Good Evaluations Guide Treatment (Part 2): The Clinical Examination and Scope of Practice

This is Part 2 of a two-part series focusing on the clinical examination process. Part 1 — Good Evaluations Guide Treatment: What Are We Doing Wrong? — shared a practical clinical example (see the case below) and addressed the process of gathering the right information to formulate an accurate diagnosis.

An 85-year-old woman walks into an outpatient swallowing clinic to get help for her difficulty swallowing. She comes out with a folder full of dietary suggestions, swallow strategies, tongue exercises, and swallowing exercises.

She faithfully performs her exercise drills every morning and evening, laughing at herself making faces in the mirror. She tries to hold her tongue out while she effortfully swallows saliva (Masako Tongue-Hold), but this is hard because her mouth is so dry. She wonders how these exercises are going to help her swallow better.

During meals, she tucks her chin and effortfully swallows two times after every bite of food. However, she still is bothered by that lump-in-the-throat sensation and the feeling of food being stuck. Liquid comes back up when she tries to wash foods down, and she can only eat a small amount before the food feels like it is coming back up into her throat. Most concerning to her, she is still losing weight. She wonders: “What am I doing wrong?”

In Part 1 we asked, “What are WE doing wrong?” Let’s continue the discussion.

In this article:

• The Art of the Clinical Examination
• Performing an Instrumental Exam
• Making Appropriate Referrals
• Our Broad Scope of Practice

The Art of the Clinical Examination

Gastroenterologist and the 2014-2015 president of the Dysphagia Research Society, Dr. Kulwinder Dua, MD shared the following thoughts at the 2015 DRS Post-Graduate Course on Integrating the Art and Science of Swallowing with Technology:

• “If technology fails you, will you be lost?”
• Will you still have “good history taking and keen observation?”
• “Are we driving technology, or is it driving us?”
• He added this quote by Sir William Osler, “The practice of medicine is an art, based on science.”

A thorough clinical examination can help us begin to establish a hypothesis and point the instrumental examinations in the right direction. The SLP who specializes in swallowing is a transdisciplinary deglutologist. In this healthcare climate, we need to be a traffic cop that helps direct the dysphagia work-up in the most cost-effective and efficient way possible.

Gathering Information During the Bedside Swallow Evaluation

The SLP may be the only clinician who spends more than 5-10 minutes evaluating a patient’s eating and swallowing. The bedside swallow evaluation is not a screen. Per Giselle Carnaby, MPH, PhD, FASHA at the 2016 Dysphagia Research Society’s Post-Graduate Course: “by definition, a screen is used to recognize a problem in a non-referred population, whereas your patient was referred to you by the team already.” Your assessment is longer and more than an observational checklist. It is a valuable billable service where you gather crucial information via:

• Detailed review of the medical record
• Thorough interview of the patient, medical team, nurses, family, and other caregivers
• Evaluation of the patient’s cognitive-linguistic, oral sensory-motor, speech, voice and 
swallowing status, with keen observation of the patient eating and swallowing
• Comparison of the patient’s current status to his/her baseline cognitive-linguistic and 
swallowing functioning
• Initiation of the rapport-building, education, and counseling
• Knowledge of the limitations of a clinical examination, as we do not have x-ray vision. Communication of the limitations can help support our recommendations for further instrumental testing. (Note: Per Dr Stephen Leder, PhD, CCC-SLP, we know that our clinical examination cannot comment on pharyngeal and laryngeal anatomy or physiology and bolus flow characteristics. We cannot rule out silent aspiration. We also cannot be fully confident in our recommendations for a diet or other interventions that are used to promote safe swallowing.⁵)

The Importance of Performing Instrumental Testing

As discussed in part one, the symptom of food getting stuck in the throat was mistaken as oropharyngeal dysphagia. I purposely painted a clinical picture of an esophageal dysmotility to illustrate how the entire treatment course can be misdirected. A thorough interview and review of medical records could have casted doubt on the oropharyngeal dysphagia hypothesis, at least enough to warrant instrumental testing.

Did the clinician think in a multidisciplinary way? Did she ask: “What else?” Did she make appropriate referrals?

When no instrumental examinations are performed, the treatment may not only be ineffective, but it may be contraindicated. Going back to the case above, tongue base exercises will do nothing for the smooth muscle in the distal two-thirds of the esophagus. Even more detrimental, the act of rapidly double swallowing a solid bolus will interfere with esophageal peristalsis by potentially disrupting the secondary clearing wave. This can make the issue of food stasis even worse. Additionally, a chin tuck is not always the perfect position, as it could cause aspiration in some cases.

So let’s ask “what else?” and perform an instrumental examination.

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Performing an Instrumental Exam

First of all, there is no gold standard in the instrumental assessment of swallowing. For years the label of “gold standard” was given to the Modified Barium Swallow Study (MBSS, aka Videoflouroscopic Swallow Study).

However, when comparing the MBSS with the FEES (Flexible/Fiberoptic Endoscopic Evaluation of Swallowing), one “cannot dichotomize,” said MBSImP creator, Dr. Bonnie Martin-Harris, PhD, CCC-SLP, BCS-S, FASHA. “It depends on the nature of the question,” stated Dr. Martin-Harris at the 2015 DRS Annual Meeting. An informed clinician with a sound hypothesis will choose the exams that best answer the clinical questions. For example, if the clinician suspects an oropharyngeal and esophageal dysphagia, then the MBSS may be the best option.

Regardless of the initial instrumental examination, the treating clinician needs to know about more than just aspiration or the bolus movement. Per Dr. Coyle, the instrumental examination is not only a picture of what is wrong, but also of what works. “Here is what happened, what it means, and what we sampled during the exam to fix it.”¹

Below are some necessary aspects of the instrumental exam:

• Provide a thorough analysis of the physiology and biomechanics of the swallow. The MBSImP, for example, rates 17 parameters of the swallow. Coyle noted at the 2015 DRS Annual Meeting that some of these parameters unfortunately evaluate what the bolus is doing. For example, the parameter of “initiation of pharyngeal swallow” rates the location of the bolus head at the onset of the first hyoid movement. Does this tell you why the bolus dropped to that point? Is it really a delayed initiation of the pharyngeal swallow response, or did the patient become distracted or have an oral containment problem with larger boluses?
• Identify not only the quantity and location of the residue, but also why the residue remained after the swallow and what worked to reduce it.
• Note when and why the penetration and aspiration occurred and the patient’s reaction to it.
• Challenge the patient with large bolus sizes (i.e., 20ml) that really mimic natural drinking. Steele et al stated that “fixed volumes of less than or equal to 10ml are smaller than natural sips and may under-challenge the swallowing system.”⁹ Adults take sips of 11-17ml in volume when allowed to drink naturally from cups.⁹ When testing 20ml size boluses, realize that delays in pharyngeal transit time and esophageal transit time may be within normal limits for healthy elderly over 80 years of age.⁷
• Challenge the patient with sequential drinking of 90-100ml, as tolerated. Gaziano et al tested various volumes with individuals with amyotrophic lateral sclerosis. Aspiration 
occurred most often with the 90cc trials, and only 5% elicited an effective cough to expel the aspirate. Aspiration occurred most often during and after the swallow (71.9%) due to ineffective laryngeal vestibule closure and ineffective or absent cough. Aspiration before the swallow was rarely seen and therefore this directs therapy.⁴ The more trials you perform, the more likely you will see aspiration. Susan Langmore, PhD, CCC-SLP, BCS-S advised more trials during a FEES when she presented at this year’s
  Dysphagia Research Society’s Post-Graduate Course. She found only 46% of the patients showed aspiration after 3 trials, whereas 68% of these patients aspirated when given up to 10 trials.
• Test the swallow strategies with 2-3 trials, making sure the chin tuck, head turn, super- supraglottic swallow, effortful swallow, Mendelsohn Maneuver, etc. are really effective.
• Recommend adjustments to diet as options based on the patient’s goals of care (most aggressive to least aggressive), rather than solely recommending nothing by mouth (NPO).
• Make suggestions for a restorative and compensatory treatment plan. This could include exercise suggestions to improve the swallow function and strategies to compensate for difficulties.

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Making Appropriate Referrals

1. Consider suggesting a consultation with a registered dietitian, especially if the patient is loosing weight as in the above case.
2. Consider suggesting a review of the patient’s medications that could cause dry mouth. Many side-effects of medications and polypharmacy can cause reversible difficulties eating and swallowing.
3. Does the patient need a referral to a neurologist? Did the exam point to unilateral or bilateral neuromuscular deficits? If there is a cognitive component to the dysphagia, is it due to a potentially “reversible dementia?”
4. Does the patient need a referral to an otolaryngologist?
   • MBSS includes the anterior-posterior view to determine if there are pharyngeal and/or 
laryngeal asymmetries.
   • FEES visualizes the structure and function directly and can certainly point to the need 
for further otolaryngology consultation.
5. Does the patient need a referral to a gastroenterologist for an esophagram?
   • FEES may show post-cricoid residue or a return of the food or liquid back up to the hypopharynx, which could indicate esophageal stasis and retrograde flow.
   • MBSS should include an esophageal sweep method, using a large liquid 
bolus and a more viscous bolus. JoAnne Robbins, PhD, CCC-SLP, BCS-S noted at the 2016 Dysphagia Research Society meeting that esophageal testing is “terribly important in older people to rule out pneumonia contributed to by what is going on lower down.”
   • With our case, the esophageal sweep would be crucial. We should at least 
provoke the liquid regurgitation when trying to wash down solid foods that the patient described. Because our analysis of the esophagus is incomplete, our recommendations may say: “Consider further testing with an esophagram for a more complete and diagnostic view of the esophagus.” The radiologist Cheri Canon, MD, FACR advised at the 2016 Dysphagia Research Society’s Post-Graduate Course that we should not call the esophageal component of our MBSS a screen. Again, that would be finding an undiagnosed issue in a normal patient. She noted what we are doing is “purely therapeutic” to check for esophageal clearance. If you have greater suspicions, than do a full barium swallow study.
   • An esophagram may not get to the full issue, especially if our patient complains of getting full quickly (early satiety). This further points to the need for a GI referral.

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Our Broad Scope of Practice

It is in our scope of practice to provide thorough evaluations of the oral, pharyngeal and esophageal stages of swallowing.¹⁰ Our knowledge and skills allow us to make appropriate referrals to efficiently help the patient and team. We can then provide brief and appropriate therapy to assist patients who have esophageal dysphagia. For example, we can suggest slight diet modifications (moist texture), train effective strategies, eliminate maladaptive ones, and provide a significant amount of education and training. This will improve the quality of life, increase intake safely, decrease risk of supraesophageal reflux/aspiration, and decrease risk of malnutrition in that patient.

Similarly, it is in our scope of practice to evaluate more than just swallowing mechanics. Our comprehensive evaluation can uncover many potentially exacerbating factors. For example, a further investigation into our 85-year old woman could reveal that recently she started eating her main meal of the day at the senior center. She described eating quickly and talking while eating with friends. Maybe she is chewing the bolus less. Additionally, her dentures are worn-down and loose from her weight loss. A review of medications revealed her physician recently increased her Lasix (furosemide), which may contribute to dry mouth.

We “weave together” information from the instrumental and clinical dysphagia evaluations, and we intervene in a multidisciplinary way to produce the best possible outcomes.¹ Always ask: What else?