Let’s start with a hypothetical situation. Let’s say you fell and now your leg hurts. You think something must be seriously wrong, so you go into your doctor’s office and they perform a bedside evaluation. The doctor then reports that they believe that your leg is broken and you are going to need a full leg cast for the next 6 weeks. Maybe you ask why they aren’t sending you for an x-ray. They respond that they have been looking at legs for a long time and they just know when a leg is broken or not. You protest and say that having a full leg brace is going to seriously change your life. They respond by saying that the x-ray is too expensive and they don’t feel comfortable letting you leave without this cast. How would you feel? I’d be confused and frustrated and heading as fast as I could to a different doctor.
Now change the leg to swallowing. Why do SLP’s only rely on their bedside swallow evaluation?
When we talk about the clinical swallow examination (CSE) it can be more useful to talk about what we don’t know than what we do know. We can get great information about the patient and their history, we can get the patient’s opinion on their swallowing problem, we can learn about the patient’s wishes, and we can observe possible signs of dysphagia or aspiration.
What we don’t know is whether or not there is aspiration. We don’t know if thicker liquids are helpful or not. We don’t know if a chin tuck helps or hurts. We don’t know what the physiological impairments are in order to generate an effective treatment plan.
Garand (2020) gives a good summary of what we don’t know:
“No study, to our knowledge, has suggested that a CSE can solely elucidate pharyngeal or upper esophageal physiology, guide treatment options, and prevent the development of dehydration, malnutrition, pneumonia, and death across the life span.” (Talk about a mic drop!)
In fact, there are many studies that show us that we aren’t very good at making a diagnosis, recommending diets, or developing treatment plans using the information from the CSE alone. Here’s the highlights from a few:
Leder (2002) found that SLP’s over-diagnosed dysphagia 70% of the time and missed aspiration in 14% of cases.
Carnaby & Harenberg (2013) found in a survey that the majority of SLP’s used self-developed assessments and recommended 47 different treatment techniques and over 90 different combinations of treatments for the same case. (Where’s the EBP?)
McCullough et al. (2015) “Data do not support use of any CSE to diagnose dysphagia, determine aspiration status, or make oral diet recommendations for patient care”
McCullough et al. (2000) found that only 44% of the measures clinicians’ used in the CSE had adequate inter- and intra- rater reliability. (We can’t even agree with ourselves?)
And finally, Leder (2015) found that “When watching the CSE video alone, results indicated an 83% inability to determine pharyngeal and laryngeal anatomy and physiology, 90% inability to determine the bolus flow characteristics of pre-swallow spillage and post-swallow residue, and 88% inability to determine overall swallow safety.”
So what is the solution? Instrumental evaluations. That’s it. There is nothing we can learn with only a CSE that would provide us with the information needed. We have to have FEES or MBSS. Period.
Need help convincing your DOR, DON, and/or administrator that you need access to instrumentation? Please reach out! That’s what I am here for! Let me do the work for you.
Carnaby, G. D., & Harenberg, L. (2013). What is “usual care” in dysphagia rehabilitation: A survey of USA dysphagia practice patterns.Dysphagia, 28(4), 567–574.
Leder, S. B. (2015).
Comparing simultaneous clinical swallow evaluations and fiberoptic endoscopic evaluations of swallowing: Findings and consequences.
Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 24(1), 12–17.
McCullough, G. H., Rosenbek, J. C., Wertz, R. T., McCoy, S., Mann, G., & McCullough, K. (2005). Utility of clinical swallowing examination measures for detecting aspiration post-stroke. J Speech Lang Hear Res, 48, 1288–1293.
McCullough, G. H., Wertz, R. T., Rosenbek, J. C., Mills, R. H., Ross, B., & Ashford, J. R. (2000). Inter-and intrajudge reliability of a clinical examination of swallowing in adults. Dysphagia, 15, 58–67.