Sunday, December 03, 2006

Are all these videos really necessary?

I have been pondering recently the increasing reliance on instrumental assessment (especially videofluoroscopic swallowing studies/modified barium swallows) in dysphagia evaluations. I get phone calls every so often from SLP’s in long-term care/skilled nursing facilities incensed that I did not do a VFSS on their patients. Never mind that I always have a reason for not performing a video -- most commonly because either (a) the patient was not appropriate (remember, I work in acute care; I like to wait until the patient is reasonably stable to do a video, otherwise the patient may change so rapidly after the video is done that the results no longer reflect the patient’s current swallowing status. Unfortunately, by the time the patient is stable, he is often on his way out the door already!) or (b) results of the video would not change management (e.g., a 92-year-old with dementia who has occasional throat clearing with thin liquids and no history of pneumonia). To some of these SLP’s, the fact that a pharyngeal phase dysphagia was suspected or signs of aspiration were observed but a video was not done is automatic proof of incompetence, laziness, negligence, or all three -- an attitude which tends to drive me up the wall (go figure!).

What are the reasons behind the heavy reliance on VFSS or other instrumental assessments? They are numerous and interrelated. The ones I’ve come up with so far:
(1) Lack of training or experience in thorough clinical assessment;
(2) Characterization of clinical dysphagia assessment as “subjective” -- and therefore falliable and unreliable -- while instrumental assessment is “objective”;
(3) Viewing clinical dysphagia assessment as merely a “screening” procedure;
(4) Fear of litigation;
(5) Overemphasis on prevention of prandial aspiration (aspiration occurring during meals);
(6) Belief that “silent aspiration” is common and frequently harmful;
(7) Belief that VFSS reflects what happens during a meal; and
(8) Belief that only instrumental assessment can yield information about the physiology of the pharyngeal swallow.

I would like to talk about each of these in more detail, but for now let’s focus on the last one -- the belief that instrumental assessment is required to gain any reliable information about the physiology of a patient’s swallow.

This is a pervasive belief, espoused by some of the most influential people in the profession, as in the following pronouncement:

“…the physiology of the pharyngeal swallow is not observable at the bedside, and the reason for any aspiration cannot be defined.” Logemann, J. After the Clinical Bedside Swallowing Examination: What Next? American Journal of Speech-Language Pathology 1991; 1: 13-20.

One book (The Source for Dysphagia by Nancy Swigert) gives the example that a dysphagic patient could have poor airway closure, causing aspiration during the swallow; poor tongue base movement and premature posterior spillage, causing aspiration before the swallow; or poor hyolaryngeal movement, causing pharyngeal residue and aspiration after the swallow, and asserts that it is impossible to tell which of these scenarios is occurring (and therefore plan appropriate treatment) without an instrumental assessment.

I don’t buy this. I’m not sure where we speech pathologists got the notion that the pharyngeal swallow is some mysterious process, revealing its secrets only to high-tech instrumental assessment (primarily VFSS/MBS). I can’t even remember the last time I saw something on VFSS that surprised me, based on the findings from my clinical evaluation. Are there times when instrumental assessment is important and necessary? Absolutely. Does it provide helpful information? Sure. Is it essential? I would say, not usually.

In the example above, I would argue that in most cases, we can know which physiological abnormalities are occurring based on clinical examination alone. A patient with poor airway closure will exhibit abnormalities in voicing -- e.g., hoarseness, breathiness, difficulty changing pitch. Patients with poor oral control will show oral (especially lingual) weakness and/or discoordination. And hyolaryngeal movement can be judged by palpation. Combine these observations and the rest of the physical examination with knowledge of the patient’s medical history, the nature of the swallowing complaint, and observations of the patient with food and liquid trials, and an experienced SLP (or other swallowing specialist) is in a good position to determine clinically what is occurring pharyngeally.


Blogger prasanna said...

Hey Keen,
I totally accept with you.I have been working in SNF and I found the reasons were correct. Its a nice blog and very informative. Thank you for the info...

7:52 PM  
Anonymous said...

I currently work in Assisted Living facilities and (in our state, SC) these are considered RESIDENTIAL not MEDICAL facilities. As such, they do not employ dieticians, do not have any medical personnel except a nurse (RN, but sometimes only LPN) and their food service depts cannot provide altered diets. If pts. need thickened liquids, they must self-manage with some assistance by "caregivers" (med-techs), who I've seen incorrectly preparing drinks mixed with Thick-it or other thickening agents.

I frequently recommend modifies because our facility faces liability if the residents in their care become sick because the appropriate medical tx was necessary and wasn't available. I also don't want to miss anything and certainly don't want to recommend a restrictive diet that would require the resident to move to a SNF unnecessarily.

I have seen clinical exams that I thought were SURELY aspiration, that were proved safe/functional on MBSS, and vice-versa. It's not often, but it happens.

Our primary population is in cognitive decline; they're unreliable historians, often leaving out important information about their swallowing abilities for fear of being sent to the hospital or to a SNF.

In acute care, we had access to more information (labs, X-rays, MD's H&P, extensive medical hx and daily vitals). I had more information at my disposal to arrive at a diagnosis and to recommend the appropriate diet/tx and subsequently, requested fewer MBS studies.

I know there are some SLPs who might recommend these studies inappropriately, because of inexperience or other factors, but I hope it's not as pervasive as you suggest.

Denise Rogers, MA CCC-SLP
Greenville, SC

4:31 PM  
Anonymous Anonymous said...

I'm in full agreement. A year ago I took over the SLP at a rehab dept. in an acute care facility. My predecessor was conducting a minimum of 12 MBSs per mo. in a county which is one of the poorest in the USA. Her training included 1 workshop and a video with no OTJ training.

I came to the facility and have have to undo some very poor info regarding MBSs and what it can do, had to put out several memos that a clinical assessment must be done first and thereafter I would decide whether an MBS was apropos or not. Currently, we do less than 1 per month.

A good clinician with some practical experience and a good working knowledge of the normal function of the swallowing should not only be able to generate a broad albeit functional-for-treatment dx. but should also be able to differentiate between oro- pharyngo- and esophago- dysphagias.

The over reliance on VFSS/ MBS, IMO, is the result of poor education, poor experience, and a complete lack of regard for a patient's wallet.

90% of my predecessor's results were negative; information which can be had with low-tech tongue blades, stethascopes, flashlight and a keen eye coupled with intelligent interpretation. My questions to myself before an MBS is always 1) "Is this necessary?" and 2)"Can I accurately reproduce the problem in front of the fluoroscope?" An answer of "no" to either question cancels the test.

Just some thoughts,
bil linzie, MS, CCC-SLP

10:12 AM  
Anonymous Anonymous said...

I also agree. Using the information from the clinical exam along with a firm foundation in neuroanatomy and physiology there is no reason why you can't successfully 'problem solve' your way into the pharynx.

10:38 PM  
Anonymous Anonymous said...

I rely heavily on my clinical skills and never perform a video without a bedside assessment first. However, there is a lot of research out there that shows really poor inter and intra-rater reliability in interpretation of clinical findings. I 100% agree that there are many situations in which a video will not provide additional information but the facts are, the clinical assessment IS subjective, silent aspiration IS common and often harmful, and instrumental studies ARE the only way to know exactly what is causing the dysphagia. Too many therapists overestimate their own clinical abilities. I would suggest that it is not the inexperienced SLPs we need to worry about, but the SLPs who are convinced that their experiences have given them x-ray eyes.

12:37 PM  
Anonymous Alisha said...

SLP. I am curious does one have to have an MBS in order to target laryngeal exercises per say. I was under the impression you could not initiate that based on a bedside. I have several patients who are on my caseload who have goals for tongue base retraction and laryngeal elevation, who have never had n MBS. Would love your feedback.

6:17 PM  

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