Byline: Ed Steger, President, National Foundation of Swallowing Disorders
[Picture at left shows the radiologist and image of the modified barium swallow (MBS) study. The MBS study shows a video documentation of the patient’s swallowing function while consuming 5 or 6 different textured substances including liquid, pudding, and a cracker.]
On April 15, 2013 I had the privilege of shadowing Denise Barringer, M.S., CCC-SLP, Manager of the Speech Language Pathology team at MD Anderson Cancer Center (MDACC) in Houston, while she conducted swallowing assessments and counseling of her patients. The Section of Speech Pathology and Audiology has an impressive team of 12 clinicians under the direction of Dr. Jan S. Lewin, Professor in the Department of Head and Neck Surgery, and Chief of the Section of Speech Pathology and Audiology.
The MD Anderson “Boot Camp” Swallowing Therapy Program was initiated about a year ago by Denise Barringer and Dr. Katherine A. Hutcheson, Assistant Professor in the Department of Head and Neck Surgery, Section of Speech Pathology and Audiology, as a way to jump start the swallowing process for patients who were having swallowing difficulties after their treatment or had plateaued (some after years) in their efforts to regain their swallowing function. Boot camp swallowing therapy is an aggressive program of swallowing treatment tailored to the individual and is generally conducted over a three week period. During this time, a patient will meet with a speech pathologist three times weekly for one hour each to learn and perform targeted exercises that have been found important based on their assessment. Individualized therapy may include traditional swallowing exercises, endoscopic monitoring, foods of various textures and viscosity, biofeedback, and coaching. They will also be provided specific exercises to perform on their days off. Although this is not a silver bullet for regaining one’s swallowing function, the before and after MBS videos I viewed showed dramatic improvement in the patient’s swallowing function. Highlights from this observation included being proactive, a multidimensional dysphagia assessment, therapies that were individually tailored to each patient’s swallowing problems, and the tight integration between the assessment process and the patient’s therapy. I’ll touch briefly on each of these areas.
Proactive – The more patients I meet, the better I understand the uniqueness of each individual’s swallowing challenges. Of the patients who had MBS exams during my visit, each one had a significantly different medical history. The patients were male and female ranging in age from their early 30s to late 70s. Patients were seen on an in- and outpatient basis. Patients had various types of cancers including recurrent brain cancer, nasal/upper lip cancer, a brain stem tumor, larynx cancer resulting in a laryngectomy, and esophageal cancer. MD Anderson’s proactive therapy approach was to conduct an MBS study prior to treatment. The proactive therapy approach starts early before the cancer treatment begins and provides an excellent baseline against which treatment impact and therapy progress can be objectively measured.
Multidimensional dysphagia assessment – Comprehensive dysphagia assessment at MDACC is the underpinning of individualized swallowing therapy. The assessment protocol includes: 1) clinical examination of the patient (your natural pattern of eating), 2) patient perception of swallowing ability (quality of life questionnaires), 3) functional ability inventories (what and with whom you eat), and 4) instrumental studies (to determine physiology and competency of the swallow based on flexible endoscopic examination of swallowing or videofluoroscopy [MBS]). Jointly, these tests describe one’s unique condition of dysphagia, and help speech pathologists construct an individualized plan for each patient.
Swallowing treatment – Depending on the results of the above assessments, treatment is tailored to each individual. This might involve oral exercises to enhance the compensatory ability of the parts of the anatomy which are working to improve swallowing (note, MDACC uses the free iSwallow iPhone app for many patients), postural changes that help compensate for parts of the anatomy that are not working properly, swallowing techniques, surface electromyography (sEMG) for biofeedback, and a variety of food textures and viscosities.
Integration with therapy – This part of the process really impressed me. Following each MBS exam, an appointment was set up with a speech pathologist to review the exam results with the patient to establish a course for further treatment. Many of these clinic visits were scheduled on the spot while the patient was still in the exam room and it was on the same day as the exam. From an outsider’s perspective, this seemed like a very thorough well thought out process. As noted earlier, this boot camp swallowing therapy was initiated a year ago and is continuing to evolve.
There are many fine medical institutions with swallowing programs throughout the US. This happened to be the first one I had the opportunity to observe from a clinician’s perspective. Thank you, Denise, for being such a wonderful host.
Miscellaneous
Stricture – A term used to identify a narrowing (e.g., in the esophagus) in one’s anatomy.
Aspiration – When liquid or food moves into the trachea (wind pipe) below one’s vocal cords. Not all aspiration results in aspiration pneumonia. Many factors contribute to aspiration pneumonia, one of which appears to be the activity level of the patient.
Late onset dysphagia – As more people are living longer who were diagnosed and treated for an oral cancers (the good news); there is a trend emerging in this population for dysphagia years after treatment has ended (the bad news).
Modified Barium Swallow (MBS) video – If you haven’t seen a MBS exam video and are curious as to what it looks like, click here to view my MBS video from July 2012. Although it looks like I’m sitting upright, I’m actually reclining at a significant angle. I do this as a compensation mechanism to allow gravity to do much of the work in moving food down my esophagus. “Gravity is my friend.”
(Note, to address any potential concerns about patient privacy, I have been certified in three HIPAA (and/or human privacy) courses over the past 18 months. No patient information was collected as part of this shadowing exercise. Each patient who was assessed during this process provided explicit permission to be observed during their exam.)