October 2007 Newsletter




Consultants in Dysphagia Evaluation and Management
817-514-MBS1 or 1-888-514-MBS1
Clinical Café Newsletter
By: Ronda Polansky M.S. CCC-SLP
October 2007
Monthly Motivation:
The pleasure you get out of life is equal to the attitude you put into it.

Upcoming E-Stim Conference – Last one of this year. Don’t miss it!
Introducing the 510K cleared RX3 electrodes for treating laryngeal elevation!
San Antonio, Texas – October 28, 2007. Professional Imaging LLC is a Mobile MBSS company in East Texas, Houston, Austin, and San Antonio, not a part of DiagnosTEX, LLC.  They have invited us as guest speakers; please call their Corp office 1-866-675-MBSS to register or any questions.

DiagnosTEX will be fully operational on Columbus Day. Other dates to remember this month
1st-7th – Residents Rights week – To honor residents living in all long term care facilities
1st-7th – National Healthcare Food service Week –  Honors employees who work behind the scenes preparing and serving food in health care facilities
16th – National Boss’ Day
14th-20th – National Healthcare Quality week – Increases awareness and appreciation of healthcare quality
21-27th – National Infection Control week
21st-27th – National Respiratory Care Week – this week used to promote respiratory health
27th – Make a Difference Day. Created by USA Weekend.  A national day of helping others.

Do Your Part!  Advocacy Tools:
Write Congress in Less Than 5 Minutes http://www.takeaction.asha.org/asha2/home

New ICD-9 Codes go into effect for Dysphagia on October 1, 2007 (www.asha.org)
787.20 Dysphagia, unspecified
787.21 Dysphagia, oral phase
787.22 Dysphagia, oropharyngeal phase
787.23 Dysphagia, pharyngeal phase
787.24 Dysphagia, pharyngoesophageal phase
787.29 Other dysphagia
The distinction of “dysphagia unspecified” and “other dysphagia” may be somewhat confusing at first. One may want to approach it by thinking that an SLP should expect a referral from a physician with the “unspecified” diagnosis while the “other dysphagia” should rarely be used. Dysphagia unspecified (787.20) is consistent with the ICD-9-CM classification as “not otherwise specified” (NOS). That is, no other distinction is made other than the diagnosis “dysphagia”. It could be the general diagnosis given as the reason for a referral to see a speech-language pathologist for more definitive diagnosis.  On the other hand, “other dysphagia” (787.29) refers to “not elsewhere classified” (NEC) in ICD-9-CM parlance. This code is needed to allow for situations when someone may be diagnosed with a type of dysphagia that is not classifiable using any of the specific codes. Rather than assign the diagnosis to “unspecified,” the ICD-9-CM convention is to assign it to this “other” code. Also, in the case of these new dysphagia codes, the ICD-

9-CM will identify other relevant terms to 787.29 other dysphagia — cervical dysphagia and neurogenic dysphagia. For a speech-language pathologist, the “other” code could be used if the diagnosis given after evaluation does not fall into one of the new four phases of dysphagia codes.

DiagnosTEX educational day last month – It was so fun to spend the weekend with many of you at the exciting conference last month here in DFW.  We enjoyed the professional discussions as well as the socialization! Also thank you all of your understanding regarding the scheduling of your MBSS the following week as we worked diligently to get everyone in.
Dysphagia Tidbit – NIH For those of you who attended the DFW conference, I would like to address some questions DiagnosTEX SLP’s have been approached with regarding study published by Christy Ludlow, Ph.D on the Effect of Surface Electrical Stimulation on Hyo-laryngeal Movement in Normal Individuals at Rest and During the Swallowing, published in 2006.  I spoke with Dr. Ludlow about her study even before it was published.  She is also aware of our E-stim protocol and its differences.  This study on the effects on the normal individuals included the use of the Vital Stim Stimulation Unit, fixed at 80Hz pulse rate and a fixed biphasic pulse duration of 700 microseconds, and 4 adult size electrodes.  These 4 electrodes were used for 10 different placements.  The results shown and discussed at the conference included no significant elevation and some anterior movement in the hyoid bone. This would absolutely be expected at the fixed settings and 4 adult sized electrodes (VitalStim, REF 59000) with a 2.1 cm round active area on submental placement. Other results indicated that placement 3B showed the greatest laryngeal descent and no significant difference in pharyngeal transit times occurring between stimulated and no stimulated swallows. The risk for aspiration and swallowing safety worsened during stimulation. When stimulation that produced hyoid bone decent at rest was applied during swallowing, it reduced the extent of laryngeal and hyoid bone elevation in healthy adults and temporarily modified a normal swallow despite the intact musculature and normal coordination. The results suggested that normal healthy adults were not able to overcome the stimulation effects and that their hyo-laryngeal elevation did not achieve the same level as during nonstimulated swallows. 
For those who have attended our conferences on E-stim, know that our protocol requires the following:
          Waveform – Symmetrical Biphasic
·         Output intensity – 0 – 100 milliamps (mA)
·         Frequency – 30 pulses per second (pps or Hz)
·         Phase duration – 40 to 250 microseconds (µsec)
·         Channel mode – single
·         Ramp  – 0.4 – 1 second
·         Cycle time – 1 to 5 (1 to 3 or 1 to 2 option is nice)
We have documented hyolaryngeal elevation both on fluoro and FEES and specific placement of 2 electrodes on the submandibular area and identifying a motor point.  In our first 2007 conference we were able to share the results of our ongoing study. In this study, 64% of the patients who received at least 20 days of the NMES protocol had a diet upgrade, while 36% of the patients did not improve in diet upgrades.  It should be noted that 4 patients were already at a high swallow rating prior to beginning therapy (mechanical soft with thin liquids), and therefore did not have much room to improve.  In the traditional therapy arm of this review 10% of patients improved to achieve a diet upgrade, 80% of the patients did not improve to a diet upgrade and 10% of the patients had a decline in ability.  There were no significant adverse events that occurred during this study period.  Dr. Ludlow and I spoke at the conference and I hope we have the opportunity to share more of our information with her soon.  We are excited about the ongoing research in so many areas of this hot topic.  I look forward to more!
NEW – Rx3E 510 cleared Electrodes for Laryngeal elevation
Custom designed to fit the submandibular area with silver inlays for maximum conduction! Available Oct. 20th!!!!
To order call 1-800-793-5544.The 510K cleared Rx3E electrodes to treat reduced laryngeal elevation, used with the protocol in this upcoming conference, can be used with any current FDA approved NMES devices on the market for muscle reeducation with the correct parameters, at a cost of $8.95 per 4 reusable electrodes.  Only 2 are required for the ESP protocol.  At $8.95 for 1 package of 4 electrodes (2 electrodes being used at a time and reusable for 5-6 treatments, one package lasting approximately 10-12 treatments) or .75 cents per E-Stim treatment with the Rx3E.

FYI – If Hyolaryngeal exercises are recommended as a therapeutic recommendation, this does encompass
E-Stim as TX for laryngeal elevation as well as other traditional exercises.  Under our treatment recommendation these recommendations are based off the general pathology of the swallow and the treating therapists determines specific application of the treatment plan.