Bedside Evaluation of Dysphagia - Edward Hardy - 1999 - Imaginart - 9781883315108 - Anna's Archive

Imaginart International, Inc.
307 Arizona Street

Bisbee, AZ 85603
Copyright © 1995 by Imaginart International, Inc. All Rights Reserved.
This work may not be reproduced or transmitted in any form or by any means, including, but not
limited to, electronic, mechanical, photocopying and recording by any information storage or
retrieval system without special permission from the publisher.
Cover design by Kelly Hume.
Edited by Cindy Drolet and C. Gilles-Brown.
Manufactured in the United States of America.
ISBN 1-883315-10-7
Editor’s Note: For the sake of clarity alone, we have used “he” to refer to the patient.
Acknowledgements
It is a fascinating experience to develop an idea into a product for use by speech-language

pathologists. The Bedside Evaluation of Dysphagia (B.E.D.) began as an idea based on the
dysphagia assessment method at San Jacinto Methodist Hospital in Baytown, Texas, and
developed into this publication.
I have many individuals to thank for their contributions to the development of the B.E.D.
First, thanks go to the speech-language pathology staff of San Jacinto Methodist Hospital
for practical suggestions in formulation of the test format throughout the many stages of its
development. Also, thanks go to the following clinical reviewers from various locations
across the United States who provided useful comments and suggestions: Jody Brown,
Rubye Bloeser, Pamela Craib, Patricia DeLuke, Gloria Martin, Lindia Meadows, Diane
Robbins, Natalie Robinson, and Betty Schrepfer. I would like to extend a special thank you
to Dr. Martha Burns for her review of the B.E.D. and for her insightful and practical sugges-
tions which have been incorporated into the final version of this protocol.
Special recognition goes to Carol Stach for sharing her highly respected clinical expertise
and for her thorough review of this publication. Additionally, thanks go to Cindy Drolet
and C. Gilles-Brown at Imaginart for their wonderful professionalism in guiding this pro-
ject from its inception to completion.
Finally, a debt of gratitude is owed to my wife and son, Debbie and Stephen, for their
unconditional love and sacrifices which have allowed me to spend the many long hours
alone at the computer to prepare this publication.
‘i
*
'
f ‘
4
“7 f;
3
ia ] ‘
iL hed
.
DOW W SOUrik ef 766) C.0i.4

. i 'w Of
é
ose 4w seattivons Dew ot tenon oes

| 7 vii OP
}
or Hes Teeter xr Se?. ty mh
CA wel
ge, _ wp!
nb
Contents
Introduction
Development ofthe Bk. D. aineete ix ue arse Pate rH rn ered REA woes 1
Safety Factors
SALIVR OWS LOWS ee een Re tee Mere er ee eeu ey a ev cas eaten t 2
REVS UIT CRSCSG Seek Bs ie BSA Ra Ae nS Ree rec ag ne 4
Administration of the B.E.D.
Sopplies Steet 2 corer Rea Gee ener cee See eee ey ey Seka ce ee oes see oes 4
SECUIOUS Fae eee ee Nee eR eece eNews Adaya ete ne sen eee oe see et 4
PNANo nVESVRm ac ELO196SBTSs RA. Satine Tag RY VEST HEI eT DUPE CREASE ORR an Pe 5
Scorn Guider Re Meee ae Sem Re Solr ce teeta ered ewe Mos SOE Iy! 5
COUNTSeUTMaaya)Resa
Tesaaq, 5 SA A eS A oo Cae Ae eee ER Eee Ta er ee 6
Cratiial INervesth aes wert re Seer tine fee tee RET HS TERRI LORE ALR. t 6
Filling Out the Response Form

Identifying Informationian a seicap cach ct vif thes oA seth). «AMOR SUM IASSsOREO v4. 7
Behavioral aracteristicsee yet ett tere ye nk cise eas cst eRajaces oases ce RMR ws x. 7
Cognition and Communication Screening
CBO
OREULOT rye Oe ies cine setae esta et ete a else oferta <iingh oF ss As ates eae s 8
ROCEDLIVEN ANGUSOCie trans eile Rist ele besagain ats cht tolemeres10
Expressive Language Speech Production a. aren cans sa. eaters Gene i 12
Oral-Motor Examination
LIPSaet oe fe ten ee Peas Pe ree ae eee tect Oe tne heey mee aes Pie nate eee 14
Bayt
-aPoP thes saepe rp oR Ik Oe ate aN EE SL NATE SRE SIONS Fe 17
Soft Palatéu 500.775 Vet, THREES ERE NS Pe Se ee zz
CTheek sa aio oe 55 aiaee atin ghBelge eta cea Wito oes aia a fee ie cle 24
Mandible “sinrg 6a ee eet ees Gis Ri eee okt wee iene: ect ee eee 25
Oral-Pharyngeal Dysphagia Symptoms Assessment
The Normal Swallow. <. suai. wi «see Be ery gaie'aleh od sos alee 30 28
Instructions for Swallowing Assessment
Dysphagia Symptoms iy) nce see eek ke ee 30
Regular Method oo 0 27.2 tere oe Se cance Bz
Saliva Swallows Only yon. ee pe ae ce «Se ace ee ao
Assessing the Triggering of the Pharyngeal Swallow .................. 34
Additional Observations’... . 6.4.2. .05.+ +++ «+> «ccyehsehdel ere Ee)ante ae men eree35
Summary Report Form

Identifying Information % 0:25. seers, Sole re etal ohne hii open eee ee 36
SUIMIMALY. crisis 5 ois/eain oilers Wrenn obra etin olalelo Peper aah neta san haat cee 36
Recommendations %« sie unis cessed tains ae or eo ene nee eee 36
Instrumental Assessment ». 572 si). iev ort lamin sc eye iene Ong ee 36
Diet ComsistOnCy 2 iescts:s:sis-c tyenhs ceareretsis es «rates ee Shae atecf aa ey etc ae avs
Compensatory Strategies. <0. 6)... es eee nc + + oon 0 ote epee Gene i? eee 39
Rehabilitation-Techniques 0... 0.2 25-: 5.050 ay sa oan ne ae 4]
Other oi cc aise vine wis, bevel sige ale 8'sletaiy leblelaek ce 6 ata nen ea 42
References
balsas 5 pieole,e:dinuale ws Ha Osher oe 2 wey Gre oe Oe Wekaie Minbisls 6 eyeRTsaka telcgetgh aioe te ae mae one 43
About the Author

Skin Raed ain tie wide Wis oleely asta syme ofa e agers since tk clade Oe ek Sang eee es eee Ce! 44
Introduction 1
Development of the B.E.D.
The Bedside Evaluation of Dysphagia (B.E.D.)™ was developed following the author’s exten-
sive experience with adult patients in a variety of settings including acute care, rehabilita-
tion and home health. Based on the need for a short, practical method of evaluating swal-
lowing at bedside, the B.E.D. was developed to create a more uniform tool for assessing
adult patients with dysphagia.
In order to fully assess a patient to determine if the possibility of dysphagia exists, the swal-
lowing therapist (typically the speech-language pathologist) is charged with gathering
information that describes the patient’s swallowing abilities. In addition, other factors such
as behavior, communication and cognition, and oral-motor skills may influence the
patient's ability to swallow safely. The B.E.D. has been designed to assess swallowing abili-
ties and the factors which may influence those abilities so that the swallowing therapist has
a more complete “picture” of the patient.
The Oral-Motor Examination was developed as a separate section of the test because it
allows the clinician to systematically assess the oral-peripheral structures and their func-
tion in isolation. This is done prior to observing actual swallows in the Oral-Pharyngeal
Dysphagia Symptoms Assessment portion of the test because the act of swallowing is such
a dynamic process. Swallowing involves simultaneous structural movements that are not
always visible to the examiner while observing the swallow. For example, you may observe
that your patient has lateral sulci residue after swallowing part of a cracker, but you cannot
readily determine the cause. The Oral-Motor Examination may reveal weak buccal or lin-
gual musculature or reduced sensation of the cheeks. Any one of these conditions may
cause residue to collect in the lateral sulci.
The protocol that provided the initial basis for the B.E.D. is included in the 1993 Imaginart
publication Swallowing Disorders Treatment Manual, which the author co-wrote with Natalie
Robinson.
The B.E.D. was developed for use with a wide variety of adult neurologically-impaired
populations. Patients with right and left CVA, Parkinson's Disease, traumatic brain injury
and dementia are the most appropriate candidates for administration of the B.E.D. The
Oral-Pharyngeal Dysphagia Symptoms Assessment portion of the test is not intended for
use with patients who are tracheostomized because these patients require different testing
methods to insure appropriate evaluation of swallowing abilities. In the author’s opinion,
only experienced clinicians and those with advanced training should evaluate and treat this
patient population. For further information on swallowing disorders in patients with tra-
cheostomies, please refer to Mason, 1993.
NJ Safety Factors
Safety Factors
Saliva Swallows
Clinical discretion is advised in selecting food and liquid consistencies to administer to
patients suspected of having dysphagia. The swallowing therapist must determine potential
risk factors, such as the patient’s ability to tolerate aspiration, and decide on a case by case
basis whether introduction of food and/or liquid consistencies is appropriate. Saliva swal-
lows may be tested in lieu of actual food and liquid swallows. Observation of the patient
during saliva swallows instead of during actual food and liquid swallows may be done
when the swallowing therapist feels the patient is at high risk for aspiration with any con-
sistency of food and liquid by mouth. The therapist can utilize many sources of informa-
tion to help determine whether the patient is at high risk for aspiration prior to administra-
tion of the B.E.D. The following list includes factors which should be considered when
making decisions regarding administering actual foods and liquids versus testing saliva
swallows only.
Level of alertness
Type and severity of medical diagnosis
History of aspiration pneumonia
Ability to manage own secretions
The clinician should be aware that results of a bedside swallowing evaluation using saliva
swallows may not yield the same information as swallows of actual foods and liquids due to
the small volume of saliva being swallowed and its usually thin consistency. In other words,
saliva swallows do not provide the clinician with enough information to judge the
oral/pharyngeal swallowing mechanism’s function with various consistencies and volumes
of food and liquid. Saliva swallows do allow the therapist to make some judgments of swal-
lowing function utilizing a small volume of a single consistency (saliva).
Evaluation of saliva swallows should not be used as the only measure of determining
whether a patient can tolerate consistencies of food and liquid by mouth. Instrumental
evaluation using such procedures as the modified barium swallow or EE.E.S. (fiber-optic
endoscopic evaluation of swallowing) should be used to further analyze the patient’s swal-
lowing abilities in order to make appropriate recommendations regarding diet consisten-
cies, compensatory strategies and rehabilitation techniques.
Assessment with saliva swallows is outlined in the instructions for Swallowing Assessment
(Saliva Swallows Only) on page 33.
Safety Factors 3
Warning Signs
The swallowing therapist should pay particular attention to the following warning signs
which have been shown to be correlated with the occurrence of aspiration (Linden, et.al.,
1993).
Poor posture/positioning — any time the patient is slumping, reclining or lying

down during food or liquid intake
Impaired palatal gag reflex — absent, diminished or hypersensitive on either or
both sides of the soft palate
Abnormal voluntary cough — impaired ability to produce a forceful cough upon
command
Coughing or choking before, during or after swallowing
Change in vocal quality, i.e., wet/gurgly, hoarse, breathy, strained/strangled fol-
lowing swallows
Impaired laryngeal elevation — minimal or no movement of the larynx when the
pharyngeal swallow is triggered. Normal elevation is approximately 3/4".
Impaired secretion management — no ability or minimal ability to initiate
oral/pharyngeal stage swallows to clear secretions
4 Administration
Administration of the B.E.D.

The Bedside Evaluation of Dysphagia is a clinical assessment tool which should be utilized
as part of a more comprehensive evaluation of swallowing impairment. The comprehensive
dysphagia evaluation may include a patient/caregiver interview, Bedside Evaluation of
Dysphagia, and an instrumental assessment such as the modified barium swallow proce-
dure. The swallowing therapist may choose to administer the entire B.E.D. or may select
sections of the protocol deemed most appropriate for the patient being evaluated. Specific
procedures necessary for evaluating dysphagic patients will depend on factors such as the
swallowing therapist’s training, the cognitive and/or medical status of the patient, and the
availability of technology. For further information on common dysphagia assessment pro-
cedures please refer to Hardy and Robinson, 1993; Logemann, 1983; Logemann, 1992 and
Langmore, et.al, 1988.
Supplies
Response form (includes Summary Report)
Penlight
Tongue depressor
Cotton-tipped swab
Cup
Latex gloves
Towel (cloth or paper)
Approximately 2 oz. water
Approximately 2 oz. thickened liquid (tomato juice/nectar consistency)
Approximately 2 tsp. (12 cc) pureed food consistency (i.e., applesauce or pudding)
Approximately 1/4 of a cracker or a cookie
Optional: Any other food or liquid consistency the swallowing therapist judges to be appro-
priate
Sections
The B.E.D. consists of the Response Form and Summary Report for the patient’s chart. The
Response Form contains five sections: Identifying Information, Behavioral Characteristics,
Cognition and Communication Screening, Oral-Motor Examination and Oral-Pharyngeal
Dysphagia Symptoms Assessment. The Summary Report contains three sections:
Identifying Information, Summary and Recommendations.
Administration 5
Administration Time
Administration time varies depending on the type and severity of the patient’s dysphagic
symptoms, his cognitive abilities, and his cooperation. Average administration time ranges
from approximately 15 minutes to 45 minutes.
Scoring Guide
Complete instructions for administering and scoring the B.E.D. are detailed for each sec-
tion of the test. Also, clinical implications for the Behavioral Characteristics, Cognition and
Communication Screening and the Oral-Motor Examination sections of the B.E.D. are dis-
cussed below.
Please refer to pages 45-51 for an example of how to complete the Response Form and the
Summary Report.
Behavioral Characteristics Place a check mark (/) beside all behav-

iors observed.
Cognition and Communication Record your observations of each item as

Screening WNL (within normal limits) or IMP
(impaired). Write any appropriate
remarks in the Comments section.
Oral-Motor Examination Record your observations of each item as

WNL (within normal limits) or IMP
(impaired). Write or circle any appropri-
ate remarks in the Comments section.
Oral-Pharyngeal Dysphagia Symptoms | Place a check mark (/) in the appropri-

Assessment ate box when impairment is observed.
Circle pertinent information and write
(Regular Method or Saliva Swallows Only)
any remarks or code letters in the
Comments section. Code letters (A-])
correspond to impairment in specific
volumes and consistencies administered.
Administration
Clinical Implications
Clinical implications of impaired behaviors on the patient’s swallowing safety are discussed
in the following sections of the manual: Behavioral Characteristics; Cognition; Receptive
Language; Expressive Language/Speech Production; Oral-Motor Examination: Lips,
Cheeks, Tongue, Soft Palate, Mandible and Larynx. Each set of clinical implications is high-
lighted by a box and is located at the end of each section.
The Clinical Implications sections provide the swallowing therapist with guidelines for
understanding how the impaired behavior can affect swallowing abilities.
Cranial Nerves
Utilizing information gathered from the patient’s medical history such as results of com-
puterized tomography (CT) scans, magnetic resonance imaging (MRI) studies and clinical
neurological examinations, the swallowing therapist will be able to correlate information
gathered during the Oral-Motor Examination section of the B.E.D. with possible sensory
and motor cranial nerve damage.
For each test item in the Oral-Motor Examination, a corresponding cranial nerve (either
sensory or motor component) has been listed. When the Oral-Motor Examination is com-
plete, the clinician will be able to quickly infer which cranial nerve(s) has been damaged by
looking down the far right side of the Response Form.
Results of possible cranial nerve damage should be used with clinical discretion because
other types of neurological impairment may cause similar symptoms during the bedside
examination. For example, oral apraxia may prevent the patient from performing some of
the oral-motor tasks on the B.E.D. Also, cognitive deficit as a result of dementia or other
neurological condition may prevent the patient from performing some oral-motor tasks on
this test. For these reasons, the swallowing therapist should always make judgments regard-
ing possible cranial nerve impairment in conjunction with the patient’s medical history,
diagnosis, clinical examination by the physician, and available neurological imaging results.
5
Behavioral Characteristics
Filling Out the Response Form

Identifying Information
Record pertinent identifying information in this section and at the top of the Summary
Form: Patient’s Name, Age, Swallowing Therapist, Diagnosis, Date of Onset, Date of
Evaluation, Current Diet Consistency, and Reason for Referral.
This section is concerned with identification of specific patient behaviors that may posi-
tively or negatively influence swallowing function. Upon initial contact with the patient, the
swallowing therapist should begin observing the individual’s behavior. The following ques-
tions should be answered and a check mark placed beside all behaviors observed. How
alert is the patient? Does he appear lethargic or listless? Is the patient cooperative with the
clinician? Combative? Does the patient acknowledge the presence of swallowing difficulty?
(Many patients with dysphagia deny its existence.) Does the individual display left or right-
sided neglect (lack of awareness of the left or right side of the body)? Is the patient impul-
sive? Does he exhibit slow response patterns which may influence his swallowing abilities?
Is the patient’s posture such that it negatively impacts the safety of the swallow? Does the
individual display any other behavioral characteristics which may have an impact on his
ability to swallow foods or liquids?
Clinical Implications of Behavioral Deficits

Observing the patient’s behavioral characteristics during the bedside evaluation allows the swal-
lowing therapist to predict which patients make optimal therapy candidates. For example, if the
patient exhibits a reduced level of alertness or is uncooperative with the clinician, swallowing eval-
uation and subsequent treatment may not be warranted until the patient becomes more amenable
(i.e., level of alertness or compliance improves) to further evaluation attempts by the therapist.
Patients who deny or are unaware of dysphagia symptoms alert the clinician that thorough educa-
tion of the patient regarding their specific swallowing problem(s) will be needed. Generally, the
more the patient understands his problem, the better he will be able to participate in a swallowing
management program.
Patients who are unaware of or neglect one side of the body will need training to “find” food and
liquids that are placed in front of them on their affected side. These patients may also need guid-
ance in placing food and liquid into the oral cavity on the unaffected side to aid in manipulation
of the bolus.
Those patients who exhibit impulsive behavior such as eating too rapidly may place themselves at
greater risk for aspiration since pharyngeal residue may accumulate after each bolus is swallowed,
and this residue could spill into the open airway.
Poor posture or positioning has been associated with an increased risk for aspiration (Linden, et
al., 1993). Any position in which the patient is not sitting upright with the hips flexed at approxi-
mately 90 degrees may be considered poor posture or positioning.
Cognition

Many patients with dysphagia also have cognitive and communication disorders. A screen-
ing of these skills will provide the clinician with basic information needed to interact effec-
tively with the patient. Formal evaluation of speech, language and cognitive skills should be
completed as a separate procedure from the bedside assessment due to the length of time
required to complete a thorough assessment of these areas. If these areas have not been pre-
viously assessed, the screening section of this test may be administered. The swallowing
therapist should interpret impaired responses on the Cognitive and Communication
Screening section of the B.E.D. as indicative of the need for further assessment. The B.E.D.’s
Cognitive and Communication Screening section should never be used as a formal assessment
of these areas.
Cognition
Short Term Memory

At the beginning of your assessment, tell the patient your first or last name and that you are
going to be asking him to recall your name throughout the evaluation. Then approximately
every 5 minutes (for at least 3 attempts), ask the patient to recall your name.
Within Normal Limits: The patient should be able to recall the examiner’s name on
two out of three consecutive requests presented at five
minute intervals during a 15 minute period in order to be
considered within normal limits. Responses by patients
who exhibit motor speech impairments which reduce
speech intelligibility can be scored as within normal limits.
Impaired: Inability to recall any two of three verbalizations of the
swallowing therapist's name presented at five minute inter-
vals for a period of 15 minutes during the evaluation.
Incorrect word choices, i.e., Sue for Jane; and inappropriate
responses due to reduced comprehension and/or memory
abilities should be scored as impaired.
Cognition 9
Orientation:
Ask the questions below and record the patient’s responses next to the questions on the
form. Additional space is provided in the Comments section.
What day is today?
What month are we in?
What year are we in?

Where are you?
Within Normal Limits: The patient should be able to indicate the day, month and
year. The patient should also be able to give his location. A
categorically correct location is acceptable. For example,
“Tm in the hospital” and “ ’m in San Jacinto Methodist
Hospital” should both be considered correct responses.
Impaired: Responses are impaired if more than one day, one month,
and one year ahead or behind the correct answer. All incor-
rect responses to the location question are considered
impaired except those that may be categorically correct
such as hospital for rehabilitation unit or office for clinic.
Attention
Observe the patient’s behavior to determine if he is able to maintain sufficient sustained
attention necessary for adequate nutritional intake and swallowing safety.
Within Normal Limits: The patient should be able to sustain attention for the peri-
od of time required to complete the B.E.D. Depending on
the patient’s individual situation, sustained attention may
be required for periods of time ranging from 15 to 45 min-
utes. This is the average time needed to complete the test
and reflects the minimum period of time required by a
patient to complete a meal.
Impaired: Attention is impaired when the patient is not able to sustain
attention for the time required to complete the B.E.D.
Impairment is also noted when the patient is highly dis-
tracted by auditory and/or visual stimuli and requires fre-
quent redirection back to the task at hand.
10 Receptive Language
Clinical Implications of Cognitive Deficits
In order for the patient to be able to master compensatory strategies or rehabilitation maneuvers,
he must be able to recall new information presented verbally. Impairment in short-term memory
abilities may prevent a patient from learning new information such as tilting the chin down (a
compensatory strategy) or the Mendelsohn maneuver (a rehabilitation technique).
Orientation to time and location concepts are basic cognitive skills necessary for day to day social
functioning. Patients who are not oriented tend to have difficulty fully participating in a swallow-
ing improvement program because they may not know where they are or have any awareness
about when mealtime occurs.
Attention deficits may reduce the patient's ability to sustain attention for sufficient periods of time
necessary for adequate nutritional intake and swallowing safety.
Receptive Language
One-Step Command
Ask the patient either to open his mouth or raise his hand. Other one-step tasks such as
having the patient close his eyes or stick out his tongue may be attempted if deemed appro-
priate by the swallowing therapist. Some patients may require a gestural cue with the verbal
request to help them respond accurately. If cues are given, simply record the cues given in
the Comments section of the form.
Note: Be sure to check the available patient information to be sure that the patient does
not have significant muscle weakness which would prevent him from moving the
mouth or other part of the body. If muscle weakness of the extremities interferes
with completion of the command, substitute another command such as “Look up”
or “Close your eyes”.
Within Normal Limits: Responses are considered within normal limits if the
patient is 100% accurate at following one-step commands.
It is considered within normal limits if the patient is able to
respond appropriately by reading the command versus hav-
ing it presented verbally.
Impaired: Check the impaired box if the patient makes no attempt to
perform the command or if he attempts the command and
is unsuccessful.
Receptive Language 11
Two-step command:
Instruct the patient to point to the door, then point to the ceiling. Another two-step com-
mand may be used in place of the one supplied if deemed more appropriate by the swal-
lowing therapist.
Within Normal Limits: 100% accuracy at following the two-step command. It is
considered within normal limits if the patient is able to
respond appropriately by reading the command versus hav-
ing it presented verbally.
Impaired: Check the impaired box if the patient makes no attempt to
perform the two-step command or if he partially completes
the command. Also, if the patient performs a two-step com-
mand that is not related to the request, this would be con-
sidered impaired.
Answer personally relevant yes/no questions

Have the patient answer at least two personally relevant questions requiring a yes or no
response. The two examples provided are “Are you in the hospital?” and “Are the lights on?”
Other yes/no questions that are relevant to the specific patient may be substituted.
Within Normal Limits: 100% accuracy for the two questions asked. Verbal, written
or gestural responses are acceptable.
Impaired: Responses are rated as impaired when the patient answers
only one of the two questions correctly, gives no response,
or provides an unrelated response. If the patient responds
by stating “sometimes” or a similar response, then this type
of answer is also considered impaired.
Clinical Implications of Receptive Language Deficits
Generally, in order for a patient to be able to successfully participate in a swallowing intervention

program, he must be able to follow two-step commands consistently. However some compensato-
ry and rehabilitation techniques require more than two steps to complete. If techniques requiring
more than two steps are identified by the swallowing therapist as beneficial for the patient (and
subsequently verified via instrumental assessment), then a more in-depth measure of receptive
language skills is recommended. In order to gather specific information on the patient’s ability to
follow multi-step commands, the therapist may choose to administer the receptive language com-
ponents of such tests as the Western Aphasia Battery (Kertesz, 1982) or the Boston Diagnostic
Aphasia Examination (Goodglass and Kaplan, 1983).
The client’s ability to give accurate yes/no responses is critical to the success of a swallowing
improvement program. The ability to comprehend instructions and give accurate responses to
basic questions on the B.E.D. will help the clinician judge how well the patient will give reliable
feedback during a swallowing intervention program.
he Expressive Language/Speech Production
Expressive Language/Speech Production
Count from 1 to 10
Say to the patient, “T’d like for you to count from one to ten.”
Within Normal Limits: Patient says the numbers from one to ten. Responses should
be accurate and intelligible.
Impaired: Note in the Comments section any of the following:
Productions which contain omissions of part or all of
words
Reduced articulation resulting in distorted or imprecise
consonant/vowel productions
Rapid or slow rate of speech
Abnormal resonance, i.e., hypo- or hypernasality
Reduced respiratory support
Also, note presence of anomia, perseveration or jargon.
Tell me the days of the week

Say to the patient, “Now Id like for you to tell me the days of the week.” The swallowing
therapist should provide the patient with cueing if needed and record a description of the
cueing in the Comments section.
Within Normal Limits: Patient says all of the days of the week, starting at any point.
words
Abnormal resonance, i.e., hypo- or hypernasality
Also note presence of anomia, perseveration or jargon.
Expressive Language/Speech Production ts
Name and Address

Ask the patient to tell you his name and address. Some patients are not accustomed to stat-
ing their full street address and may only state the town in which they live. When this
occurs, verbally prompt the patient by asking him to provide you with his house number
and street and make a note in the Comments section that verbal cueing was required.
Within Normal Limits: Patient states first and last name, street address and city
(state of residence and zip code are optional). Responses
should be accurate and intelligible.
words
Abnormal resonance, t.e., hypo- or hypernasality
Also, note presence of anomia, perseveration or jargon.
Clinical Implications of Expressive Language/Speech Production Deficits
Impairment in expressive language and/or speech production skills may prevent the patient from
adequately providing the clinician with necessary verbal feedback during swallowing therapy.
Having gathered this information, the swallowing therapist may decide to complete additional
testing to further evaluate expressive language and speech intelligibility.
Results of a more in-depth assessment of expressive communication skills (including speech

intelligibility) will allow the clinician to understand the nature and severity of these skills so that
further interaction with the patient is more successful.
14 Oral-Motor Examination — Lips
The oral-motor portion of the B.E.D. includes assessment of the structure and function of
the lips, cheeks, tongue, soft palate, jaw (mandible) and larynx. Also included is evaluation
of the touch sensitivity of the patient’s lips, cheeks, tongue and soft palate. The correspond-
ing cranial nerve is included for each task so that the swallowing therapist can identify the
sensory or motor component suspected of being damaged.
In cases where the patient has difficulty following spoken instructions, the clinician is
encouraged to demonstrate the task — smiling, puckering, etc. The patient’s response is
scored as “within normal limits” if he performs it correctly following the demonstration.
Lips
Lip closure at rest

Observe the patient's lip closure at rest.
Within Normal Limits: Upper and lower lip make contact in a symmetrical, resting
posture.
Impaired: Drooping unilaterally or bilaterally, fasciculation (repetitive
tremor-like movement), incomplete closure of the lips (due
to reduced muscle tone or as seen in “mouth breathing”), or
involuntary movement of the lips should be circled in the
Comments section.
Corresponding
Cranial Nerve: Facial VII (motor)
Protrusion
Say to the patient, “I want you to pucker your lips.” If the patient is not able to produce a
pucker by imitating you, try having him say “oo.”
Within Normal Limits: Symmetrical, full protrusion of the lips.
Impaired: No movement; drooping unilaterally or bilaterally. Record
any groping or uncoordinated movements, fasciculation,
partial movement of the lips (may indicate reduced
strength and range of motion), or involuntary movement.
Corresponding
Oral-Motor Examination — Lips a5
Retraction
Say to the patient, “Smile really big for me.” Demonstration by the swallowing therapist is
acceptable. If the patient is not able to do this by imitating you, have him say “ee.”
Within Normal Limits: Symmetrical, full retraction of the lips into a smile.
Impaired: No movement; drooping unilaterally or bilaterally. Record
any groping or uncoordinated movements, fasciculation, or
partial or involuntary movement of the lips.
Corresponding
Rapid protrusion/retraction (3 seconds)

Ask the patient to “Pucker and smile as fast as you can until I tell you to stop.”
Demonstration by the swallowing therapist is acceptable. Observing for three seconds will
allow you to determine the adequacy of the alternating movements. If the patient is not able
to do this by imitating you, have him say “ee” and “oo” as rapidly as possible. Record the
number of sets of alternating movements and any impairment in the Comments section of
the form.
Within Normal Limits: Full, symmetrical pucker and retraction of the lips. At least
two sets of alternating movements must be completed with-
in three seconds.
Impaired: No movement or lips drooping unilaterally or bilaterally.
Record any groping or uncoordinated movements, fascicu-
lation, or partial or involuntary movement of the lips.
Performance of only a single pucker and smile within three
seconds is considered impaired.
Corresponding
Rapid Closure
Say to the patient, “Now I want you to say ‘puh, puh, puh’ as fast as you can.” This will allow
you to determine the ability to obtain closure of the lips during rapid movement. If the
patient cannot imitate this task, have him repeat or read aloud the following sentence so
you can observe bilabial closure: Bob met Barbie at the beach.
Within Normal Limits: Approximately 6 repetitions in 3 seconds (2 repetitions per
second) is considered within normal limits.
16 Oral-Motor Examination — Lips
Impaired: Fewer than 3 repetitions in a 3 second period of time is

considered impaired.
Corresponding
Strength
Instruct the patient to place his lips around a tongue depressor placed horizontally in the
front of the mouth. Ask him to press down as hard as possible with the lips while you try to
remove the tongue depressor. This allows you to judge the strength of the patient’s labial
musculature. Subjective judgments of good, fair, or poor strength should be made and cir-
cled in the Comments section of the form.
Within Normal Limits: A firm grasp of the tongue depressor by the lips should
allow the swallowing therapist to feel significant resistance
when trying to remove it. This is considered within normal
limits for lip strength. Circle good in the Comments section.
Impaired: Any reduced ability to firmly grip the tongue depressor
with the lips while the swallowing therapist tries to remove
it. Circle your judgment of fair or poor in the Comments
section.
Corresponding
Touch Sensitivity
Ask the patient to close his eyes. Lightly touch two random areas in the four quadrants of
the upper and lower lips with a tongue depressor or cotton-tipped swab. See Figure 1. The
patient should indicate if he felt each touch.
Within Normal Limits: The patient should indicate verbally or gesturally that the
touch was felt twice in each quadrant of the upper and
lower lips.
Impaired: Touch sensitivity is impaired if the patient indicates one
touch was felt or no touch at all in each quadrant of the
upper and lower lips.
Corresponding
Cranial Nerve: Glossopharyngeal IX (sensory)
Oral-Motor Examination — Tongue a7
Figure 1. Anterior view of lips depicting four quadrants. Dots indicate random locations to touch
to determine sensitivity.
Clinical Implications of Lip Deficits
Reduced lip sensation, strength and range of motion may result in drooling, biting the lip, pock-
eting material in the anterior sulcus and spilling material out of the front of the mouth.
Tongue
Protrusion
Ask the patient to stick out his tongue. Check for deviation to the left or right side of the
mouth. Also look for fatigue and fasciculation (tremulous movement of the tongue). Write
or circle the appropriate remark under the Comments section of the form.
Within Normal Limits: A fully extended midline tongue protrusion for at least two
seconds is considered within normal limits.
Impaired: Moderate to minimal protrusion of the tongue; deviation to
the right or left; inability to keep the tongue protruded for
at least two seconds; and tremulous movement of the
tongue (fasciculation) are considered impaired.
Corresponding
Cranial Nerve: Hypoglossal XII (motor)
Retraction
Ask the patient to pull the tongue as far back into the mouth as possible.
Within Normal Limits: Maximum retraction of the tongue into the oral cavity.
Tongue tip may curl up when retracted. It should move
posteriorly in the oral cavity behind the lower front teeth
(or lower front gum if edentulous), rather than remain sta-
tionary and lift up over the lower front teeth or gum.
18 Oral-Motor Examination — Tongue
Impaired: Moderate to no retraction of the tongue; lifting the tongue

without moving it posteriorly in the oral cavity.
Corresponding
Lateralization
Ask the patient to move the tongue to the left and right corner of the lips. Next, ask the
patient to move his tongue from one corner to the other corner of his lips as rapidly as pos-
sible. Finally, have the patient push the tongue into the left and then right cheek.
Within Normal Limits: Maximum contact of the tongue tip to the corners of the
left and right sides of the lips; maximum contact of the
tongue tip to each cheek; at least 3 repetitions of steady,
even, corner to corner movements of the tongue should be
completed to be considered within normal limits for the
rapid left/right lateralization task.
Impaired: No movement, moderate to minimal movement, tremulous
movement and groping are considered impaired. Less than
3 repetitions or unsteady, jerky movement of the tongue
during attempts at rapid lateralization should be scored as
impaired.
Corresponding
Tongue-tip Elevation
Ask the patient to open his mouth wide, hold, then raise the tip of the tongue to the roof of
the mouth just behind the front teeth or gum (if edentulous). Then ask him to try to reach
his nose with his tongue.
Within Normal Limits: Contact of the hard palate with the tip or blade of the
tongue. When reaching toward the nose, the tongue tip or
blade of the tongue should make contact with the upper
edge of the top lip to be considered within normal limits.
Impaired: Score as impaired if you observe no movement, minimal
movement, or inability of the tongue tip or blade to reach
the upper edge of the top lip.
Corresponding
Oral-Motor Examination — Tongue 19
Tongue-tip Depression
Have the patient move the tip of his tongue to behind his bottom teeth or gum (if edentu-
lous). Next, have the patient stick out his tongue and point it down toward his chin.
Within Normal Limits: Lowering the tongue tip to behind the bottom teeth (it is
normal for the tongue to touch the teeth or gum); lowering
of the tongue tip out of the mouth to any point below the
bottom lip is considered within normal limits.
Impaired: Minimal to no lowering of the tongue either in the oral cav-
ity or outside of the mouth.
Corresponding
Tongue Strength
Ask the patient to position the tongue in the following manner:
Stick the tongue out and push it against a tongue depressor or gloved finger.
The clinician should apply gradual resistive force with the tongue depressor
against the tip of the tongue. At the same time, the patient should be asked to
push the tip of the tongue against the tongue depressor. A subjective judgment
of good, fair, or poor strength should be recorded in the Comments section.
Inside the oral cavity, move the side of the tongue to the /eft and push it against
the broad side of a tongue depressor held horizontally by the swallowing thera-
pist. The clinician should apply gradual resistive force with the tongue depres-
sor against the left side of the tongue. At the same time, the patient should be
asked to push the left side of the tongue against the tongue depressor. A subjec-
tive judgment of good, fair or poor strength should be recorded in the
Comments section.
Inside the oral cavity, move the side of the tongue to the right and push it
against the broad side of a tongue depressor held horizontally by the swallow-
ing therapist. The clinician should apply gradual resistive force with the tongue
depressor against the right side of the tongue. At the same time, the patient
should be asked to push the right side of the tongue against the tongue depres-
sor. Record your subjective judgment of good, fair or poor strength in the
Comments sections.
Inside the oral cavity, elevate the blade (not the tip) of the tongue and push it
against a tongue depressor. The clinician should apply gradual resistive force
with the tongue depressor against the blade of the tongue. At the same time, the
patient should be asked to push the blade of the tongue against the tongue
20 Oral-Motor Examination — Tongue
depressor. A subjective judgment of good, fair, or poor strength should be

recorded in the Comments section.
Forcefully push the tongue into the left cheek. The therapist should apply resis-
tance against the bulging cheek with two or three fingers. Record your judg-
ment of strength in the Comments section.
Forcefully push the tongue into the right cheek. The therapist should apply
resistance against the bulging cheek with two or three fingers. Record your
judgment of strength in the Comments section.
Within Normal Limits: Strong resistance against a tongue depressor or gloved fin-
ger for the tip, blade, and sides of the tongue.
Impaired: Moderate, minimal, or no resistance of the tongue against
the tongue depressor or finger.
Corresponding
Touch Sensitivity
Ask the patient to close his eyes. Tell the patient, “I’m going to touch your tongue in differ-
ent spots with this swab (or tongue depressor). Let me know if you can feel the touch.” With
a cotton-tipped swab (or tongue depressor) the therapist should assess the sensitivity of the
tongue by lightly touching random locations within the following areas on the tongue from
the front to the back (see Figure 2):
Left Anterior Third

Left Middle Third
Left Posterior Third
Right Anterior Third
Right Middle Third
Right Posterior Third
Within Normal Limits: To be considered within normal limits, the patient should
indicate either verbally or gesturally that he felt each touch.
Impaired: The swallowing therapist should mark “IMP” when there is
no response to touch on any specific location of the tongue.
Oral-Motor Examination — Tongue 21
Corresponding
Cranial Nerve: Left Anterior Third Facial VII (sensory)
Left Middle Third Facial VII (sensory)
Left Posterior Third Glossopharyngeal IX (sensory)

Right Anterior Third Facial VII (sensory)
Right Middle Third Facial VII (sensory)

Right Posterior Third Glossopharyngeal IX (sensory)
Figure 2. Anterior view of the tongue depicting six areas. Dots indicate
random locations to touch to determine sensitivity.
Clinical Implications of Tongue Deficits
Reduced tongue sensation, strength and range of motion may result in an inability to manipulate
material in the oral cavity to form it into a cohesive bolus. It may also result in food residue on the
hard palate and pocketing material in the anterior and/or lateral sulci. It may cause the patient to
inadvertently bite the tongue as well.
22 Oral-Motor Examination — Soft Palate
Soft Palate
Deviation From Midline

Ask the patient to open the mouth so that you may observe the soft palate at rest. Note any
deviations from midline in the Comments section of the form.
Within Normal Limits: The resting soft palate should look symmetrical in appear-
ance with no deviation to the right or left.
Impaired: Deviations to the right or left from midline are considered
impaired.
Corresponding
Cranial Nerve: Glossopharyngeal IX (motor)
Ability to Raise the Palate

Ask the patient to say “Ah.” Observe the soft palate for upward and backward movement.
Within Normal Limits: Maximum upward and backward movement of the velum
should be observed during phonation of the “Ah”
Impaired: Limited or no upward movement of the velum during
phonation of “ah”; presence of hypernasal or hyponasal res-
onance which may indicate reduced velopharyngeal clo-
sure.
Corresponding
Cranial Nerve: Vagus X (motor)
Ability to Sequentially Raise and Lower the Palate

Ask the patient to say “ah, ah, ah.” Maximum upward movement of the velum should be
observed during phonation. The palate should also lower between each “ah.”
Within Normal Limits: Maximum upward movement of the velum should be
observed during phonation of the “ah, ah, ah”
Impaired: Limited or no upward movement of the velum during
phonation of “ah, ah, ah”; presence of hypernasal or
hyponasal resonance which may indicate reduced velopha-
ryngeal closure.
Corresponding
Oral-Motor Examination — Soft Palate 23
Touch Sensitivity
Tell the patient that you'd like to check the palatal gag reflex by touching the back of the
mouth with a tongue depressor. Touch the soft palate with a tongue depressor in the center
on the right side (and note the patient’s response); then touch the center on the left side
(and note response).
Within Normal Limits: A strong, reflexive jerking movement of the oral structures
including the soft palate and anterior faucial arch regions
should be observed upon the tongue depressor’s immediate
contact with the right and left sides of the soft palate.
Impaired: No movement, diminished movement or hypersensitive
movement on either side of the palate should be recorded
as impaired and circled in the Comments section of the
form.
Corresponding
Cranial Nerve: Glossopharyngeal IX (sensory) or Vagus X (motor)
Clinical Implications of Soft Palate Deficits
Reduced soft palate sensation, strength and range of motion may result in decreased palatal gag
reflex, hypernasal speech and/or nasal reflux (liquid or food which moves into the nasal cavity
instead of down toward the esophagus). Poor soft palate function may also cause premature
spillage of material over the back of the tongue prior to the triggering of the pharyngeal swallow.
Impaired palatal gag reflex has been shown to be associated with aspiration. Keep in mind, how-
ever, research has shown that 10% of “normal” females and 40% of “normal” males do not display
a gag reflex. (Logemann, 1991). The swallowing therapist should not make clinical decisions
based solely on impaired palatal gag reflex. The entire “clinical picture” of impaired swallowing
symptoms should be taken into consideration prior to making further evaluation or treatment
decisions. Please refer to page 3 for a listing of dysphagia warning signs that can assist you in the
decision-making process.
24 Oral-Motor Examination — Cheeks
Cheeks
Facial Symmetry
Observe the patient’s facial symmetry at rest. Note any asymmetries such as facial “droop.”
This will appear as sagging of the cheeks and lips.
Within Normal Limits: Facial musculature should be symmetrical with no droop-
ing on right or left sides to be within normal limits.
Impaired: Reduced muscle tone (drooping) is considered impaired
and should be recorded in the Comments section of the
form.
Corresponding
Ability to Symmetrically Puff Cheeks

Have the patient puff his cheeks. Look for symmetrical bulging of right and left cheeks. Be
sure to check the function of the velum prior to this task because reduced velopharyngeal
seal can result in decreased oral pressure and may contribute to the patient’s inability to
puff his cheeks.
Within Normal Limits: The cheeks should be symmetrical when puffed.
Impaired: Asymmetry of the cheeks when puffed is considered
impaired, as are minimal and no movement of the cheeks.
Record your observations in the Comments section.
Corresponding
Touch Sensitivity
Ask the patient to close his eyes. Tell the patient, “’m going to touch your cheeks in differ-
ent spots with this swab (or tongue depressor). Let me know if you can feel the touch.” With
a cotton-tipped swab (or tongue depressor) touch at least two random locations inside the
right and then the left cheek and record patient response.
Within Normal Limits: The patient should respond to each touch either verbally or
gesturally to be considered within normal limits.
Impaired: No response or any indication by the patient of diminished
sensitivity is considered impaired. Record this information
by circling absent or diminished in the Comments section.
Oral-Motor Examination — Mandible 25
Corresponding
Cranial Nerve: Glossopharyngeal IX (sensory)
Clinical Implications of Cheek Deficits
Reduced cheek sensation, strength and range of motion may result in pocketing food in the later-
al sulci and biting the cheek.
Mandible
Ability to open mouth adequately

To assess mandibular function necessary for mouth opening, ask the patient to open the
mouth as wide as possible.
Within Normal Limits: The patient should be able to open his mouth wide enough
for a spoon or other implement such as a tongue depressor
to fit inside the mouth without difficulty.
Impaired: Observations of mildly, moderately, or severely restricted
mouth opening should be considered impaired and record-
ed in the Comments section of the form.
Corresponding
Cranial Nerve: Trigeminal V (motor)
Ability to rapidly open and close the mouth

Ask the patient to open and close the mouth as rapidly as possible. Note any slowness, lack
of coordination or incomplete lip closure.
Within Normal Limits: At least two repetitions of mouth opening and closing per
second should be accomplished by the patient to be consid-
ered normal. Lips should make complete contact with each
attempt at closure of the mouth in order to determine full
range of motion for the jaw.
Impaired: No movement or less than two repetitions of mouth open-
ing and closing per second is considered impaired.
Incomplete lip closure is also scored as impaired.
Oral-Motor Examination — Larynx
Corresponding
Ability to Lateralize the Jaw

Have the patient move his jaw to the right, then to the left. Indicate no movement or
reduced movement of the mandible in the Comments section.
Within Normal Limits: Visible movement of the lower jaw past midline to the
patient's right and left sides is within normal limits.
Impaired: No movement or minimal movement which does not bring
the lower jaw past midline on the right or left is considered
impaired.
Corresponding
Clinical Implications of Mandibular Deficits
Impaired mandibular function may result in reduced side to side and rotary action of the jaw
which assists in the formation of a cohesive bolus during the oral preparatory phase of the
swallow.
Larynx
Note: Because it is not possible to view the larynx directly during the bedside assessment,
the clinician can only make inferences regarding the function of this structure. In
many cases further evaluation via the MBS or other instrumental tool is indicated
to more definitively assess the function of the larynx during swallowing.
Vocal Quality
Ask the patient to say “ah” for one to two seconds while you record your subjective judg-
ment of vocal quality in the Comments section of the form.
Within Normal Limits: Clear, sustained phonation with adequate volume is within
normal limits .
Impaired: Any vocal quality that is wet/gurgly, breathy, hoarse, or
harsh is considered impaired.
Corresponding
Oral-Motor Examination — Larynx 5
S|
Volitional Cough
Ask the patient to cough and clear the throat. The focus of this task is on how forcefully the
patient is able to perform. Circle the appropriate observation in the Comments section of
the form.
Within Normal Limits: A strong, forceful cough should be scored as within normal
limits.
Impaired: The inability to produce a cough upon command or a weak
cough is considered impaired.
Corresponding
Cranial Nerve: Vagus X (Motor)
Clinical Implications of Laryngeal Deficits
Reduced function of the larynx may result in decreased lifting of the larynx; hoarse, wet, gurgly
or breathy vocal quality before, during, or after the swallow; coughing before, during, or after the
swallow; and inability to produce a cough upon command. Weakness when coughing or clearing
the throat may indicate reduced ability to clear foreign material from the larynx. If the patient
exhibits impaired vocal quality, referral to an otolaryngologist may be indicated for further evalu-
ation of vocal fold function.
28 Oral-Pharyngeal Dysphagia Symptoms Assessment
Oral-Pharyngeal Dysphagia Symptoms Assessment

This section of the evaluation is designed to assess oral and, to some degree, pharyngeal
swallowing abilities by administering actual foods and liquids to the patient. Evaluation of
oral and pharyngeal stage swallowing abilities is accomplished by giving the patient graduat-
ed amounts of liquid and solid materials. Specific symptoms which signal dysphagia can be
observed during the evaluation. Pharyngeal stage swallowing abilities, however, can only be
inferred at bedside because the swallowing therapist cannot directly observe the pharynx. A
brief review of normal swallowing physiology is included below.
The Normal Swallow

The process of swallowing can be divided into four stages: oral preparatory, oral, pharyngeal
and esophageal. The act of deglutition or swallowing involves a complex series of move-
ment patterns which carry material from the oral cavity through the pharynx and into the
esophagus.
The Oral Preparatory Stage

The initial stage of the swallowing process, the oral preparatory stage, involves placing food
or liquid on the tongue, mixing the material with saliva and forming it into a bolus. With a
liquid, the bolus is formed by holding it between the tongue and the anterior portion of the
hard palate. With solids requiring mastication, lateralization (side to side movement), as
well as rotary action of the tongue and mandible, is required to manipulate the material
into a bolus. The upper and lower teeth tear and crush the solid material which falls back
onto the tongue and is mixed with saliva. This process is repeated until the material has
been formed into a cohesive bolus. Lip and cheek tension prevents material from lodging in
the anterior and lateral sulci. The velum or soft palate is pulled anteriorly and makes con-
tact with the back of the tongue to prevent material from prematurely spilling into the
pharynx prior to the patient’s triggering of the pharyngeal swallow. When the bolus has
been prepared, it is held by the anterior tongue in a cupped position against the hard palate
before the oral stage of the swallow is initiated.
The Oral Stage

The oral stage of the swallow begins at the point where the bolus is propelled posteriorly in
the oral cavity. To initiate the movement of the bolus posteriorly, the tongue elevates to the
hard palate and progressively elevates anteriorly to posteriorly to move the material into
the pharynx. A groove is created on the lingual midline which guides the material down the
tongue and into the pharynx. When the bolus reaches the anterior faucial arch region, a
complex sequence of muscular movements occurs in the pharynx and larynx which ends
the oral stage of the swallow and begins the pharyngeal phase. Transit time for completion
of the oral stage of the swallow is approximately one second.
Oral-Pharyngeal Dysphagia Symptoms Assessment 29
The Pharyngeal Stage

In the normal swallowing process, the pharyngeal swallow occurs when the bolus reaches
the anterior faucial arches. Little is known about the exact event which causes the pharyn-
geal swallow to occur. It is thought that stimulation of the anterior faucial arch region by
food or liquid sends sensory information to the reticular formation in the brain stem. The
brain stem intercepts this sensory information, and, together with cortical input, sends
motor commands back to the pharynx and larynx to initiate the muscular movements of
the pharyngeal stage of the swallow.
During this stage of the swallow, the velum elevates and makes contact with the posterior
pharyngeal wall to prevent material from entering the nasal cavity. The base of the tongue
retracts toward the pharyngeal wall, and the pharyngeal wall contracts toward the base of
the tongue. This creates pressure in the pharynx which helps to propel the bolus through
the pharynx and into the esophagus. Elevation of the hyoid bone is initiated.
Simultaneously, elevation and anterior movement of the larynx occurs, which “tucks” the
larynx under the base of the tongue to help prevent material from entering the airway. This
results from the laryngeal strap muscles being pulled upward by lifting of the hyoid. The
larynx then acts as a valve which closes at three levels, inferiorly to superiorly. The first level
of closure is at the true vocal folds. Next, the false vocal folds adduct. The final level of
laryngeal closure occurs when the base of the epiglottis makes contact with the aryepiglot-
tic folds. The epiglottis inverts to provide airway protection.
Perlman and her colleagues suggested in 1992 that the epiglottis may be mechanically
affected by the movement of the hyoid bone. These researchers have theorized that oral
involvement and epiglottic movement might be related via muscular connections between
the tongue and epiglottis. In other words, the function of the tongue may impact the move-
ment of the hyoid which in turn may influence epiglottic function. Relaxation of the
cricopharyngeal musculature occurs at the same time as the lifting and anterior movement
of the larynx. It is this upward and anterior movement of the larynx that pulls open the
cricopharyngeal sphincter, thus allowing the bolus to pass into the esophagus. Pressure
from the bolus traveling down the pharynx helps to widen the cricopharyngeal region to
allow maximum clearance of the bolus into the esophagus. In the normal swallowing
process, the pharyngeal stage of the swallow is completed in approximately one second.
The Esophageal Stage

The fourth phase of the swallowing process, the esophageal stage, requires 8 to 20 seconds
to complete. Peristalsis, or wave action of the esophageal musculature, carries the bolus
through the esophagus and into the stomach.
30 Instructions for Swallowing Assessment
Instructions for the Swallowing Assessment

The regular assessment method begins with administration of graduated amounts of thin
liquid followed by thick liquid (nectar or tomato juice consistency), pureed, and solid con-
sistencies. The clinician should stop administration of a particular consistency of food or
liquid if coughing, choking or a change in vocal quality is observed. These observations
may indicate that the patient is aspirating. Further evaluation via instrumental assessment
will probably be needed to fully investigate the pharyngeal stage of the swallow if cough-
ing, choking or a change in vocal quality occurs during the Oral-Pharyngeal Dysphagia
Symptoms Assessment.
The swallowing therapist may choose to continue the evaluation when a mild delay in trig-
gering the pharyngeal swallow (1-2 seconds) is the only pharyngeal symptom observed.
Use the scoring key below, and write or circle any pertinent information in the Comments
section. Code letters A - J, which correspond to the food and liquid consistencies and vol-
umes being tested, are located at the top of the columns. In the Comments section, lines are
provided next to each comment so that the swallowing therapist can write appropriate
remarks or code letters when necessary. For example, if the patient exhibits residue in the
lower anterior sulcus after being given 3 cc of thick liquid, the clinician should write “D” on
the line next to “Lower”. If the patient exhibits pocketing of the 5cc volume of pureed con-
sistency in the lower left lateral sulcus, the therapist should write “H” on the line next to
“Lower left” in the Comments section.
Key: Y = _ IMP, impaired (a) > G) = Code letters indicate consistency/volume
Dysphagia Symptoms
The following observable symptoms of dysphagia should be monitored by the swallowing

therapist throughout the bedside evaluation.
Oral Stage of the Swallow

® Drooling or spillage of material out of the mouth before, during or after the swallow.
Drooling or spillage may be the result of decreased lip seal. Circle in the
Comments section whether the leakage was observed on the patient's right side,
left side or bilaterally, and use the code letters to indicate at which volume and
consistency this occurred.
© Pocketing or residue in the oral cavity. Pocketing may be the result of decreased lip
seal, cheek/facial paresis or paralysis, reduced oral sensation, reduced tongue
function and/or dry mouth (xerostomia). In the Comments section, circle any
observation of pocketing or residue in the patient’s upper and/or lower anterior
Instructions for Swallowing Assessment 31
sulci (spaces between the lip and gum) or in the lateral sulci (spaces between the
cheek and gum). Also indicate by circling whether residue was observed on the
patient’s tongue or on his hard or soft palate. Use code letters to indicate volumes
and consistencies.
© Multiple swallows per bolus (piecemeal deglutition). Reduced tongue function may
cause the patient to need multiple swallows to propel the entire bolus into the
pharynx. Record the average number of swallows per bolus for the entire assess-
ment in the Comments section.
Pharyngeal Stage of the Swallow

© Delay in triggering the pharyngeal swallow. Little is known about the exact event
that triggers the pharyngeal swallow. Delays may be caused by reduced sensory
information in the anterior faucial arch region. Detailed instructions for assessing
the triggering of the pharyngeal swallow may be found on page 34. Record the
approximate delay in seconds in the Comments section on the form.
© Coughing or choking before, during or after swallowing. These symptoms may be
caused by material which falls into the open airway. Numerous impairments may
occur in isolation or in combination to cause the laryngeal penetration that trig-
gers coughing or choking. These impairments include delay or absent triggering
of the pharyngeal swallow, vallecular and/or pyriform sinus pooling, reduced
hyoid and laryngeal elevation and deviant epiglottic function.
© Change in vocal quality, i.e., wet/gurgly, hoarse, breathy, strained/strangled, follow-
ing swallows. Changes in vocal quality may be the result of material which enters
the airway and rests on the vocal folds. During the bedside evaluation, the swal-
lowing therapist will not be able to determine whether the material has fallen
below the level of the true vocal folds. Further instrumental assessment may be
indicated if vocal quality is impaired, i.e., breathiness, hoarseness.
© Impaired laryngeal elevation. This may be caused by reduced tongue function,
and/or reduced hyoid elevation. The larynx should lift approximately two centime-
ters (3/4") during the pharyngeal stage of the swallow. You can assess laryngeal ele-
vation while evaluating the triggering of the pharyngeal swallow. Circle reduced in
the Comments section if the larynx elevates less than two centimeters and none if it
does not move at all. Use code letters to indicate volume and consistency.
Note: Some swallowing therapists prefer to perform a swallowing assessment
without giving food or liquid to the patient. Instead, the clinician
observes “dry” or saliva swallows in order to judge the patient’s oral and
pharyngeal swallowing abilities. The saliva swallow technique for assess-
ing swallowing function is described after the instructions for the regular
swallowing assessment. (See page 33).
32 Instructions for the Swallowing Assessment
Regular Method
Note: For all consistencies and volumes tested, circle pertinent observations in the
Comments section. Write appropriate remarks or code letters when necessary.
Thin Liquid
1. For most patients, begin with 3 cc or 1/2 teaspoon of thin liquid, i.e., water consis-
tency, administered by spoon. For some patients, such as those with severe head
injuries who have difficulty managing their own saliva, you may wish to begin the
assessment by administering thicker consistencies. (See Thick Liquid below.) Place
a check in the box next to the symptom in the 3cc column if impairment is
observed.
2. If there is no indication of pharyngeal difficulty such as wet, gurgly or hoarse
vocal quality; coughing or choking, etc.; continue with 5 cc or 1 teaspoon of thin
liquid, and mark your observation of each symptom in the 5 cc column.
3. If you suspect no pharyngeal difficulty with the 5 cc amount of thin liquid, have
the patient drink 2 to 3 swallows of thin liquid from a cup. The patient should
remove the cup from his mouth between each swallow. Mark your observation of
dysphagia symptoms in the Cup column.
Thick Liquid
1. Administer 3 cc or 1/2 teaspoon of thick liquid and place a check in the box
under 3 cc if impairment is noted.
2. If symptoms of pharyngeal difficulty are not present with the 3 cc amount, give
the patient a 5cc amount of thick liquid and check your observation of each
symptom in the 5cc column.
3. If you suspect no pharyngeal difficulty with the thick liquid consistency in the 5 cc
amount, have the patient drink 2 to 3 swallows of thick liquid from a cup. The
patient should remove the cup from his mouth between each swallow. Record your
observation of dysphagia symptoms by placing a check in the box under the Cup
column.
Pureed
|. Administer 3 cc or 1/2 teaspoon of pureed or blended food consistency such as
applesauce, pudding, mashed potatoes, etc. Record your observation of dysphagia
symptoms by placing a check in the box under the 3cc column.
Instructions for the Swallowing Assessment 33
2. If there are no signs of pharyngeal dysphagia with the 3cc amount, continue by
administering a 5cc or one teaspoon amount of the pureed consistency. Record
your observation of dysphagia symptoms by placing a check in the box under the
5cc column.
Solid
1. Write the name of the item being tested on the blank line under Solid.
2. To assess the patient’s ability to chew and manipulate solid materials, administer
1/4 piece of a small shortbread cookie or cracker. Record your observation of
dysphagia symptoms by placing a check in the box under the Solid column.
Other
This column is to be used if other consistencies of food and liquid are utilized by the swal-
lowing therapist during the evaluation. Examples of “other” liquid consistencies are semi-
thick (buttermilk, nectar), and ultra-thick (honey, cream soup). Examples of “other” solids
are ground (ground meats) and mechanical soft (soft cooked vegetables, meat loaf) consis-
tencies. The swallowing therapist should utilize the same protocol for assessment of these
consistencies as that outlined in the preceding sections on thin liquid, thick liquid, pureed
and solid consistencies. If saliva swallows are tested, they should be recorded in this section
following the instructions given below.
Method for Saliva Swallows Only

1. Write “saliva” as the item used on the blank line in the Other column on the
Oral-Pharyngeal Dysphagia Symptoms Assessment form.
2. Ask the patient to swallow. Do NOT administer any foods or liquids to the
patient.
3. Indicate the observation of any of the dysphagia symptoms listed in the Other
column, using the scoring key below.
Key: &% = IMPimpaired
4. In the Comments section of the form, circle pertinent information (if

observed). Place a check mark (/) in the appropriate box when impairment is
observed. Circle pertinent information and write any remarks in the Comments
section.
a Instructions for the Swallowing Assessment
Assessing the Triggering of the Pharyngeal Swallow
You can estimate the effectiveness of the triggering of the pharyngeal swallow by the fol-
lowing method. (See Figure 3 below.) Place your outstretched fingers lightly on the individ-
ual’s neck with the forefinger behind the anterior mandible (sublingual area), second finger
on the hyoid bone, and third and fourth fingers on the thyroid cartilage and cricoid carti-
lage, respectively. Placing your fingers on the mandible and hyoid bone will help you detect
the initiation of the oral transit stage (first lingual movement to propel the bolus posterior-
ly). Impairment in triggering of the pharyngeal swallow should be recorded if the hyoid
bone takes longer than one second to move upward and forward following the first sublin-
gual movement. The third and fourth fingers can detect the upward movement of the lar-
ynx upon the initiation of the pharyngeal swallow as well.
thyroid
cartilage
cricoid
Figure 3. Finger placement on the patient’s neck to “feel” for the triggering of the pharyngeal swallow.
Instructions for the Swallowing Assessment 35
Additional Observations
Additional observations may be noted by the swallowing therapist during the Oral-
Pharyngeal Dysphagia Symptoms Assessment. Check Yes or No to indicate the occurrence
of the following during either the “Regular” or “Saliva Swallows Only” method.
© Head or neck posturing while swallowing may indicate that the patient is attempt-
ing to compensate for oral or pharyngeal stage dysphagia symptoms. Circle the
appropriate remark in the Comments section if you observe the patient moving
his head forward, to the left, to the right or extending it in any direction.
© Associates pain with swallow. Pain may indicate a range of conditions from a
minor sore throat to cancer. Further evaluation by a physician may be indicated if
this condition is identified.
© Nonoral feeding method. This indicates that the patient does not receive any nutri-
tion by mouth. Instead, the patient may receive nutrition in one of the following
ways as determined by his physician. Circle the appropriate method in the
Comments section.
NG — Nasogastric tube
A thin, flexible tube which is inserted into the nasal cavity, through the phar-
ynx and esophagus, down into the stomach by which nutrition is delivered.
IV — Intravenous tube
A thin, flexible tube which is inserted into a vein at the anatomical location
chosen by the physician through which intravenous nutrition and hydration
are introduced.
G-tube — Gastrostomy tube

A soft, flexible tube which is surgically inserted into the patient’s stomach in
order to deliver blended table food or other specially formulated nutrition.
Other
Some patients may receive nutrition in other less common ways such as
J-tube (jejunostomy) or TPN (total parenteral nutrition) feeding methods.
© Has natural teeth. Indicate whether the patient has natural teeth and whether they
are adequate or inadequate for chewing. Circle whether the patient has no teeth
(edentulous) or wears dentures. If the patient wears dentures, circle whether they
are adequate or inadequate for chewing.
e Adequate oral hygiene. Indicate whether the patient has a clean, “healthy looking”
oral cavity. Inadequate oral hygiene may include tooth decay, mouth odor and
residue on tongue, soft palate or hard palate. Circle or write the appropriate
remark in the Comments section.
36 Summary Report Form
Summary Report Form

This form may be completed and used as a guide for a more formal report or detached and
placed directly in the patient’s medical chart.
Identifying Information
Record pertinent identification information. This section contains the patient’s Name, Age,
Swallowing Therapist, Diagnosis, Date of Onset, Date of Evaluation, Current Diet
Consistency and Reason for Referral. You may also wish to stamp the form with your facili-
ty’s medical record information if you plan to place the form directly into the patient's
medical chart.
Summary
This section is provided for the swallowing therapist to summarize the B.E.D. results in
narrative form. Use the reporting format you are most comfortable with.
Recommendations
Upon completion of the Bedside Evaluation of Dysphagia, the swallowing therapist should
make recommendations in the following areas:
Instrumental assessment
Diet consistency (including N.P.O. with nonoral feeding strategy)
Compensatory strategies
Rehabilitation techniques
Assessment by interdisciplinary team members (i.e., dentist, occupational therapist,
etc.)
Each area of recommendation is discussed below.
Instrumental Assessment
Based on the information obtained from the bedside assessment, the swallowing therapist
should make a decision regarding the need for further assessment of the patient’s swallow-
ing abilities. For example, coughing following thin and thick liquid consumption may indi-
cate laryngeal penetration and possible aspiration. Because the clinician is unable to direct-
ly view the pharyngeal stage of the swallow at bedside, further evaluation using instrumen-
tal assessments such as the modified barium swallow (M.B.S.) or fiber-optic endoscopic
evaluation of swallowing (RE.E.S.) may be warranted to definitively assess laryngeal and
pharyngeal function. The clinician may choose to refer for instrumental assessment when
Recommendations — Diet Consistency 37
symptoms other than coughing/choking and a change in vocal quality are observed. For
example, when the patient has impaired palatal gag reflex and a documented history of
aspiration pneumonia, the swallowing therapist may refer the patient for a modified bari-
um swallow in the absence of overt symptoms such as coughing or change in vocal quality.
The swallowing therapist may wish to make referrals for these instrumental assessments
when the patient is observed to exhibit the following warning signs.
¢ Poor posture/positioning
¢ Impaired palatal gag reflex
¢ Abnormal voluntary cough
© Coughing or choking before, during or after swallowing
¢ Change in vocal quality, i.e., wet/gurgly, hoarse, breathy, strained/strangled fol-
lowing swallows
¢ Impaired laryngeal elevation
¢ Impaired secretion management
Diet Consistency
Recommendations regarding the diet consistency the patient is able to tolerate should also
be made if warranted. Typically, liquid consistencies (thin, thick) are chosen by the swal-
lowing therapist to accompany food consistencies (pureed, mechanical, soft, regular). On
page 38 are examples of common diet consistencies that may be recommended following
bedside evaluation of swallowing.
If the swallowing therapist determines that the patient is not able to tolerate any diet con-
sistency by mouth, and no further evaluation is recommended, NPO; nonoral feeding strat-
egy recommended should be selected. When the swallowing evaluation reveals that the
patient is not able to tolerate any diet consistency by mouth and further evaluation is rec-
ommended, NPO until further evaluation completed, nonoral feeding strategy recommended
should be chosen. If no changes in diet consistency are recommended following bedside
swallowing assessment, then Continue previous diet consistency can be checked. Write the
patient’s current diet consistency on the blank line next to this recommendation. If a
change in diet consistency is recommended based on the B.E.D. results, select Diet consis-
tency recommended, and write the appropriate diet recommendation on the blank line.
38 Recommendations — Diet Consistency
Diet ery é
Examples Guidelines for Recommendation
Consistency
When the swallowing therapist determines that

the patient is at high risk for possible aspiration
as indicated by coughing, choking or a change in
vocal quality with any of the consistencies and
volumes of foods and liquids tested. Also, when
the patient’s cognitive impairment and level of
alertness interfere with his ability to swallow safe-
ly and/or efficiently. Frequently, further testing via
modified barium swallow is also recommended.
= _
Thin liquid Water, apple juice, Patients may be allowed thin liquids in addition
tea, coffee, etc. to other foods when no oral or pharyngeal diffi-
culties are suspected or observed.
Thick liquid Nectar, tomato When a delay in triggering the pharyngeal swal-
juice, cream gravy, low is observed and no other pharyngeal difficul-
ty is suspected or observed, i.e., coughing,
cream soup, etc. wet/gurgly vocal quality before, during or after
swallows
Pudding, mashed When the patient exhibits difficulty with the oral
potatoes, apple- preparatory or oral stage of swallowing with mild
: or no pharyngeal symptoms of dysphagia sus-
sai anes pes pected or observed. Tongue pumping, lack of oral
etabies, etc. coordination and an inability to form material
into a cohesive bolus are some of the symptoms
that may contribute to a pureed diet consistency
recommendation.
Mechanical soft Soft cooked vegeta- When the patient exhibits reduced oral stage
bles, pasta, baked swallowing abilities but is able to manipulate soft
food with more texture than a pureed consisten-
apples, baked chick- cy (with mild or no pharyngeal symptoms of
en, etc. dysphagia suspected or observed). Meats may be
chopped or ground, depending on how the
patient handles chewing solid consistencies dur-
ing the oral preparatory and oral stages of the
swallow.
Regular All consistencies of When mild or no oral stage difficulties are

foods and liquids observed and no pharyngeal stage symptoms of
dysphagia are suspected or observed.
Note: It is common practice to choose one liquid consistency and one food consistency
for a patient.
Recommendations — Compensatory Strategies 39
Compensatory Strategies
Recommendations should be made regarding any compensatory strategies that might be
needed, There are a number of compensatory strategies that can be implemented in the
treatment of patients with dysphagia. These strategies can be used alone or in combination
with rehabilitation techniques depending on their effectiveness with individual patients.
The following compensatory strategies may be selected upon completion of the B.E.D.
(with or without recommendation for M.B.S. or RE.E.S. study). These strategies are not the
only ones available to a therapist. Rather, they represent those strategies which can be cho-
sen with clinical discretion without the absolute need for further verification by instrumen-
tal assessment when no pharyngeal difficulties are observed or suspected. Place a check
mark next to the strategies recommended.
© Supervising or assisting eating and drinking. When treating dysphagic patients, the
swallowing therapist should make recommendations regarding the amount of
supervision and/or assistance needed during oral intake, including snacks. The
level of supervision and assistance will depend upon the severity of the swallowing
difficulty and on patient cooperation, alertness and cognitive status. Some dys-
phagic patients may require very close supervision or a great deal of assistance,
while others may only need help intermittently.
© Sitting Upright with Hips Flexed to 90 Degrees. Postural changes are compensatory
measures which facilitate the patient’s swallowing ability. They are optimally used
with dysphagic patients who exhibit at least moderately intact cognition and the
ability to follow simple commands, i.e., tilt chin down or turn head to one side. A
patient exhibiting significantly reduced cognition or receptive language ability may
not be able to utilize postural changes as a compensatory technique. This individ-
ual usually demonstrates minimal carry-over from session to session and requires
continual verbal, visual or tactile cues. Some of these patients may eventually bene-
fit from cues if all those who help with feeding use the cues consistently.
Generally, patients who do not exhibit anatomical disturbances such as oral or
oropharyngeal cancer resulting in surgical removal or resection of the tongue, lips,
pharynx, etc., or those with medical conditions such as hypotension or vertigo,
should sit upright with hips flexed to 90 degrees during all oral intake, including
medication intake. This position allows for the natural flow of material through the
oral cavity and pharynx to the esophagus via anatomic propulsion, with the benefit
of gravitational pull. If a patient is restricted to bed rest and is required to eat or
drink in bed, the clinician or caregiver should elevate the head of the bed to its
upright position. It may be necessary to put pillows behind the patient’s back and
head to achieve proper body alignment.
40 Recommendations — Compensatory Strategies
© Reducing the size of the bolus. The swallowing therapist may recommend the
reduction of the bolus size to 1/3 to 1/2 teaspoon (or 2 to 3 cc) to increase swal-
lowing safety. A spoon with a smaller “bowl” may be used in an effort to manage
the size of the bolus. Spoons with shallow bowls are normally available in occu-
pational therapy departments. Typically, dysphagic patients tolerate smaller than
normal amounts of liquids and solids more efficiently, thereby reducing the risk
of aspiration.
Avoiding the use of drinking straws. Many dysphagic patients have difficulty con-
trolling the amount of liquid taken in through a straw. It is easy for too much liq-
uid to flow into the patient’s mouth. The caregiver can control liquid flow by
pinching the straw but can only estimate the volume of liquid in the straw.
Therefore, the use of a straw is usually discouraged with most dysphagic patients.
Checking for pocketing. Patients with oral stage dysphagia that is characterized by
lateral and/or anterior sulcus pooling or pocketing usually require the caregiver to
check for pocketing of food in these cavities. Reduced cheek tension, decreased
oral sensation and impaired tongue and lip function make it hard for these patients
to clear away food independently. (These patients may also be dysarthric due to
reduced oral agility.)
First, ask the patient to perform tongue sweeps (maneuver the tongue from side to
side in the lateral and/or anterior sulci) within the oral cavity to determine his abil-
ity to clear food independently. Then, check the oral cavity yourself to determine
how well the food has been cleared. If the patient is unable to remove the material
independently, assist him either with gloved fingers or long cotton swabs.
If the patient has a left-sided facial droop (left-sided facial weakness), the clinician
should check the upper and lower left lateral sulci, the anterior sulci, and beneath
the tongue for remaining food particles. The same technique would apply to
patients having right-sided facial weakness.
The clinician should also be concerned with patients who have improperly fitting
dentures. Food particles may become lodged between the gum ridge and dentures,
and, if not removed and the patient reclines, those food particles may dislodge and
cause the patient to aspirate. This is an essential compensatory strategy with
patients exhibiting oral stage dysphagia who also have oral and/or facial paresis or
paralysis. After meals the clinician should check for pocketing with long cotton-
tipped swabs, or, wearing latex gloves, with her fingers. The swallowing therapist
also needs to train patients, staff and family to check for pocketing to ensure con-
sistent and proper treatment. In most cases, dentures should be routinely cleaned at
least once daily by the patient or caregiver. It is a good idea for patients with loose-
fitting dentures to clean them after each meal to eliminate build-up of food parti-
cles between the gums or hard palate and the denture plates.
Recommendations — Rehabilitation Techniques 41
Additional space is provided for other compensatory strategies the swallowing therapist
may recommend. For example a patient may have difficulty drinking from a regular cup,
therefore, the clinician may recommend the use of a nosey cup to compensate for the diffi-
culty. Other compensatory strategies such as tilting the chin down, turning or tilting the
head to the right or left, swallowing at least two times per bolus, and alternating solids with
liquids should be recommended only after instrumental assessment. These strategies are
not recommended until after instrumental assessment because the swallowing therapist
cannot verify their effectiveness at the bedside. For a more complete discussion of these
strategies, please refer to Hardy and Robinson, 1993.
Rehabilitation Techniques
The swallowing therapist may recommend rehabilitation techniques following completion
of the bedside evaluation. These techniques can be used alone or in combination with com-
pensatory strategies depending on their effectiveness with individual patients. The follow-
ing rehabilitation techniques may be selected upon completion of the B.E.D. (with or with-
out recommendation for M.B.S. or FE.E.S. study). These are not the only techniques avail-
able to the therapist. Rather, they represent those techniques which can be chosen with
clinical discretion without the absolute need for verification by instrumental assessment
when no pharyngeal difficulties (other than a mild delay in triggering the pharyngeal swal-
low) are observed or suspected. Place check marks next to the techniques recommended.
® Thermal-Tactile Stimulation. Also referred to as thermal stimulation, thermal sen-
sitization, and thermal application. This is an indirect treatment approach which
stimulates the triggering of the pharyngeal swallow through repeated cold (ther-
mal) contact (tactile) to the anterior faucial arch region. It is designed to be effec-
tive with patients who exhibit a delayed or absent triggering of the pharyngeal
swallow. Its purpose is to heighten sensitivity in the anterior faucial pillar area, so
that when food or liquid is introduced, the pharyngeal swallow may be triggered
more readily. This technique may be chosen when the clinician observes no other
pharyngeal stage symptoms of dysphagia, i.e., coughing or wet/gurgly vocal qual-
ity, that would necessitate the need for further instrumental evaluation.
© Oral-Motor Exercises. The use of oral-motor exercises is an indirect treatment

approach to strengthen and improve range of motion of the labial, lingual, facial
and mandibular muscles. The exercises may be helpful for patients who have pro-
longed oral and/or pharyngeal transit times caused by reduced lingual mobility
or oral sensation, lack of oral coordination and reduced manipulation of the
bolus, or labial or facial weakness or incoordination. The swallowing therapist
should tailor the exercise program to meet the needs of the individual.
Other rehabilitation techniques such as the Mendelsohn Maneuver and the Supraglottic
Swallow technique should be recommended only after instrumental assessment. These
2 Recommendations
techniques are not recommended until after instrumental assessment because the clinician
cannot verify their effectiveness at the bedside. For a more complete discussion of these
and other techniques, please refer to Hardy and Robinson, 1993.
Other
The swallowing therapist should also make recommendations to the patient’s physician
regarding referral to other interdisciplinary team members for further assessment if war-
ranted. For example, a patient with poorly fitting dentures may require the services of a
dentist. An individual who displays motoric difficulty getting food from the plate to the
mouth may need a referral to an occupational therapist. Record this information under
“Other” on the form.
Response Form and Summary Report Example

The example that follows on pages 45-51 is included as a guideline for completion of the
B.E.D. response form and Summary Report. The fictitious person represents a typical
patient with a history of left hemispheric stroke, aphasia, dysarthria and dysphagia.
References 43
References
Goodglass, H. and Kaplan, E. Boston Diagnostic Aphasia Examination. Philadelphia: Lea
and Febiger, 1983.
Groher, M., (Ed.). Dysphagia: Diagnosis and Management. Stoneham, MA: Butterworth
Publishers, 1984.
Hardy, E. and Robinson, N. Swallowing Disorders Treatment Manual. Bisbee, AZ: lmaginart
Press, 1993.
Kertesz, A. The Western Aphasia Battery. New York: Grune and Stratton, 1982.
Langmore, S.E., Schatz, K. and Olsen, N. Fiber-optic endoscopic examination of swallowing
safety: A new procedure. Dysphagia, vol. 2, no.4: 216-219 (1988).
Linden, P., Kuhlemeier, K. V., and Patterson, C. The probability of correctly predicting sub-
glottic penetration from clinical observations. Dysphagia, vol. 8, no. 3: 170-179, (1993).
Logemann, J. Evaluation and Treatment of Swallowing Disorders. San Diego, CA: College
Press, 1983.
Logemann, J. New Dimensions in Dysphagia Management, Course II. Seminar presented in
Houston, TX, 1991.
Mason, Mary F. Speech Pathology for Tracheostomized and Ventilator Dependent Patients.
Newport Beach, CA: Voicing!, 1993.
Perlman, A.L. Major Issues in the Diagnosis and Treatment of Oropharyngeal Dysphagia.
Seminar presented at the Texas Speech-Language-Hearing Association Annual Convention,
Fort Worth, TX, 1993.
44 About the Author
About the Author

Edward Hardy, M.S., CCC-SLP, is Director of the Center for Audiology and Speech
Pathology at San Jacinto Methodist Hospital in Baytown, Texas. He received his B.S. in
Speech and his M.S. in Speech Pathology from Lamar University in Beaumont, Texas. Mr.
Hardy has been an adjunct clinical supervisor for Lamar University since 1990. He special-
izes in managing dysphagia in neurologically-impaired adults. He maintains memberships
in the Houston Association for Communication Disorders, Texas Speech-Language-
Hearing Association and the American Speech-Language-Hearing Association. Mr. Hardy
enjoys spending time with his wife, Debbie, and his son, Stephen. Travel, racquetball and
gardening are his special interests.
BEDSIDE EVALUATION OF DYSPHAGIA™ RESPONSE FORM
Patient’s Name: fou Swallow Age: 7.2 Swallowing Therapist: Sue Speech
Diagnosis: _2 — Cl Date of Onset: 9//5/96 Date of Evaluation: __9/20/96
Current Diet Consistency: Regular with all liquids Reason for Referral: _Coughing with liquids
Check all behaviors observed:
_woS Alert Lethargic

aes Cooperative Uncooperative
Aware of Difficulty Unaware of Difficulty
Left or Right Neglect Impulsive
Poor Posture/Positioning Other:

Cognition
Short-Term Memory: _ Initially, then at 5 minute intervals, Number of times name repeated by examiner in 15 minutes _3
ask patient to recall your name. Number of times name recalled by patient in 15 minutes ___2
WNL=Recall offirst or last name on 2 of3 requests in 15 minutes..
Orientation: What day is today? __ Tuesday

What month are we in? ___September
What year are we in? ___/996
Where are you? __ the hospital
Attention: _Is the patient able to sustain attention necessary

for safe swallowing?
Receptive Language
RATT
ST We ey
One-step command: Open your mouth, or raise your hand. Ja
COMMENTS
(Choose one.)
Two-step command: Point to the door, ther’ o the

ceiling.
Answer personally relevant yes/no questio
Are you in the hospital? Are the lights on?
Count from | to 10.
State the days of the week.
State name and address.
WNL = within normal limits IMP = impaired

Copyright © 1995 Imaginart International, Inc. 307 Arizona Street, Bisbee, Arizona 85603, U.S.A. All rights reserved. 45
COMMENTS Corresponding Cranial Nerve

Write or circle appropriate remark. Sensory Motor
Lip closure at rest Droops on Left Mouth Breathing

Rroops on Right Involuntary Movement
Droops Bilaterally Mouth Breathing
Protrusion: Pucker your lips. Droops on Left No Movement
Rroops on Right Partial Movement
Droops Bilaterally Involuntary Movement
Retraction: Smile Droops on Left No Movement
Droops on Right Parti-) Movement
Droops Bilate: "= _ Ir lun ty Movement
Rapid protrusion/retraction (3s onds,°
Pucker and smile as fastas yc ‘anuntillt~.
you to stop.
WNL=2 sets of alternating movements in 3 secc
Rapid closure: Say “puh, puh, pu. ’as fa . as
you can.
WNL=6 repetitions in 3 seconds
Strength: Remove tongue depressor from

between closed lips.
*Touch Sensitivity:
| Tongue
Write or circle appropriate remark. Sensory Motor
Protrusion: Stick out your tongue Fasciculation XII

sae Deviates to: Left
WNL=fully extended midline protrusion for 2 seconds.
Retraction: Pull your tongue as far back into V, XII

your mouth as you can,
Lateralization:
To left corner of lips: Move your tongue to XII
the left corner of your lips.
To right corner of lips: Move your tongue to
the right corner of your lips.
Rapid left/right lateralization: Move your | XI
tongue from corner to corner of your
lips as fast as you can.
WNL=at least 3 repetitions ofsteady corner to
corner movements. ; oS
Into left cheek: Touch the inside of your left
cheek with your tongue.
Into right cheek: Touch the inside of your
right cheek with your tongue.

46 Copyright © 1995 Imaginart International, Inc. 307 Arizona Street, Bisbee, Arizona 85603, U.S.A. All rights reserved.
Tongue, continued
WNL IMP COMMENTS ponding Cranial Nerve
Corresponding
Write or circle appropriate remark Sensory Motor
Tongue-Tip Elevation:
To hard palate: Open your mouth. Put the wf XI
tip of your tongue to the roof of your
mouth behind your teeth.
To upper lip: Try to reach your nose with
your tongue.
Tongue-Tip Depression:
To floor of mouth: Open your mouth. Put / x
the tip of your tongue behind yor.
bottom teeth.
To lower lip: Try to reach your chin *
your tongue.
Strength: Ask the patient to position the wiyzue

in the following manner.
Tip against tongue depressor a
Left side of tongue against tongue =

depressor
Right side of tongue against tongue

depressor
Elevated blade against tongue depressor
Tongue in left cheek against finger

resistance
Tongue in right cheek against finger

resistance
*Touch Sensitivity (Tongue)

Ask the patient to close his eyes. Tell the
patient: “I’m going to touch your tongue in
different spots with this swab [or tongue
depressor]. Let me know if you can feel the
touch.” With a cotton-tipped swab or tongue
depressor, touch the following locations and
record patient response.
Left Anterior Third
Left Middle Third
Left Posterior Third
Right Anterior Third
Right Middle Third
Right Posterior Third
* Touch Sensitivity tasks may be administered in sequence or grouped together prior to or following the other oral exam tasks.

- Soft Palate
WNL CALS
Write or eon ae
circle appropriate are
remark S ensory
r Motor
Deviation from midline: Deviates to: Left i IX

Observe palate at rest.
Deviates to: Lett

Ability to raise palate:
Sav, “Ah.”
Ability to sequentially raise and lower palate: BUSES Ey ponaes :

say, “Ah, ah, ah.”
“Touch Sensitivity Absent ( Diminished ) Hypersensitive

Palatal Gag Reflex ;
Touch the soft palate
with a tongue depressor.
Absent Diminished Hypersensitive
WNL COMMENTS Corresponding Cranial Nerve

Write or circle appropriate remark. Sensory
Facial Symmetry:
Observe facial symmetry at rest.
Ability to symmetrically puff cheeks:

Puff out your cheeks.
*Touch Sensitivity (Cheeks) Absent

Ask the patient to close his
eyes. Tell the patient: “I’m
going to touch your cheeks
in different spots with this
swab [or tongue
depressor]. Let me know if
you can feel the touch.” Absent Diminished
With a cotton-tipped swab
or tongue depressor, touch
random locations inside
the right and left cheeks
and record patient
response.
* Touch Sensitivity tasks may be administered in sequence or grouped together prior to or following the other oral exam tasks.
Mandible
WNL | IMP COMMENTS Corresponding Cranial Nerve
Write or circle appropriate remark Sensory Motor
Ability to open mouth adequately: Opening is:

Open your mouth as wide as possible. vA mildly moderately severely
restricted restricted restricted
Ability to rapidly open and close the mouth: icomplete lip closure
Open and close your mouth as quickly as uncoordinated
possible.
WNL=2 repetitions per secon:
Ability to lateralize the jaw: N_10vement on: Left Right

Move your jaw to the mn >t, th: .1 to the ieft.
bi al ; - Decreased movement on: Leftf ( Right —)
tla
WNL COMMENTS Corresponding Cranial Nerve
Write or circle appropriate remark. Sensory
Vocal quality: Wet/gurgly Breathy

Have the patient sustain “ah.” Bparse
WNL=clear sustained phonation with adequate volume.
Volitional cough Unable to

Have the patient cough on command. perform
WNL=strong, forceful cough.
Warning! The examiner should utilize clinical judgment in administering foods and liquids to the patient. Each patient is
unique. Some patients may not be appropriate candidates for administration of all consistencies in all volumes. Suction
equipment and personnel trained in its use should be readily available.
Key: / = _ IMP, impaired (i) = Code letters indicate consistency/volume
Oral-
LPharyngeaDySPee esSymptoms Assessment
DYSPHAGIA N /
Comments
SYMPTOMS K M ; WS ne
Ele o Circle pertinent information.
Write appropriate remarks or code letters when necessary.
Item Used Item Used
—OralStage
Drooling or spillage of material Leakage on: € Right ) Bes Oma
out of the mouth before, Left
during or after the swallow. | Bilateral
Pocketing of material / residue | Anterior Sulcus:

in the oral cavity. | | | Upper Lower
Lateral Sulcus:
Upper Left
Lower Left
Soft Palate
Multiple swallows per bolus. Average number

of swallows per bolus:
Delay in triggering the eaperrcncte Delay:

pharyngeal swallow. Sass
J | 5 _| Secon
Coughing or choking before, Before During ae

during or after swallowing. tf
Change in vocal quality, i-e.,

wet/gurgly, hoarse, breathy, J
strained/strangled following Strained/strangled
swallows. Breathy
Additional Ob servations
COMMENTS
Write or circle appropriate remark.
Head or neck posturing while swallowing Forward Left Right Extended
Associates pain with swallow
Non-oral feeding method NG IV _G-tube Other:
Has natural teeth Natural teeth: Adequate/ Inadequate for chewing

(Wears dentures:) \ Adequatey Inadequate for chewing
Edentulous (no teeth)
Adequate oral hygiene Residue on: Tongue Mouth Odor

Soft Palate
Hard Palate Other:
BEDSIDE EVALUATION OF DYSPHAGIA™ SUMMARY REPORT
Patient’s Name: fohu Swallow Age: 7.2 Swallowing Therapist: Sue Speech
Diagnosis:__2 — CLM Date of Onset: 9/75/96 Date of Evaluation: 9/20/96
Current Diet Consistency: Kegular with all liguids Reason for Referral: _ Coughing with liquids
Summary
Cag & Comm: anomia and flaccid dysarthria present; Cognition and receptive language skills appear tebe WNL.
OnalMotor Exam: Decreased lip, longue, cheek & jaw strength and range ofmotion onR Impained sensation of ant. 113 of
Recommendations
Modified Barium Swallow Study

Fiber-Optic Endoscopic Evaluation of ee (RE.E.S.) Study
NPO: Non-oral feeding strategy recommended
NPO until further evaluation completed; non-oral feeding strategy recommended.
Continue previous diet consistency:
Diet consistency recommended:
Supervise orassi g Thermal-Tactile Stimulation

Sit upright with ps flexed to 90° Oral-Motor Exercises:
Reduce size of bolus to
No drinking straws
Other:
Sue Spooch, MS, CCC-SLP

Swallowing Therapist
4 ? shay $") f ae | ftc* '
tac Miele, a
ree ‘
;
eee
é
itor . a are
9 vo Me
? ( wh pwigtet | " 7,
’ [ 5
(woo enw ie Sy nur (are fe :

i 7 ir @
} | ,., saan oyge gah itn SP!

r an er
Pe ee le
aC eninge?
ont a ‘See as
§,tat-—
uma psinart 307 Arizona Street Bisbee, AZ 85603 ISBN 1-883315-10
WTO
WT</
W7-

Bedside Evaluation of Dysphagia - Edward Hardy - 1999 - Imaginart - 9781883315108 - Anna's Archive

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Bedside Evaluation of Dysphagia - Edward Hardy - 1999 - Imaginart - 9781883315108 - Anna's Archive

Uploaded by

Copyright:

Available Formats

Imaginart International, Inc.

307 Arizona Street

Copyright © 1995 by Imaginart International, Inc. All Rights Reserved.

Cover design by Kelly Hume.

Edited by Cindy Drolet and C. Gilles-Brown.

Manufactured in the United States of America.

It is a fascinating experience to develop an idea into a product for use by speech-language

DOW W SOUrik ef 766) C.0i.4

ose 4w seattivons Dew ot tenon oes

Development ofthe Bk. D. aineete ix ue arse Pate rH rn ered REA woes 1

REVS UIT CRSCSG Seek Bs ie BSA Ra Ae nS Ree rec ag ne 4

Administration of the B.E.D.

Filling Out the Response Form

Summary Report Form

About the Author

Development of the B.E.D.

Poor posture/positioning — any time the patient is slumping, reclining or lying

Administration of the B.E.D.

Behavioral Characteristics Place a check mark (/) beside all behav-

Cognition and Communication Record your observations of each item as

Oral-Motor Examination Record your observations of each item as

Oral-Pharyngeal Dysphagia Symptoms | Place a check mark (/) in the appropri-

Filling Out the Response Form

Clinical Implications of Behavioral Deficits

Cognition and Communication Screening

Short Term Memory

What year are we in?

Clinical Implications of Cognitive Deficits

Answer personally relevant yes/no questions

Clinical Implications of Receptive Language Deficits

Generally, in order for a patient to be able to successfully participate in a swallowing intervention

Expressive Language/Speech Production

Tell me the days of the week

Name and Address

Clinical Implications of Expressive Language/Speech Production Deficits

Results of a more in-depth assessment of expressive communication skills (including speech

Lip closure at rest

Rapid protrusion/retraction (3 seconds)

Impaired: Fewer than 3 repetitions in a 3 second period of time is

Clinical Implications of Lip Deficits

Impaired: Moderate to no retraction of the tongue; lifting the tongue

depressor. A subjective judgment of good, fair, or poor strength should be

Left Anterior Third

Left Posterior Third Glossopharyngeal IX (sensory)

Right Middle Third Facial VII (sensory)

Clinical Implications of Tongue Deficits

Deviation From Midline

Ability to Raise the Palate

Ability to Sequentially Raise and Lower the Palate

Clinical Implications of Soft Palate Deficits

Ability to Symmetrically Puff Cheeks

Clinical Implications of Cheek Deficits

Ability to open mouth adequately

Ability to rapidly open and close the mouth

Ability to Lateralize the Jaw

Clinical Implications of Mandibular Deficits

Clinical Implications of Laryngeal Deficits

Oral-Pharyngeal Dysphagia Symptoms Assessment

The Normal Swallow

The Oral Preparatory Stage

The Oral Stage

The Pharyngeal Stage

The Esophageal Stage