Falsetto extensions

COMPENSATION

• Syringe


• Chin tuck

Treatment PlanningComponent 6: Initiation

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0 = Complete anterior movement

1 = Partial anterior movement

Targeted InterventionComponent 9: Anterior Hyoid Excursion

• Sensory

- Visual feedback

• Motor

- Suprahyoid strengthening and range of motion

- Sustained hyolaryngeal movement at the height of the swallow (Mendelsohn maneuver)

- Shaker exercise (contraindicated – trach)

- Expiratory Muscle Strength Training (EMST)


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– Feedback of electrical activity from muscle groups is immediate

– Duration of of laryngeal elevation (Mendelsohn Maneuver)

– Amount of electrical activity in submandibular muscles (Effortful Swallow)

Mendelsohn Maneuver Effortful SwallowSteele et al., 2012

Surface Electromyography (sEMG) Biofeedback

Suprahyoid Musculature


Mendelsohn maneuver

• Reduced hyolaryngeal motion

• Facilitates and sustains

laryngeal closure and PES

opening (Cook et al., 1989;

Jacob et al., 1989)

• Facilitates and sustains

contraction of oropharyngeal

muscles

Kahrilas, Logemann, Krugler & Flanagan, 1991


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Kahrilas, Logemann, Krugler, & Flanagan, 1991

Mendelsohn Maneuver: Sustained Hyolaryngeal Excursion


EXERCISE


• ROM exercise



• Mendelsohn maneuver– sEMG

COMPENSATION

• Syringe


• Chin tuck

Treatment PlanningComponent 9: Anterior Hyoid Excursion

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0 = Complete inversion

1 = Partial inversion

Targeted InterventionComponent 10: Epiglottic Inversion

• Compensation

- Effortful Swallow

• Sensory

- Viscous Bolus

• Motor

– Pharyngeal contraction exercise (swallow and squeeze)

– Tongue base retraction


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Increased Bolus Viscosity has a positive effect (lower score)

on key swallowing components

Epiglottic Movement Scores

Pudding

Th

in

0 1 2

0 43 0 0

1 16 14 1

2 9 13 23

p < 0.001

Worse scores on thin

Blair J, Armeson K, Hill, E., Martin-Harris B

• tongue base retraction

• pharyngeal contraction/stripping

• Effort increasea posterior tongue

base and pharyngeal movement

(Pouderour & Kahrilas, 1995)

Effortful swallow (swallow and squeeze)


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EXERCISE


• ROM exercise




• Therapeutic viscous bolus trials

• Effortful swallow– sEMG

COMPENSATION

• Syringe


• Chin tuck

• Effortful swallow

Treatment PlanningComponent 10: Epiglottic Inversion

0 = Complete distension and duration; no obstruction of flow

1 = Partial distension/partial duration; partial obstruction of flow

2 = Minimal distension/minimal duration; marked obstruction of flow

Targeted InterventionComponent 14: PES Opening

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• Compensation



- Postural techniques (head turn, chin tuck)

- Employ maneuver (Mendelsohn)

• Motor

- Suprahyoid strengthening and flexibility

(range of motion)

- Sustained hyolaryngeal movement at the

height of the swallow

- Pharyngeal contraction exercise (swallow

and squeeze)

- Shaker exercise


Targeted Intervention

Increased Bolus Viscosity has a positive effect (lower score)

on key swallowing components Blair J, Armeson K, Hill, E., Martin-Harris B

Pharyngeal Stripping Wave Scores

Pudding

Th

in

0 1 2

0 53 0 0

1 16 34 1

2 1 4 10

p < 0.001

Worse scores on thin

Component 14: PES Opening

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Chin tuck + Head turn

• Delayed initiation of the pharyngeal

swallow

• Unilateral pharyngeal bulging/paresis

• Decreased PES opening

• Unilateral laryngeal dysfunction

• Extrinsic pressure to thyroid

cartilage, increases adduction


• Shaker exercise

- Improved hyolaryngeal excursion and UES/PES opening

- Healthy normal subjects and patients with chronic dysphagia

- Contraindicated in individuals with tracheostomy

Suprahyoid Muscles & UES/PES Opening

Shaker et al., 1997 & 2002


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EXERCISE


• ROM exercise






COMPENSATION

• Syringe


• Chin tuck


• Mendelsohn maneuver

• Head Turn

Treatment PlanningComponent 14: PES Opening

0 = No bolus between TB and PPW (Posterior Pharyngeal Wall)

1 = Trace column of contrast or air between TB and PPW

2 = Narrow column of contrast or air between TB and PPW

4 = No appreciable posterior motion of TB

Targeted InterventionComponent 15: Tongue Base Retraction

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• Compensation



• Posture (chin tuck)

• Motor

• Tongue hold (Masako maneuver)

• Pharyngeal contraction

exercise (Effortful swallow)


• Anchoring the anterior tongue

causes the glossopharyngeal portion

of the superior constrictor muscle to

use more force in contracting.

• Decreases space between base of

tongue and posterior pharyngeal

wall to aid in efficiency of bolus

transport in pharynx.

Masako maneuver


swallowingdisorderfoundation.com

Logemann & Fujiu, 1996

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EXERCISE


• ROM exercise






• Masako maneuver

COMPENSATION

• Syringe


• Chin tuck



• Head Turn

Treatment PlanningComponent 15: Tongue Base Retraction

0 = Complete pharyngeal clearance

1 = Trace residue within or on pharyngeal structures

2 = Collection of residue within or on pharyngeal structures

3 = Majority of contrast within or on pharyngeal structures

Targeted InterventionComponent 16: Pharyngeal Residue

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• Dependent on physiologic cause (pharyngeal contraction (Components

12/13), tongue base retraction (Component 15), PES opening (Component

14))

• Compensation



- Alter position

- Liquid wash

- Double/multiple Swallows


Reclined Position

• Inefficient oral transit

• Decreased pharyngeal clearance

• Utilizes gravity to clear oral cavity

• Redirects bolus away from

laryngeal vestibule

• Maintains retention in pharyngeal

recesses


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EXERCISE


• ROM exercise






• Masako maneuver

COMPENSATION

• Syringe


• Chin tuck



• Head turn

• Reclined position

• Liquid wash

• Double swallow

Treatment PlanningComponent 16: Pharyngeal Residue

Tailored Therapy

EXERCISE


• ROM exercise






• Masako maneuver

COMPENSATION

• Syringe


• Chin tuck

• Head turn

• Reclined position



• Double swallow

• Liquid wash

DIET• PEG

• Supplemental nectar thick liquids

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• 10 weeks of structured therapy:

– 2 weeks at 3x/week as IP• Sessions lasted 30-45 minutes

• 15 repetitions of each exercise were performed

• Goal: 5 reps/min

– 8 weeks at 1x/week as OP• 1 hour

• 25 reps each

• 5 reps/min

– Independent home exercise• Adherence: 3x daily performance of all exercises

• 10 reps each

• 5 reps/min

Treatment Course

Post-Treatment MBS

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Post-Treatment MBSImP Scores

PAS Scores

• Thin – 2: material enters airway, remains above the


• Nectar – 1: material does not enter airway

• Honey – 1: material does not enter airway

• Pudding – 1: material does not enter airway

• Solid – 1: material does not enter airway

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Additional Tailored Therapy

EXERCISE


• ROM exercise




• Masako maneuver

• Shaker

COMPENSATION

• Suck-swallow


• Double swallow

• Liquid wash

DIET

• DC PEG

• Thin liquids

• Mechanical soft

SCHEDULE

• Continue structured tx 1x/week for 4 weeks – focus on oral components

• Continue independent exercise at 2x/day, 10 reps/exercise, 5 reps/min

Standardized Reporting

• Improved financial performance

• Improved quality of care

• Reduced malpractice risk

• Compliance with HIPAA, other government

regulations

• Improved job satisfaction for providers and staff

TRANSLATING RESEARCH INTO PRACTICE (TRIP)-II.

FACT SHEET, AHRQ PUBLICATION No. 01-P017.

Electronic Medical Record

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Database and Dysphagia Registry

• Database - medical, demographic, MBSImP™© scores, treatment, outcome data (de-identified)

MBSImP™© Clinical Report

The Interface Allows the Registered Clinician to…

• enter patient medical histories, MBSImP™© study scores, and

related information in a manner that is efficient and HIPAA

compliant

• quickly produce a clinical report of each MBSImP™© study

• track the status of his/her patients over time

• evaluate the success of patient management and treatment

strategies

• optimize patient care through practices consistent with evidence-

based medicine

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History & Subjective Information

• Demographics

• Primary diagnosis

• Comorbidities

• Morbidities

• Medical history

• Surgical history

• Medical treatments

• Medications

• Allergies

• Social History

MBSImP™© Clinical Report

• Intake/diet status

• FOIS score

• Pain assessment

• Patient reported outcomes

History & Subjective InformationMBSImP™© Clinical Report

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History & Subjective InformationMBSImP™© Clinical Report

• Patient Positioning

• VFSS Viewing Planes

• Consistencies & Volumes

• MBSImP Scores Narrative

Study Details & ScoresMBSImP™© Clinical Report

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• Clinical findings

• Measurement of function

• Standardized scoring

• Outcome Tracking



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Clinical Assessment & Plan of CareMBSImP™© Clinical Report

Clinical Assessment & Plan of CareMBSImP™© Clinical Report

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• Specific • Achievable • Timely

• Measurable • Realistic

Prognosis & GoalsMBSImP™© Clinical Report

Prognosis & GoalsMBSImP™© Clinical Report

Standardizing Dysphagia Practice In Patient-Centered Care · – Hypertension – Arthritis •...

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