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Tools of the trade: VFSS Edition

Implementing a VFSS analysis tool doesn’t have to be complicated—if you know your options! We'll go through the major contenders (yes, there's a printable chart) so you can find the best fit for your facility. 

October 4, 2022

We know it’s best practice to use a specific study protocol and analysis reporting tool for VFSS (see here and here). It provides guidelines to ensure we’re doing the same thing each time we conduct a swallow study and holds us to a higher standard in our analysis and report writing. This benefits everyone: the patient,  the physician reading our reports, and us getting our patients to the next level of care.

 

But do you ever feel stuck in selecting a VFSS analysis tool? 

 

You’ve probably heard of a few, but it can be hard to choose when there are so many options, plus funding and productivity concerns to balance. You just want to select the best tool for your facility, after all, and no one likes having to choose twice.

 

We took the time to compare a number of the VFSS analysis tools that are out there. We skipped tools that only measure one thing (like the Penetration Aspiration Scale) and focused on the more comprehensive tools meant to help you capture the study as a whole. The ones featured here are the ones we’ve seen frequently mentioned in research or often used by clinicians; there are more tools out there. You’ll want to keep in mind, though, that even clinicians with certifications in interpreting instrumental swallow studies or their BCS-S tend to struggle with identifying primary physiologic impairments in patients with complex swallowing difficulties unless they’re using frame-by-frame analysis. We’ve pointed out which tools make use of this strategy.

Jennifer Hyles, MA, CCC-SLP

Below, we’ve broken down everything you’ve ever wanted to know about these VFSS tools. It’s a lot, but you can also download this easily digestible chart that includes more information about research, time, and bolus selection—another tool at your disposal, if you will. 

 

(Download the PDF here)
 

Now to unpack this VFSS toolbox!

 

ASPEKT-C: Analysis of Swallowing Physiology: Events, Kinematics and Timing (Clinical)

  • What does it measure? Pharyngeal physiological parameters which assess swallowing safety and swallowing efficiency.
  • Does it require frame-by-frame analysis? Yes
  • Useful for identifying pathophysiology and treatment targets? Yes. No oral phase deficits are assessed, but the ASPEKT-C does measure things like laryngeal vestibule closure, swallow timing, swallows per bolus, residue quantities and pharyngeal constriction for each bolus. The method can also be used on compensatory swallows to appreciate effect. There’s also a treatment planning flowsheet available.
  • Does it describe severity or normality? Yes, a binary of “typical” or “atypical” is scored for each bolus on each parameter. These ratings are defined relative to quantitative normative reference values, for healthy adult swallowing, which are available for thin to extremely thick liquids (IDDSI 0 to 4).
  • How do I use it? The ASPEKT-C is free! Use this worksheet and scoring sheet, after consulting this step-by-step instruction manual and this YouTube tutorial from Dr. Catriona Steele herself. There is no standardized administration protocol. You’ll need analysis software (like Image J – a free and easy to download tool). Don’t miss the best practice VFSS chart which discusses how frame rate, bolus administration, sip size, and more that can affect these values. For those who want to pursue formal training, a certificate training course for ASPEKT-C is planned for launch in 2023.
  • Who developed this tool? Dr. Catriona Steele and colleagues
  • What else should I know? The ASPEKT-C (C stands for CLINICAL) was developed specifically for practicing clinicians with time constraints, so it’s worth trying even if you’re worried about productivity. The full ASPEKT Method can be used for comprehensive analysis of a larger number of physiologic components. This might be a better choice if your facility is involved in research or a VFSS-specific QI project. The ASPEKT Method has been studied with a wide range of patient populations and has established strong reliability.

 

DIGEST:  Dynamic Imaging Grade of Swallowing Toxicity

  • What does it measure? Swallowing efficiency and airway safety.
  • Does it require frame-by-frame analysis? No.
  • Useful for identifying pathophysiology and treatment targets? No. It assesses only residue and the degree of airway invasion.
  • Does it describe severity or normality? Yes. The total score corresponds with a severity rating of pharyngeal dysphagia, ranging from 0 (normal) to 4 (life-threatening).
  • How do I use it? The scoring form and guidelines can be found here for free. The authors suggest using a standardized VFSS protocol during your study, like the one from the MBSImP. Courses, like this one from MD Anderson, can provide in-depth training, but the DIGEST is easy to score and use with any protocol. You can find the DIGEST rating form here. It's important to note that in 2022, the authors made some changes to the DIGEST (but haven't yet created a new form). The changes you'd need to know about:
    • If your patient has a PAS of 3-4 just once, they have a Safety Grade 0
    • If they have a PAS of 3-4 more than once, they have a Safety Grade 1
    • Patients who have a single, not gross, aspiration incident resulting in a PAS of 7-8 will still receive a Safety Grade 1, but if they also have a PAS of 5-6 on a different bolus, you should increase their score to a Safety Grade 2.
  • Who developed this tool?  Hutcheson et al.
  • What else should I know? According to the authors, the DIGEST is “not intended to replace more validated measures of biomechanical, kinematic, physiologic, and temporal parameters of the swallow.” Instead, it’s meant to quickly grade pharyngeal swallow function, useful in making broader treatment decisions with patients with head-and-neck cancer, for example. With that purpose in mind, the reliability and validity of the DIGEST is quite strong.

 

DOSS: Dysphagia Outcome and Severity Scale 

  • What does it measure? The DOSS rates the functional severity of the patient’s dysphagia (including oral phase events).
  • Does it require frame-by-frame analysis? No.
  • Useful for identifying pathophysiology and treatment targets? Not really. Pharyngeal function is being assessed, but there’s not a direct line to the physiologic components. For example, Level 1 indicates “the patient may exhibit severe pharyngeal retention, unable to clear,” but you’d still need to determine why the residue was there.
  • Does it describe severity or normality? Yes, there are seven levels, ranging from “normal swallow function” to “severe dysphagia.” These take into account what they’re eating, the amount of assistance they require, and what the VFSS revealed.
  • How do I use it? Many clinicians say that the reporting form and subsequent ratings (found in Tables 1 and 3 here) take less than 5 minutes to complete. Because we couldn’t find any trainings and some studies have found concerns with reliability, you'll have to sit down with your coworkers to define certain terms (such as the difference between moderate and severe pharyngeal retention) for this to be useful in practice.
  • Who developed this tool? O’Neil and colleagues
  • What else should I know? This scale has been in use since 1999 and remains popular because of its ease of use (which we frantically busy acute care therapists can appreciate), but also because it considered patient functioning more globally. You might determine treatment targets using a different tool and rely on the DOSS levels to help patients, caregivers, and other medical staff to understand the functional impact of the patient’s dysphagia.
     

MBSImP: Modified Barium Swallow Impairment Profile

  • What does it measure? Oral, pharyngeal, and proximal esophageal swallowing physiology.
  • Does it require frame-by-frame analysis? Not necessarily, but you likely do need the ability to replay and slow down your studies.
  • Useful for identifying pathophysiology and treatment targets? Yes. 17 components, to be exact.
  • Does it describe severity or normality? Sort of. Most physiologic components are rated on an ordinal scale, and there are also oral, pharyngeal, and esophageal impairment scores. Higher scores equal greater impairment, so you can infer a level of severity.
  • How do I use it? In order to use the MBSImP, you must complete (and renew!) their certification course. The training is a treasure trove of education about normal and impaired swallow function, and you’ll also have a set protocol to follow in the fluoro suite. Although the MBSImP has a reputation for being a bit time-consuming, it’s also commonly used by grad schools, meaning lots of SLPs are familiar with it. That notoriety should help with implementation, while your biggest barriers might be admin support for the time it takes to interpret and write up.
  • Who developed this tool? Dr. Bonnie Martin-Harris and colleagues
  • What else should I know? You can find answers to FAQs here. The MBSImP’s reliability and validity are well studied and strong. However, many institutions are using the 17 physiologic components as a general outline of what we should comment on in reports but skipping the scoring part. In those cases, analysis isn’t standardized, but the reports are still comprehensive in their observations. We’ve all gotta start somewhere, right?
     

mVDS: Modified Videofluoroscopic Dysphagia Scale

  • What does it measure? The mVDS rates nine oral and pharyngeal swallow components in an attempt to quantify the severity of the person’s dysphagia.
  • Does it require frame-by-frame analysis? No. Replay may be helpful, though.
  • Useful for identifying pathophysiology and treatment targets? Meh. While some physiologic components are rated by this tool, interpretation is a little tricky. Some ratings are a bit overly subjective (Is this residue more or less than 10%?) while others might feel like overly limiting categories (yes or no for mastication, for example). More on this below.
  • Does it describe severity or normality? Sort of. A higher score (max of 100) indicates greater diet limitation and more severe dysphagia, but there’s no guidance for interpretation (Does a score of 50 indicate moderate dysphagia or mod-severe? How low does someone need to score to have a normal swallow?)
  • How do I use it? The mVDS is in Table 1 of this open-access article. That’s a great question—and one that we can’t really answer. The authors of this tool don’t tell us if it should be scored based on the entire study, or on each IDDSI level (or even each bolus!). There’s also no operational definition of the swallowing events you’re measuring, like lip closure or epiglottic inversion, so you’d need to explicitly decide these things with your coworkers for this tool to be useful. This lack of operational definitions likely led to its wide range interrater reliability, studied here.
  • Who developed this tool? Chang et al.
  • What else should I know? This is a re-design of the Videofluoroscopic Dysphagia Scale and a recent study validated it for use in the frail & deconditioned population. Some physiologic parameters of the VDS were faulted for being ambiguous, so the tool was modified to improve the psychometrics (though in our opinion, this tool is still too ambiguous for you to use as-is).
     

Swallowtail

  • What does it measure? The Swallowtail provides fully computerized measurements of swallow physiology and bolus movement.
  • Does it require frame-by-frame analysis? Not by you!
  • Useful for identifying pathophysiology and treatment targets? Yes, with the bonus that judgements about pathophysiology are computerized and therefore objective.
  • Does it describe severity or normality? Sort of. There is normative data, so if your patient scores more than two standard deviations outside of normal, you can label it as disordered.
  • How do I use it? Since this is computer software, the purchase comes with training. Interestingly, there is the standardized procedure (which is important, because it’s then compared to the normative data), but then there’s a flexible procedure portion in which the SLP can trial their own textures, maneuvers, etc. Once you’ve purchased the software and your team’s trained, VFSS analysis is reportedly a breeze. The downside to this, of course, is that you’ll have to convince administration to purchase the software.
  • Who developed this tool? Dr. Rebecca Leonard and Dr. Katherine Kendall, among others.
  • What else should I know? Does the name sound familiar? Dozens of studies (like here, here, and here) have used Swallowtail to obtain VFSS measurements. Whether it will catch on with that kind of gusto among practicing clinicians remains to be seen. There are student, professor, and research versions of the software available for purchase.
     

VIP: Videofluroscopic Interpretation of Physiology 

  • What does it measure? Functionality of the swallow with an emphasis on timing of laryngeal vestibule closure and UES opening.
  • Does it require frame-by-frame analysis? Yes.
  • Useful for identifying pathophysiology and treatment targets? Definitely. The VIP rating form requires clinicians to determine why airway invasion or residue occurred.
  • Does it describe severity or normality? Each swallow is rated as normal, functional, or disordered, and supported with rationale. The tool includes normal values for the timing measures, based on this study of healthy normals, but it’s unclear exactly what bolus type those values represent or how to interpret them. You may need to use these cautiously.
  • How do I use it? To access VIP, you have to purchase Tiers 1 & 2 of this training. The VIP itself is a spreadsheet-based tool. Overall, it scaffolds your thinking when analyzing swallows and planning treatment strategies. The required trainings have helpful information on both normal and abnormal swallowing, plus how to calculate the timing measures. However, you are prompted to register for related coursework to fully understand the physiological components measured. You and your coworkers may benefit from making a cheat sheet for the physiological events measured by the VIP to be sure that you’re assessing them accurately and reliably.
  • Who developed this tool? Dr. Ianessa Humbert
  • What else should I know? Unlike the other tools here, VIP is not published in a peer-reviewed journal. However, the tool itself is based on well-researched principles of swallowing physiology and the training is comparable to some of the others listed here. The downside is that we don’t have VIP-specific information about reliability (do you make the same assessment each time or the same assessment as your coworkers did using the tool?) or validity (how accurately does it describe your patient’s dysphagia or predict dysphagia-related outcomes). You’ll particularly want to keep the reliability in mind if you’re implementing the VIP across your SLP team.
     

Don’t forget to download our printable chart here to compare these tools, including more information and research you might need to justify your choice of VFSS analysis tool for your facility.

 

Whether you’re looking to advance your own med SLP skills, working on a process improvement project, or wanting to get on the same page as the other SLPs in your facility, implementing any single analysis tool like these will help you level up. Even using modified versions to suit your needs (ahem, hello productivity requirements) can be a good starting point for improvement. 
 

(Psst! Do you do swallow studies on babies and kids as well? Check out some relevant reviews here and here on objective VFSS analyses for those populations.) 


 

Chang, M., Lee, C., & Park, D. (2021). Validation and inter-rater reliability of the Modified Videofluoroscopic Dysphagia Scale (mVDS) in dysphagic patients with multiple etiologies. Journal of Clinical Medicine. https://doi.org/10.3390/jcm10132990 

 

Chang, M., Choi, H., & Park, D. (2022). Usefulness of the Modified Videofluoroscopic Dysphagia Scale in determining the allowance of oral feeding in patients with dysphagia due to deconditioning or frailty. Healthcare. https://doi.org/10.3390/healthcare10040668

 

Donohue, C., Robison, R., DiBiase, L., Anderson, A., Vasilopoulos, T., & Plowman, E. (2022). Comparison of validated videofluoroscopic outcomes of pharyngeal residue: Concordance between a perceptual, ordinal, and bolus-based rating scale and a normalized pixel-based quantitative outcome. Journal of Speech, Language, and Hearing Research.  https://doi.org/10.1044/2022_jslhr-21-00659 [available to ASHA members]


Henderson, M., Miles, A., Holgate, V., Peryman, S., & Allen, J. (2016). Application and verification of quantitative objective videofluoroscopic swallowing measures in a pediatric population with dysphagia. The Journal of Pediatrics. https://doi.org/10.1016/j.jpeds.2016.07.050
 

Hutcheson, K., Barrow, M., Barringer, D., Knott, J., Lin, H., Weber, R., Fuller, C., Lai, S., Alvarez, C., Raut, J., Lazarus, C, May, A., Patterson, J., Roe, J., Starmer, H., & Lewin, J. (2016). Dynamic Imaging Grade of Swallowing Toxicity (DIGEST): Scale development and validation. Cancer. https://doi.org/10.1002/cncr.30283
 

Martin-Harris, B., Humphries, K., & (Focht) Garand, K. (2017). The Modified Barium Swallow Impairment Profile (MBSImP™©) – Innovation, dissemination and implementation. Perspectives of the ASHA Special Interest Groups. https://doi.org/10.1044/persp2.sig13.129 [available to ASHA SIG members]

 

O’Neil, K., Purdy, M., Falk, J., & Gallo, L. (1999). The Dysphagia Outcome and Severity Scale. Dysphagia. https://doi.org/10.1007/pl00009595

 

Stevens, M., Schiedermayer, B., Kendall, K., Ou, Z., Presson, A., & Barkmeier-Kraemer, J. (2021). Physiology of dysphagia in those with unilateral vocal fold immobility. Dysphagia. https://doi.org/10.1007/s00455-021-10286-4

 

Swan, K., Cordier, R., Brown, T., & Speyer, R. (2018). Psychometric properties of visuoperceptual measures of videofluoroscopic and fibre-endoscopic evaluations of swallowing: A systematic review. Dysphagia. https://doi.org/10.1007/s00455-018-9918-3

 

Vansant, M., Parker, L., McWhorter, A., Bluoin, D., & Kunduk, M. (2020). Predicting swallowing outcomes from objective videofluoroscopic timing and displacement measures in head and neck cancer patients. Dysphagia. https://doi.org/10.1007/s00455-020-10091-5

 

Waito, A. A., Steele, C. M., Péladeau-Pigeon, M., Genge, A., & Argov, Z. (2018). A preliminary videofluoroscopic investigation of swallowing physiology and function in individuals with oculopharyngeal muscular dystrophy (OPMD). Dysphagia. https://doi.org/10.1007/s00455-018-9904-9

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Jessica Hirliman, MS, CCC-SLP

Jessica Hirliman, MS, CCC-SLP

Jessica Hirliman is a writer for The Informed SLP. She works in both acute care and outpatient rehabilitation specializing in adult dysphagia. She is particularly clinically passionate about the head and neck cancer population, as well as palliative/end-of-life issues and medical ethics. She also treats pediatric feeding and swallowing impairments, voice and upper airway disorders, and adult neurogenic communication disorders. She earned a Masters degree from Emerson College in Boston, MA and currently lives in upstate New York with her husband and 3 children.
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