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This table provides a list of popular exercises used to improve laryngeal elevation.
Reference: Murray, T., Carrau, R. L., & Chan, Karen M. K. (2022). Clinical management of swallowing disorders.

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Jaw Strength Exercise Research Findings 

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Jaw Strength Exercise Research Findings 

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Jaw stretch exercises are used to increase the strength and ROM of the jaw muscles.
1. Place hand in chin.
2. Push your chin down in hand until jaw is open wide and hold for 10 seconds.
3. Relax.
4. Repeat.

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The lip range exercise is used to increase labial muscle ROM.
1. Smile as wide as possible pushing back against any weakness.
2. Hold position for 5 seconds, then pucker lips.
3. Hold pucker for 5 seconds then pull back into smile again.
4. Repeat trials.

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The lip strength exercise works to increase strength in the labial muscles.
1. Place a piece of cloth between the lips.
2. Pull the cloth with your hand while holding down on it with your lips.
3. Relax
4. Repeat trials.

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Tongue range exercises are another form of exercise to increase the lingual range of motion. Examples of these exercises are provided in the video.

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The jaw opening exercise is used to improve the strength of jaw muscles.
1. Open your mouth as wide as possible.
2. Feel the muscles under your tongue at the front of your neck and squeeze tightly.
3. Hold squeeze 10 seconds.
4. Relax/repeat trials.

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Tongue stretch exercises focus on increasing the strength of your lingual muscles. Examples of these are provided in the video.

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Tongue stretch exercises focus on improving the ROM of the lingual muscles. Exercises include:
1. Sticking your tongue out as far as possible and holding it straight for 15 seconds.
2. Stick your tongue out and push to the left/right for 15 seconds .
3. Stick your tongue out and push it up/down for 15 seconds.
4. Relax/repeat trials.

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Oral motor exercises (OMEs) are composed of various exercises involving the tongue, lips, jaw, and larynx to improve muscle strength to provide a safer swallow function. These exercises are commonly used in dysphagia therapy for various population groups. Popular OMEs are listed under this section, along with videos or diagrams to provide visual examples.

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Conclusions: More research regarding OMEs and their effectiveness needs to be established. 

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Conclusions: More research regarding OMEs and their effectiveness needs to be established. 

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Research indicates that OMEs might provide beneficial swallowing improvements in select adult dysphagia populations. However, due to the limited studies available to provide the results, as well as contradicting data that has been published, more evidence needs to be provided in order for clinicians to regard OMEs as an efficient treatment technique. Furthermore, due to the lack of research regarding the long-term effects, OMEs cannot be regarded as highly efficient therapy for dysphagia as there is little evidence any progress they provide will be retained.
Lastly, because there is minimal research regarding pediatric dysphagia and the use of OMEs, this cannot be regarded as an efficient therapy technique until there is any evidence provided that it might work, even in short term trials for the pediatric population.

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While research regarding the short-term outcomes of OME as a treatment for dysphagia are limited, research regarding the long-term effects is even more minimal. The majority of existing research regarding OME efficacy acknowledges the lack of evidence surround the long-term benefits and express the need for further research. Currently, there is still little to no research that has been brought to light regarding this issue. Other concerning factors regarding the analyses of OME efficacy includes research involving pediatric dysphagia. There is a severe lack of current studies assessing the effectiveness of OME as a therapy technique in pediatric dysphagia.

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Although research suggests that OME appear to be an effective treatment for dysphagia in various populations, there are still many limitations to these findings. The majority of existing research is limited due to sample sizes, generalizability, and reducibility among research trials. Many studies note that their results might be heavily impacted by extraneous variables that tend to differ among participants throughout the studies, which is evident in the contradicting outcomes that have been published regarding specific techniques (i.e. masako, effortful swallow, tongue resistance training). Because of these mixed results, when determining whether or not to include the use of OMEs for dysphagia treatment clinicians must base the decision on the patient's specific case history and conduct research regarding the effects of each exercise on patients with a similar population group, if there is research available.

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This study acknowledges the different types of dysphasic treatments that are typically incorporated in therapy have limited evidence to support their efficiency, which in turn leaves clinicians feeling unsure about what treatments to provide for their pediatric dysphagia clients.

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Pediatric Dysphagia Rehabilitation: Considering the Evidence to Support Common Strategies

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Dysphagia in pediatric populations can result in multiple adverse health outcomes. Therefore, childhood swallowing difficulties must be diagnosed accurately and managed appropriately. Effective the...

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These researcher performed a systematic review on the effectiveness of dysphagia therapy techniques including OMEs. Overall, the researchers state there appears to be a positive trend in the use of OMEs for short-term improvements of dysphagia symptoms. However, the researchers note that the sample size of papers was small and results of studies were typically unable to be generalized. Furthermore, the researches expressed the need for studies researching the long-term effects of these treatment plans.

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Using MESH terms, 2844 articles were found in PubMed and 268 in Embase. Using free-text words resulted in another 1609 articles in PubMed and 501 in Embase. However, the combined searches of MESH terms plus free text yielded 4040 articles in PubMed and 748 in Embase. An overlap of 142 articles occurred when the searches were merged. Thus, the systematic literature search resulted in a total of 4646 articles, 59 of which met the inclusion criteria (see Methods section).

Tables 1, 2, 3, 4, and 5 present an overview of all included articles. The studies are divided into five groups based on the type of intervention: bolus modifications and management (Table 1), facilitation techniques (Table 2), swallow postures and swallow maneuvers (Table 3), other interventions (residual category) (Table 4), and combination of interventions (Table 5). The first group covers what is considered to be compensatory techniques, whereas the residual category includes rehabilitative techniques. All other interventions are classified as compensatory and/or rehabilitative techniques [ 10, 11]. The first column of each table gives the level of evidence using the ABC rating scale according to Siwek et al. [ 7]. The second column indicates how the data were handled, i.e., using statistical analyses or descriptive statistics to compare pre- versus post-therapy data. If subgroups were compared using statistical analysis but differences between post- and pre-therapy status were described using descriptive statistics, the study was assigned to the latter method. Authors are listed in alphabetical order. For each study, the following data are summarized: number of patients, evaluation techniques, kind of therapy used in addition to (if applicable) diagnostic or therapy subgroup(s), and authors' key findings. The number of subjects refers to the group of subjects on which the study results are based. If studies contain subject groups that fall outside the scope of the present review article, these groups are not mentioned in the tables. Sometimes the primary purpose of a study is not to objectify the effects of swallowing therapy. However, if pre- and post-treatment data are present, the study is included.

Information on qualitative assessment has been given in the tables as well. For any of the randomized controlled trials (level A) no (redundant) information on randomization has been given. However, for trials using different treatment groups and an unclear or no random allocation of subjects, information has been added regarding the questionable randomization. Blinding of outcome assessors is considered essential. Assessors should be blinded for the treatment group as well as for pre- versus post-therapy status. When using swallowing maneuvers (such as chin tuck) or different viscosities (such as paste versus liquid) during videofluoroscopy, blinding is not applicable and is therefore not mentioned in the table. As far as patient attrition is concerned, the table gives the number of individuals who died, were lost to follow-up, or otherwise did not complete the intervention (if mentioned in the article). However, in the case of single-session interventions, such information is not applicable.

Ultimately, 59 studies were included. The results showed 10 high-quality randomized controlled trials (level A) and 49 well-designed nonrandomized clinical trials (level B). The authors of nine of the 10 A studies and 25 of the 49 B studies performed statistical analyses to evaluate the therapy effects. All other studies used descriptive analyses. The 59 included studies are described briefly below.

Bolus Modification and Management (Compensatory Techniques)

Bolus modification means adjusting the viscosity, volume, temperature, and/or acidity of the bolus. Seven studies describe the effects of bolus modification (Table 1). The Groher study [ 12] is the earliest to focus on viscosity modulation. It is also the only randomized controlled trial in this group of studies. Prior to therapy, all patients ( N = 46) suffering from pseudobulbar dysphagia were on a pureed diet plus fluids and had experienced at least one period of aspiration pneumonia. Subjects were randomly assigned to two groups: One received pureed foods and nonaltered liquids and the other had a soft mechanical diet with altered or thickened liquids. After 6 months of intervention, the author concluded that the latter group had experienced significantly more episodes of pneumonia than the group with an unaltered diet. In a later study of a group of residents ( N = 212) who were on a mechanically modified diet, Groher and McKaig [ 13] described the changes in dietary level after a single evaluation by a speech and language pathologist. Dietary levels were classified as mechanical, mechanical soft, pureed, or enteral. Using descriptive statistics, the authors found that 91% of all subjects were able to tolerate diets at a level above that of alimentation received before the evaluation. They continued on these diets during a 30-day follow-up evaluation. Four percent of the subjects were found to be at dietary levels higher than they could tolerate, whereas only 5% were considered to be at the appropriate level.

Five more nonrandomized clinical trials that performed statistical analyses were found in the literature. All studied the effects of bolus modification using single sessions. Bhattacharyya et al. [ 14] compared the effects of liquid versus paste boluses in a group of subjects with unilateral vocal fold paralysis. Among all subjects showing aspiration and/or penetration (31 of 55 subjects), 25% aspirated on thin liquids but not on paste boluses. Penetration occurred in 79% of the subjects when using liquid and 50% when using paste. The authors concluded that thicker food consistencies were likely to be safer for oral intake in patients with unilateral vocal fold paralysis due to decreased risk of laryngeal penetration and aspiration.

Clavé et al. [ 15] confirmed that increasing the bolus viscosity from liquids to nectar and pudding for patients with either nonprogressive brain diseases ( N = 46) or neurodegenerative diseases ( N = 46) significantly improved both the efficacy and the safety of swallowing by reducing aspiration and penetration during swallowing. Increasing the bolus viscosity did not affect the timing of swallow response or the bolus kinetic energy, whereas increasing the bolus volume significantly impaired the efficacy and safety of swallowing. However, Bisch et al. [ 16] demonstrated that increasing the bolus volume and the viscosity decreased pharyngeal delay times in two smaller populations, namely, subjects with either mild dysphagia ( N = 10) or moderate to severe dysphagia ( N = 8). The effects of bolus temperature on swallowing disorders or swallow measures proved to be negligible.

Logemann et al. [ 17] studied the effects of changed bolus acidity and volume in stroke patients ( N = 19) and a group of patients with other mixed neurological etiologies ( N = 8). Sour boluses compared to nonsour boluses significantly improved the timing of the onset of the oral swallow. Stroke patients also exhibited reduced pharyngeal delay time, oral transit time, and improved swallow efficiency, whereas the other group exhibited reduced aspiration. Increasing the bolus volume significantly increased oral residue and number of swallows but decreased the oral transit time, pharyngeal delay time, and pharyngeal transit time in both groups.

Using timed water-swallow testing in acute stroke patients ( N = 12), Hamdy et al. [ 18] concluded that the combined thermal (cold) and chemical (sour) modification of water substantially altered swallowing behavior in dysphagic stroke, resulting in slowed swallowing and reduced swallow capacity. Such results were not found when using either thermally or chemically modified boluses.

Facilitation Techniques (Compensatory Techniques and/or Rehabilitative Techniques)

Facilitation techniques include a variety of interventions such as surface electrical stimulation or thermal application at the anterior faucial pillars (Table 2). Four randomized controlled trials were found that deal with facilitation techniques. Bülow et al. [ 19] compared the outcome of neuromuscular electrical stimulation ( N = 13) with that of traditional swallowing therapy ( N = 12) in stroke patients using videofluoroscopy, dietary level, oral motor function testing, and a patient's self-evaluation. Although statistically significant positive therapy effects were found for both groups combined, no statistically significant difference in therapy effect between the groups was present.

Power et al. [ 20] applied surface electrical stimulation at the anterior faucial pillars during a single 10-min session in acute hemispheric stroke patients. Patients were randomized to either electrical stimulation ( N = 8) or sham stimulation ( N = 8). The authors concluded that when compared to baseline data, neither of the interventions resulted in significant differences in oral transit time, swallow response time, pharyngeal transit time, laryngeal closure duration, cricopharyngeal opening duration, or aspiration severity. No differences were observed between the two groups.

Two other randomized controlled trials conducted by Rosenbek et al. [ 21, 22] were related to thermal application at the anterior faucial pillars. The earlier study [ 21] used a single-subject withdrawal or ABAB design. The total subject population included seven multiple-stroke patients. Subjects were randomly assigned to a week-long period of thermal application ( N = 6) or to a week of no therapy ( N = 1). Thermal application consisted of on average 18 trials per session five times per day. Each trial consisted of repeated strokes on the pillars using a chilled laryngeal mirror followed by a swallow (water or ice chips). Overall, no strong evidence was found that dysphagia improved after 2 weeks of thermal application alternating with 2 weeks of no thermal application. The second study [ 22] used a cross-over design to determine the short-term effects of thermal application. A group of stroke subjects ( N = 22) swallowed ten times in untreated and treated conditions. It was found that swallowing durations were highly variable within and across subjects. Furthermore, thermal stimulation significantly reduced the duration of stage transition and total swallow duration compared to no treatment.

Three nonrandomized clinical trials [ 23- 25] applied statistical analyses to measure the effects of surface electrical stimulation. Using a retrospective design in a group of acute-care patients, Blumenfeld et al. [ 23] compared the outcome of surface electrical stimulation of the pharyngeal and laryngeal musculature ( N = 40) with that of traditional therapy ( N = 40). The latter included therapeutic exercises, compensatory maneuvers, and diet-texture modifications. Treatment success was determined by comparing the swallow scores measured upon admission and prior to discharge on a seven-point swallow-severity scale (nothing safe / aspiration of saliva up to toleration of all consistencies). After therapy, both groups showed significant improvement in severity score. The group that received electrical stimulation showed more improvement, required fewer sessions, and displayed a trend toward shorter length of hospitalization than the group receiving traditional therapy. However, part of the improvement might have been the result of spontaneous recovery.

Ludlow et al. [ 24] studied the effects of surface electrical stimulation under four different conditions in a group of patients with diverse neurological pathologies ( N = 11): no stimulation ( N = 11?), stimulation at sensory threshold level during swallowing ( N = 8), stimulation at motor threshold level during swallowing ( N = 10), and stimulation at rest ( N = 10). Only significant hyoid depression occurred during stimulation at rest. Aspiration and pooling were significantly reduced during low sensory threshold levels of stimulation but not during maximum levels of stimulation. Patients who had reduced aspiration and penetration during swallowing with stimulation showed greater hyoid depression during stimulation at rest. Stimulation may have acted to resist patients' hyoid elevation during swallowing.

Shaw et al. [ 25] performed a retrospective study on surface electrical stimulation in 18 patients suffering from diverse neurological pathologies or post-laryngeal radiotherapy. Patients were divided into four groups according to their pretherapy overall dysphagia: near-functional swallow ( N = 2), limited swallowing requiring compensatory maneuvers ( N = 4), enteral feedings with ability to swallow certain consistencies ( N = 7), or tube feeding ( N = 5). Based on varying evaluation techniques per patient, the overall conclusion was that transcutaneous neuromuscular electrical stimulation may help patients with mild to moderate dysphagia. However, patients with the most severe dysphagia did not gain independence from tube feeding.

Two more nonrandomized clinical trials used descriptive statistics to describe therapy outcome using facilitation techniques. First, Leelamanit et al. [ 26] described the effects of stimulating synchronous contraction of the thyrohyoid muscle during swallowing with a synchronous electrical stimulator (SES treatment) in 22 patients with diverse neurological pathologies plus dysphagia resulting from reduced laryngeal elevation. Based on videofluoroscopic findings, clinical evaluation, and weight gain, the authors concluded that SES treatment improved dysphagia resulting from reduced hyolaryngeal elevation. Second, one of the earliest studies on facilitation in dysphagia was performed by Lazzara et al. [ 27]. Using thermal stimulation at the anterior faucial pillars during a single session in patients with diverse neurological pathologies ( N = 25), the results indicated an improved triggering of the swallowing reflex for at least one consistency (liquids or paste). The total transit time for liquids and paste improved in 90% ( N = 10) and 100% ( N = 14) of the patients, respectively.

Swallow Postures and Swallow Maneuvers (Compensatory Techniques and/or Rehabilitative Techniques)

Ten studies on swallow postures and swallow maneuvers in dysphagia, such as chin tuck and supraglottic or effortful swallow, were found in the literature (Table 3). Most studies described single-session interventions using videofluoroscopy of the swallowing act as an evaluation tool. The only clinical randomized trial was performed by Shaker et al. [ 28]. Twenty-seven patients with diverse etiology (neurological pathology, post-pharyngeal radiotherapy, cardiovascular disease) and abnormal upper esophageal sphincter opening underwent a head-raising exercise program. Prior to this program seven patients had been randomly assigned to a period of sham exercises. Whereas sham exercises resulted in no significant changes in biomechanical parameters, real exercises showed significant therapy effects. These include improvement in the anteroposterior diameter of the sphincter opening and the anterior laryngeal excursion, decrease of postdeglutitive residue, and resolution of aspiration. Scores on a seven-point swallowing competency scale (Functional Outcome Assessment of Swallowing Score) showed positive changes as well.

Three of nine nonrandomized clinical trials performed statistical analyses to check on therapy outcome. All three studies used subject populations smaller than ten patients in single sessions. Logemann et al. [ 29] studied the effects of head rotation in acute brainstem stroke patients with unilateral oropharyngeal dysphagia ( N = 5). The fraction of the bolus swallowed and the upper esophageal sphincter diameter increased significantly with the head turned toward the paretic side. In a later study by Logemann et al. [ 30], the effects of a super-supraglottic swallow in a group of head and neck cancer patients ( N = 9) were observed. The maneuver resulted in fewer swallowing motility disorders and in some cases the elimination or reduction of aspiration. Bülow et al. [ 31] described the effects of supraglottic swallow, chin tuck, and effortful swallow. None of these techniques reduced the number of misdirected swallows. However, effortful swallow or chin tuck resulted in significantly less deep contrast penetration into the larynx and reduction of pharyngeal retention. Swallowing techniques did not improve a weak pharyngeal constriction.

Six nonrandomized trials used descriptive statistics to study videofluoroscopic outcome parameters. Shanahan et al. [ 32] and Lewin et al. [ 33] studied the effects of chin tuck during a single session in a group of patients suffering from aspiration as a result of, respectively, diverse neurological pathologies ( N = 30) and esophagectomy ( N = 21). Both studies indicated elimination of aspiration: 50% (Shanahan et al.) and 81% (Lewin et al.) of all subjects. Bogaert et al. [ 34] confirmed that chin tuck as well as supraglottic swallow in a group of patients with diverse neurological pathologies ( N = 30) during a single session could improve the pharyngeal phase of swallowing, e.g., reduction of premature spilling and elimination or reduction of aspiration or penetration. However, no consistent effect was found. Zuydam et al. [ 35] included a group of patients ( N = 13?) following surgical resection of the oropharynx, including the base of tongue. All patients used chin tuck. If aspiration was still present, chin tuck was combined with a supraglottic swallow. At subsequent follow-up, compensatory procedures and therapy techniques proved to be successful in a third of the cases with larger tongue resections ( N = 7?) and in all cases with smaller resections ( N = 6?). Finally, two studies by Logemann [ 36, 37] should be mentioned. Using supraglottic swallow in a rather small group of nine patients after supraglottic laryngectomy, three of the nine were able to take in food orally at 2 weeks postoperatively, whereas seven of the nine were successful oral feeders by 3 months [ 36]. In a second larger study in a similar subject population combined with subjects who had undergone diverse resections, including oral cancer resections ( N = 32), postural techniques were studied with or without supraglottic swallow (single session). Postural techniques were effective in at least 60% of the patients at 1- and 3-ml volumes. If the patient first aspirated at a 3-ml volume, the posture was effective in 80% of the patients for 5-ml boluses. All patients who were able to swallow 10-ml boluses without aspiration using the posture were also able to swallow from a cup using the posture.

Other Interventions (Rehabilitative Techniques)

Two nonrandomized clinical trials were considered as a residual category (Table 4). Both studies used statistical analyses to determine therapy outcome. In a group of eight patients with idiopathic Parkinson's disease, El Sharkawi et al. [ 38] found an improved neuromuscular control of the entire upper aerodigestive tract as a result of the Lee Silverman Voice Treatment. Because this intensive voice treatment requires high phonatory effort tasks, it stimulates increased vocal fold adduction and respiratory support. Oral tongue and tongue base function during oral and pharyngeal phases of swallowing showed positive changes after therapy, i.e., an overall reduction of 51% in the number of swallowing motility disorders. For all swallow volumes and consistencies, oral transit time and oral residue were reduced and the oropharyngeal swallow efficiency was improved. In a combined group of acute ( N = 6) and chronic ( N = 4) stroke patients, Robbins et al. [ 39] studied the effects of an isometric lingual exercise program by compressing an air-filled bulb between the tongue and the hard palate. After 8 weeks of progressive resistance lingual exercises, all patients had significantly increased isometric and swallowing pressures. Patients showed significant improvement in swallowing function and dysphagia-specific quality-of-life measures, with reported changes in their social life and dietary intake. However, the therapy outcome could not be distinguished from possible spontaneous recovery.

Combination of Interventions (Compensatory Techniques and/or Rehabilitative Techniques)

A set of 31 studies used a combination of different types of interventions (Table 5). Four of these studies were randomized controlled trials.

Rosenbek et al. [ 42] investigated the effects of four intensities of tactile-thermal application combined with effortful swallowing in acute stroke patients ( N = 45). Patients were randomly assigned to receive 150 ( N = 12), 300 ( N = 10), 450 ( N = 10), or 600 ( N = 13) trials of tactile-thermal application per week for 2 weeks. No single treatment intensity emerged as superior. Overall, positive changes on an eight-point aspiration-penetration scale and decreased duration of stage transition did not reach clinical or statistical significance, possibly because the samples were too small. The study was initially designed to distinguish between the most efficacious treatment intensities. The authors recognized that the actual changes may be the result of physiological recovery as well.

Finally, Carnaby et al. [ 43] performed statistical analyses to compare differences between therapy conditions but used descriptive statistics to describe post- versus pretherapy status. The authors compared the change in dietary status in a large group of acute stroke patients ( N = 303) after usual care ( N = 102), standard low-intensity intervention ( N = 101), and standard high-intensity intervention ( N = 100). Usual care consisted of patient management by the attending physicians as per usual practice. Treatment, if offered, consisted mainly of supervising feeding and taking precautions for safe swallowing (e.g., positioning, slower pace of eating). Standard low-intensity intervention was based on compensation strategies, mainly environmental modifications (e.g., positioning), safe swallowing advice, and dietary modification. These interventions were carried out under the direction of a speech pathologist three times per week for up to 1 month. High-intensity intervention referred to direct swallowing exercises (e.g., effortful swallowing, supraglottic swallow technique) and appropriate dietary modification. These exercises were done every working day for a month or daily during the hospital stay (if less than 1 month). After 6 months the percentage of patients returning to a normal diet and receiving usual care, standard low-intensity, or high-intensity intervention was 56, 64, and 70%, respectively. A functional swallow without swallowing complications was achieved by 32% of the patients who received usual care, 43% who received standard low-intensity intervention, and 48% who received high-intensity intervention. In patients who received standard therapy, medical complications, chest infections, and death or institutionalization decreased significantly.

Twenty-seven nonrandomized clinical trials used combinations of interventions. Twelve studies performed statistical analyses while estimating therapy effects.

Denk and Kaider [ 47] included a group of 33 oncological patients with prolonged postoperative aspiration. One group ( N = 14) received conventional therapy, which included thermal stimulation, oral motor exercises, compensatory techniques, and dietary measures. Another group ( N = 19) received videoendoscopic biofeedback in addition to conventional therapy. After therapy, restoration of exclusively oral nutrition with food of all consistencies without moderate or severe aspiration was found in 71% of the patients in the conventional therapy group and in 73% of the patients receiving biofeedback as well. In the first 40 days of therapy, patients receiving biofeedback had a significantly better chance of therapeutic success. Their period of functional rehabilitation was thereby shorter compared to that of patients without biofeedback. After this first period, no more significant difference was found between the two groups.

In a study of ten patients who suffered from brainstem injury and chronic dysphagia, Huckabee and Cannito [ 48] used surface electromyography biofeedback and cervical auscultation biofeedback in combination with effortful swallow, the Mendelsohn maneuver, vocal adduction exercises, oral motor exercises, the head-lifting maneuver, and compensatory mechanisms (Outpatient Accelerated Swallowing Treatment Programme). After therapy, significant improvements were observed in swallowing physiology as measured by severity ratings of videofluoroscopic swallowing studies, diet level, and pulmonary status.

In a second study using supplemental surface electromyography biofeedback, Crary et al. [ 49] presented a systematic therapy program (retrospective study design) to 25 stroke patients and 20 patients following their treatment for head and neck cancer. Therapy outcome was scored on a seven-point functional oral intake scale (FOIS): from nothing by mouth up to total oral diet with no restrictions. Functional oral intake increased in 87% of all patients (92% of the stroke and 80% of the head and neck cancer patients) by at least one scale score subsequent to therapy. The stroke patients received significantly more therapy sessions than the cancer patients. The average change in functional oral intake reflected a trend toward statistical significance.

Carnaby-Mann and Crary [ 50] described the effects of a protocol of swallowing exercises (fast, effortful swallow) in combination with adjunctive neuromuscular electrical stimulation in a group of six patients with chronic dysphagia. Significant changes were demonstrated for clinical swallowing ability, functional oral intake, weight gain, and patient perception of swallowing ability.

In a study by Elmståhl et al. [ 51], the effects of therapy on nutritional and anthropometric variables in a group of acute stroke patients ( N = 38) were described. During a period of about 2 months, therapy focused on oral motor exercises, swallowing strategies (supraglottic swallowing, effortful swallowing, Mendelsohn maneuver, and thermal stimulation), head and neck positioning, and diet modifications. About 60% of all patients responded with better swallowing function and improved nutritional status at follow-up, thereby reducing the risk of developing malnutrition. Treatment reduced the degree of oral dysfunction (dissociation) and pharyngeal dysfunction (penetration and constrictor paresis). Changes in subjective complaints, however, did not correlate with swallowing function or nutritional improvements.

Seidl et al. [ 52] performed a pilot study to investigate the success of a neurophysiological dysphagia therapy in ten patients with neurogenic swallowing disorders following cerebral hemorrhage or head injury. As early as possible following the onset of illness, patients started facio-oral therapy based on the Bobath concept (15 sessions of 1 h over 3 weeks). Over the entire therapy period the increase in swallowing frequency and the positive changes in swallowing ability and protection of the lower respiratory tract were statistically significant. However, therapy outcome could not be distinguished from possible spontaneous recovery.

Nagaya et al. [ 53] offered a single therapy session to a group of ten patients with Parkinson's disease. The session included tongue motion and resistance exercises, exercises to increase the adduction of vocal folds, the Mendelsohn maneuver, and motion exercises for the neck, shoulders, and trunk. Therapy outcome was evaluated by electromyography. After therapy, the premotor time was reduced significantly, whereas no significant change in the duration of the EMG burst was found.

Finally, two studies by Prosiegel et al. [ 54, 55] must be added to the list of nonrandomized trials that described therapy outcome using statistical analyses. The first study [ 54] included a large patient population of 208 subjects with diverse neurological pathologies. Patients received functional swallowing therapy, including restitution methods, compensation, and adaptation. Each technique was used with more than 80% of the patients. After therapy, functional feeding status showed significant improvement: 55% of all patients, initially dependent on tube feeding, were full oral feeders after therapy. The second study [ 55], which referred to the earlier one, described therapy effects in three subpopulations consisting of patients with posterior fossa tumors or cerebellar hemorrhage ( N = 8), Wallenberg's syndrome ( N = 27), and Avellis' syndrome or unilateral paresis of the vagal nerve ( N = 8). After therapy, functional feeding status had improved significantly in all three groups. Patients with Avellis' syndrome or unilateral paresis of the vagal nerve had a significantly better functional outcome than patients with Wallenberg's syndrome. In contrast, patients with Wallenberg's syndrome had a significantly better outcome than patients with posterior fossa tumors or cerebellar hemorrhage. More than 50% of the patients with posterior fossa tumors or cerebellar hemorrhage and 30% of the patients with Wallenberg's syndrome were dependent on tube feeding. Yet none of the patients with Avellis' syndrome or unilateral paresis of the vagal nerve were on tube feeding.

Fifteen nonrandomized studies used descriptive statistics to demonstrate therapy effects in dysphagic subject populations. Logemann et al. [ 56] included a large subject population ( N = 711) of patients with Parkinson's disease ( N = 228), dementia ( N = 351), and Parkinson's disease combined with dementia ( N = 132). During a single session, three treatments for aspiration on thin liquids were tested for immediate elimination of aspiration during videofluoroscopy: chin tuck, nectar-thickened liquids, and honey-thickened liquids. Significantly more patients aspirated on thin liquids (68%) using chin-down posturing than when using nectar-thickened liquids (63%) or honey-thickened liquids (53%). About half of the patients received no benefit from any intervention. A significantly higher rate of benefit was observed in patients with Parkinson's disease only compared with patients with dementia with or without Parkinson's disease. Patients with the most severe dementia were least effected by all interventions.

Horner et al. [ 57] presented a group of brainstem stroke patients ( N = 22, excluding one deceased individual). After videofluoroscopic swallowing recordings (single session), the patients received diet modifications plus compensatory techniques (chin tuck or lateral head postures) if proven effective by videofluoroscopy. Before treatment, 68% of the patients took nothing by mouth. Eventually, based on recommendations from follow-up clinical or videofluoroscopic examinations, 9% had oral plus gastrostomy feedings, while 86% resumed full oral nutrition. No instance of pulmonary or nutritional compromise was found in any of the 19 successfully treated subjects. The authors acknowledged that the population was rather small and heterogeneous with regard to the length of time after the stroke; the mean interval between stroke and swallowing examination was 46 days (range = 1-575 days).

Nagaya et al. [ 58] studied a group of patients with Parkinson's disease ( N = 25) and a group of patients with cerebellar ataxia ( N = 23) to discern the efficiency of compensatory techniques (chin tuck and supraglottic swallow) and/or bolus modification (liquid and jelly) during a single session. Fifty-two percent of Parkinson's disease patients and 30% of cerebellar ataxia patients aspirated on thin liquid. When using jelly boluses, aspiration was absent in all subjects except for two in the cerebellar ataxia group. Six patients from each group were instructed to use chin tuck and supraglottic swallow. These techniques were not effective in five patients with Parkinson's disease and two ataxic patients.

In a patient population of 165 subjects with diverse etiologies, including neurological pathologies and head and neck oncology ( N = 165), Rasley et al. [ 59] investigated during a single videofluoroscopic examination the effects of bolus volume modulation (1, 3, 5, or 10 ml) and drinking from a cup combined with postural changes (head rotation, chin tuck, or side-lying). Changes in head or body position eliminated aspiration of at least one bolus of barium in 77% of the subjects and of all four boluses plus drinking from a cup in 25%. Chin tuck and head rotation resulted in elimination of aspiration for all volumes in 25 and 26% of the subjects, respectively. Using side-lying, two of four subjects showed elimination of aspiration for smaller swallows (1 or 3 ml). The authors concluded that postural techniques could eliminate aspiration of at least small volumes in most patients. They also concluded that the videofluoroscopic swallowing examination could be expanded to include the effect of various postures with minimal risk of increased aspiration.

Three similar studies in patients with diverse neurological pathologies compared the outcome of direct therapy, indirect therapy, and direct combined with indirect therapy [ 60- 62]. A study by Bartolome and Neumann [ 60] reported the results of therapy in 28 patients with neurological disorders that had caused cricopharyngeal dysfunction. Indirect therapy consisted of strategies to normalize impaired motor and sensory functions. Direct therapy included the Mendelsohn maneuver, supraglottic swallowing, dietary adjustments, and/or changes of head positioning. The duration of therapy varied from 2 weeks to 1 year (median = 16 weeks). Ninety percent of the patients improved after undergoing swallowing therapy: 65% by objective criteria (type and/or safety of feeding) and 25% by subjective criteria (ease of feeding and range of diet). The authors associated direct as well as indirect therapy methods with improvement. However, the three groups were rather unequal: only two patients received direct therapy and three patients received indirect therapy, whereas all other patients ( N = 23) had indirect combined with direct therapy. In another study by Neumann [ 61], 66 patients received direct ( N = 8), indirect ( N = 21), or combined therapy ( N = 37). The median treatment period was 17 weeks, with a range of 1 week to 1 year. After therapy, 84% of all patients had improved as determined by type of feeding, ease of feeding, safety of feeding, and range of diet. According to the author, both direct and indirect methods were potentially useful. In a later study by Neumann et al. [ 62], 67% of the 58 patients who were not exclusively oral feeders before therapy achieved oral feeding after therapy (median = 15 weeks, range = 2-52 weeks), which included indirect therapy ( N = 29), direct therapy ( N = 1), and combined therapy ( N = 28). All three studies showed overall positive therapy effects without distinguishing between intervention groups.

Several studies described the effects of conventional or functional therapy. In a study by Masiero et al. [ 63], 16 patients underwent early rehabilitation treatment during the acute phase of post-carotid endarterectomy. Therapy consisted of oral motor exercises, sensory stimulation, postural and compensatory techniques, dietary modifications, oral hygiene education, and family training (on average, 12 h-long sessions three times weekly). All patients returned to their preoperative diet, ten patients within 1 month and six patients within 6 months.

Denk et al. [ 64] studied oncological patients with aspiration after head and neck surgery ( N = 32). Patients received functional therapy, including thermal stimulation, oral motor exercises, compensatory techniques, and dietary measures. Most patients ( N = 27) started swallowing therapy after the healing process was completed, i.e., between postoperative days 9 and 49. Four patients started later (4 months to 2 years). Therapy lasted until a full oral intake diet was achieved, except when no further improvement of the swallowing function was expected or new tumor growth appeared. After therapy, 75% of all subjects regained full oral intake.

Using a retrospective study design, Schurr et al. [ 65] described the effects of postural, dietary, and behavioral modifications in patients with brain injury ( N = 24?). The authors found a slightly higher percentage of patients returning to oral dietary intake (83%) than Denk et al. had found. The other patients remained on long-term gastrostomy tube feeding.

Barbiera et al. [ 66] studied a group of patients with diverse neurological pathologies and varying degrees of dysphagia ( N = 36) who underwent speech therapy combined with postural techniques during their stay at a neurorehabilitation ward. Patients who were within the first 6-12 months from onset of dysphagia were included. Fourteen patients (39%) returned to free oral diet, 12 (33%) remained on a diet with some restrictions, six (17%) remained on tube feeding, and four patients (11%) died. The degree of dysphagia at the onset of therapy seemed to correlate with therapy outcome. In the initially less impaired patients, therapy outcome proved to be more positive than in the more severely dysphagic patients.

Hägg and Larsson [ 67] described the use of orofacial regulation therapy developed by Morales, including motor and sensory stimulation, in a small group of seven stroke patients with chronic dysphagia. After a 5-week treatment intervention, all subjects showed objectively positive changes based on videofluoroscopic and clinical examination as well as self-assessed swallowing improvement.

Kiger et al. [ 69] compared therapy outcome after neuromuscular electrical stimulation or VitalStim TM ( N = 11) and traditional swallowing therapy ( N = 11), including oral motor exercises, compensatory strategies, and thermal stimulation via deep pharyngeal neuromuscular stimulation. The VitalStim TM group underwent from 1 to 13 treatment sessions whereas the traditional therapy group had from 1 to 6 sessions. Evaluation techniques consisted of dietary status and endoscopic or videofluoroscopic evaluation of swallowing. Raw positive change scores for oral and pharyngeal phases appeared stable in both groups (run chart analysis). However, regarding changes in oral and pharyngeal phase dysphagia severity, dietary consistency restrictions, and progression from nonoral to oral intake, the differences between the two groups were not statistically significant.

A retrospective study by Crary et al. [ 70] in a small group of six brainstem stroke patients might be considered a pilot for the study of 2004, as mentioned earlier. Swallowing instruction, focused on bolus control and airway protection, was combined with surface electromyography used as a tool for biofeedback. Evaluation of therapy demonstrated improved swallowing coordination, longer swallow duration, and increased effort. Changes in oral intake indicated long-lasting functional benefits.

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Effects of Therapy in Oropharyngeal Dysphagia by Speech and Language Therapists: A Systematic Review - Dysphagia

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Medical and paramedical treatments should be evaluated according to current standards of evidence-based medicine. Evaluation of therapy in oropharyngeal dysphagia fits into this growing interest. A systematic review is given of the literature on the effects of therapy in oropharyngeal dysphagia carried out by speech therapists.

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This research study attempted to examine the effects of dysphagia treatment, including OMEs, for children with neurological impairment, but was unable to produce viable results due to the various disorders among the participants as well multiple other confounds.

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Interventions for oropharyngeal dysphagia in children with neurological impairment - Morgan, AT - 2012 | Cochrane Library

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Oropharyngeal dysphagia encompasses problems with the oral preparatory phase of swallowing (chewing and preparing the food), oral phase (moving the food or fluid posteriorly through the oral cavity with the tongue into the back of the throat) and pharyngeal phase (swallowing the food or fluid and mo…

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Purpose: To improve tongue strength and endurance for food and liquid bolus manipulation, mastication, and front to back bolus movement.

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Purpose: To improve the tongue control for food and liquid bolus manipulation, mastication, and front to back bolus movement.

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Results suggest that the use of the Shaker Exercise along with kinesio taping provided an effective outcome in dysphagia symptoms of patients with Gastroesophageal Reflux Disease (GERD).

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Effect of shakers exercise with kinesio taping in subjects with gastroesophageal reflux disease: A randomized controlled trial

Padwal Tanvi¹, Gurudut Peeyoosha2,*, Hajare Santosh³

¹ PG student, Department of Orthopedic Physiotherapy, KLEU Institute of Physiotherapy, Belagavi, India

² Assistant Professor, Department of Orthopedic Physiotherapy, KLEU Institute of Physiotherapy, Belagavi, India

³ Professor, Dept of Gastroenterology, JNMC, Belagavi, Karnataka state, India

*Corresponding Author: peeoo123@yahoo.com

Online published on 3 October, 2018.
Abstract

The prevalence of GERD in India ranges from 8-20% according to recently conducted studies based on different case definitions and study methodology. Although GERD is rarely life-threatening, it can severely limit daily activities and productivity. The principal goal for GERD treatment is relief of symptoms. Hence the aim of this study was to compare the effect of Shakers Exercise with kinesio taping and medical management over only medical management of GERD on severity of the disease and functional limitation. 30 participants clinically diagnosed with GERD were recruited.15 participants were allocated to control group (CMED) where only medical management was given and other 15 were allocated to intervention group (SKT)where shakers exercise, kinesio taping and medical management were given. Frequency Scale for the Symptoms of GERD was the outcome measure. Paired and unpaired t-test was used to test the significance of difference between mean values of two groups (CMED) and (SKT). Statistically significant improvement was observed in both the groups when compared before and after intervention. However, the SKT showed to be better than CMED group post intervention. It was concluded that Shakers exercise and Kinesio Taping should be incorporated along with medical management in the treatment of patients with GERD on routine basis.
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Keywords

GERD, Kinesio taping, Shakers exercise, Medical management.
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Effect of shakers exercise with kinesio taping in subjects with gastroesophageal reflux disease: A randomized controlled trial-Indian Journals

# data[].attributes.attachment_link.description
The prevalence of GERD in India ranges from 8-20% according to recently conducted studies based on different case definitions and study methodology. Although GERD is rarely life-threatening, it can severely limit daily activities and productivity.

# data[].attributes.body
Researchers report that the Shaker Exercise can provide effective improvement in the amount of residue, spillage, penetration risk, and aspiration risk in patients with Myasthenia Gravis.

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Research suggests the Shaker Exercise is an effective exercise to improve swallowing function in patients post-stroke.

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The purpose of this exercise is to strengthen the muscles that contribute to the opening of the UES and to significantly decrease the hypopharyngeal bolus pressure as it inters the UES which allows for bolus passage with less resistance.

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Purpose: To improve jaw ROM or to improve upper esophageal sphincter (UES) opening during the swallow.

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This table lists specific impairments and the exercises that would be best suited to help improve them.
Reference: Murray, T., Carrau, R. L., & Chan, Karen M. K. (2022). Clinical management of swallowing disorders.

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This table consists of popular exercises typically used to increase tongue and jaw strength or ROM.
Reference: Murray, T., Carrau, R. L., & Chan, Karen M. K. (2022). Clinical management of swallowing disorders.

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This table consists of popular exercises typically used to increase labial strength and ROM.
Reference: Murray, T., Carrau, R. L., & Chan, Karen M. K. (2022). Clinical management of swallowing disorders.

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1. Turn your head to the left/right.
2. Hold your breath tightly.
3. Let go and say "ahhh".
4. Repeat trials.

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1. Place one or both hands under your chair and pull.
2. Hold your breath tightly.
3. Relax.
4. Repeat trials.

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1. Take a breath.
2. Bear down and hold your breath for 10 seconds.
3. Relax.
4. Repeat trials.

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Research indicates the use of motor swallowing exercises improves dysphagia symptoms such as loss of bolus control, piecemeal swallow, and residue on the tongue, valleculae, and pyriform sinuses in patients with Parkinson's Disease.

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Issue title: Neurobehavioural Disorders after Traumatic Brain Injury: Assessment, Treatment and Outcome

Guest editors: Roger Ll. Wood

Article type: Research Article

Affiliations: [a] Division of Neurology and Epidemiology, Federal University of Bahia, Salvador, Brazil | [b] Department of Speech-Language Pathology, Health Sciences Institut, Federal University of Bahia, Salvador, Brazil

Correspondence: [*] Address for correspondence: Ana Caline Nóbrega, Division of Neurology and Epidemiology, Rua Padre Feijó, 29 (4° floor) - Canela, Salvador, Bahia, CEP: 40.110-170, Brazil. Tel.: +55 71 3247 6982; E-mail: [email protected]

Abstract: Objective:To investigate the effect of motor swallowing exercises on swallowing dynamic, quality of life and swallowing complaints in Parkinson's disease (PD). Design:A before-after trial. Setting:University Medical Center. Participants:Parkinson's disease patients with dysphagia complaints. Interv entions:Motor swallowing exercises designed to increase the strength and range of motion of the mouth, larynx and pharyngeal structures, coordination between breathing and swallowing, and airway protection. Patients should perform the exercises twice a day, five days a week, for five weeks. Main outcome measure(s):The primary outcome was the difference before and after the intervention in number of swallowing videofluoroscopic events (Swallowing Score). The secondary outcomes were quality of life (QOL) and swallowing complaints. Results:Fifteen patients concluded the study (10 man/5 woman; mean age 59.2 ± 9.17). The videofluoroscopic events with greater improvement were loss of bolus control (P < 0.03), piecemeal swallow (P = 0.05) and residue on the tongue (P < 0.01), valleculae (P = 0.01) and pyriform sinuses (P = 0.05). Lingual pumping and dental absence were interfering factors associated with treatment failure (beta standardized coefficient = −16.6, 26.2; P = 0.02, 0.002, respectively). The domains with greater improvements in QOL were fear (P = 0.02) and symptom frequency (P = 0.05). Regarding swallowing complaints, patients reported to have reduced mainly their difficulty in moving food in the mouth when chewing (P = 0.02). Reduction in swallowing disorders was not related with QOL improvement (cor = 0.13, [95% CI, 0.6-0.4], P = 0.63). Conclusions:Motor swallowing exercises may reduce swallowing disorders in PD patients without lingual pumping and dental absence and impact positively QOL and swallowing complaints in individuals with PD.

Keywords: Parkinson's disease, rehabilitation, deglutition disorders

DOI: 10.3233/NRE-130918

Journal: NeuroRehabilitation, vol. 32, no. 4, pp. 949-955, 2013

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Do swallowing exercises improve swallowing dynamic and quality of life in Parkinson's disease?

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Issue title: Neurobehavioural Disorders after Traumatic Brain Injury: Assessment, Treatment and Outcome Guest editors: Roger Ll. Wood Article type: Research Article Affiliations: [a] Division of Neurology and Epidemiology, Federal University of Bahia, Salvador, Brazil | [b] Department of Speech-Language Pathology, Health Sciences Institut, Federal University of Bahia, Salvador, Brazil Correspondence: [*] Address for correspondence: Ana Caline Nóbrega, Division of Neurology and Epidemiology, Rua Padre Feijó, 29 (4° floor) - Canela, Salvador, Bahia, CEP: 40.110-170, Brazil.

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Research findings indicate that patients with head and neck cancer should employ the use of jaw, tongue, lips, and larynx ROM exercises for the first 3 months post surgical procedures. This research indicates that ROM exercises improves global measures of swallowing as compared to patients who do not use them.

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Head and neck cancer and its treatment frequently cause changes in both speech and swallowing, which affect the patient's quality of life and ability to function in society. The exact nature and severity of the post-treatment changes depend on the location of the tumor, the choice of treatment, and the availability and use of speech and swallowing therapy during the first 3 months after treatment. This paper reviews the literature on speech and swallowing problems in various types of treated head and neck cancer patients. Effective swallowing rehabilitation depends on the inclusion of a video-fluorographic assessment of the patient's oropharyngeal swallow in the post-treatment evaluation. Pilot data support the use of range of motion (ROM) exercises for the jaw, tongue, lips, and larynx in the first 3 months after oral or oropharyngeal ablative surgical procedures, as patients who perform ROM exercises on a regular basis exhibit significantly greater improvement in global measures of both speech and swallowing, as compared with patients who do not do these exercises.

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Speech and swallowing rehabilitation for head and neck cancer patients.

# data[].attributes.attachment_link.description
Head and neck cancer and its treatment frequently cause changes in both speech and swallowing, which affect the patient's quality of life and ability to function in society. The exact nature and severity of the post-treatment changes depend on the location of the tumor, the choice of treatment, and the availability and use of speech and swallowing therapy during the first 3 months after treatment.

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Research suggests that tongue strength exercises provide a positive effect on tongue motility, bolus formation, tongue to palate contact, premature bolus loss, and oral transit time in post-stroke patients.

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Highlights

*

Tongue stretching exercises increased the tongue motility in patients with dysphagia after stroke.

*

Tongue stretching exercises had a positive effect on oromotor function in patients with dysphagia after stroke.

*

Tongue stretching exercises can be used as an effective treatment for patients with oral dysphagia.

Abstract

Objectives

This study investigated the effect of tongue stretching exercises (TSE) on tongue motility and oromotor function in patients with dysphagia after stroke.

Design

This study was designed as a 4-week, double-blind, two-group, block randomized controlled trial. A total of 25 patients were randomly allocated into either the experimental (n = 13) or the control group (n = 12). The experimental group received TSE from an occupational therapist. TSE were divided into dynamic and static passive stretching exercises (20 repetitions each). The intervention was performed five times a week for four weeks. Tongue motility was measured before and after the intervention as the distance from the lower lip to the tip of tongue during maximum protrusion of the tongue. Measurements were performed twice each time and the mean value recorded. Oromotor function was assessed using the oral phase events of the videofluoroscopic dysphagia scale (VDS) based on a videofluoroscopic swallowing study.

Results

The experimental group showed significant differences in tongue motility, bolus formation, tongue to palate contact, premature bolus loss, and oral transit time in the oral phase of VDS ( p < 0.05 for all) before and after the intervention, whereas the control group showed a significant difference only in lip closure ( p  < 0.05).

Conclusion

This study demonstrated that TSE have a positive effect on tongue motility and oromotor function in patients with dysphagia after stroke. Therefore, we recommend TSE as an effective treatment for dysphagia.

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Tongue stretching exercises improve tongue motility and oromotor function in patients with dysphagia after stroke: A preliminary randomized controlled trial

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Tongue stretching exercises increased the tongue motility in patients with dysphagia after stroke. * Tongue stretching exercises had a positive effect on oromotor function in patients with dysphagia after stroke. * Tongue stretching exercises can be used as an effective treatment for patients with oral dysphagia.

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Tongue strengthening exercises were not found to have any significant improvement in tongue strength or swallowing measures in patients treated with chemoradiotherapy for oral/oral pharyngeal cancer.

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Abstract

Tongue strength is reduced in patients treated with chemoradiotherapy for oral/oropharyngeal cancer. Tongue strengthening protocols have resulted in improved lingual strength and swallowing in healthy individuals, as well as in patients following a neurological event. However, no studies have examined the efficacy of tongue strengthening exercises on tongue strength, swallowing, and quality of life (QOL; Head and Neck Cancer Inventory) in patients treated with chemoradiotherapy. A randomized clinical trial examined the effects of a tongue strengthening programme paired with traditional exercises vs. traditional exercises alone. Dependent variables included tongue strength, swallowing, and QOL in a group of patients with oral and oropharyngeal cancer treated with primary radiotherapy with or without chemotherapy. Differences with regard to tongue strength and oropharyngeal swallow efficiency (OPSE) were not observed within or between groups. QOL in the eating and speech domains improved following treatment in both groups. However, the experimental group demonstrated greater impairment in QOL in the social disruption domain following treatment, whereas the control group demonstrated a slight improvement in functioning. Tongue strengthening did not yield a statistically significant improvement in either tongue strength or swallowing measures in this patient cohort. Patient compliance and treatment timing may be factors underlying these outcomes.

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Effects of exercise on swallowing and tongue strength in patients with oral and oropharyngeal cancer treated with primary radiotherapy with or without chemotherapy

# data[].attributes.attachment_link.description
Tongue strength is reduced in patients treated with chemoradiotherapy for oral/oropharyngeal cancer. Tongue strengthening protocols have resulted in improved lingual strength and swallowing in healthy individuals, as well as in patients following a neurological event. However, no studies have examined the efficacy of tongue strengthening exercises on tongue strength, swallowing, and quality of life (QOL; Head and Neck Cancer Inventory) in patients treated with chemoradiotherapy.

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Research findings report that chin-tuck against resistance, jaw opening against resistance, and effortful swallow exercises show a significant increase in mean tongue strength, jaw-opening strength, anterior tongue strength, suprahyoid muscle volume, and maximum mouth opening after 6 weeks of implementation in patients with head and neck cancer.

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Tongue-to-palate resistance training has a significant impact on increasing tongue strength and oropharyngeal swallowing function in patients post stroke.

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,

Corresponding Author

Department of Rehabilitation Science, Graduate School, Inje University, Gimhae, Korea

Correspondence: Ji-Su Park, Department of Rehabilitation Science, Graduate School, Inje University, 197 Inje-ro, Gimhae, Gyeongsangnam-do 621-749, Korea.

E-mail: jisu627@hanmail.net
Search for more papers by this author

First published:

Summary

Tongue function can affect both the oral and pharyngeal stages of the swallowing process, and proper tongue strength is vital for safe oropharyngeal swallowing. This trial investigated the effect of tongue-to-palate resistance training (TPRT) on tongue strength and oropharyngeal swallowing function in stroke with dysphagia patients. This trial was performed using a 4-week, two-group, pre-post-design. Participants were allocated to the experimental group ( n = 18) or the control group ( n = 17). The experimental group performed TPRT for 4 weeks (5 days per week) and traditional dysphagia therapy, whereas the control group performed traditional dysphagia therapy on the same schedule. Tongue strength was measured using the Iowa Oral Performance Instrument. Swallowing function was measured using the videofluoroscopic dysphagia scale (VDS) and penetration-aspiration scale (PAS) based on a videofluoroscopic swallowing study. Experimental group showed more improved in the tongue strength (both anterior and posterior regions, P = 0·009, 0·015). In addition, the experimental group showed more improved scores on the oral and pharyngeal phase of VDS ( P = 0·029, 0·007), but not on the PAS ( P = 0·471), compared with the control group. This study demonstrated the effectiveness of TPRT in increasing tongue muscle strength and improving swallowing function in patients with post-stroke dysphagia. Therefore, we recommend TPRT as an easy and simple rehabilitation strategy for improving swallowing in patients with dysphagia.

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Tongue‐to‐palate resistance training improves tongue strength and oropharyngeal swallowing function in subacute stroke survivors with dysphagia

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Corresponding Author Department of Rehabilitation Science, Graduate School, Inje University, Gimhae, Korea Correspondence: Ji-Su Park, Department of Rehabilitation Science, Graduate School, Inje University, 197 Inje-ro, Gimhae, Gyeongsangnam-do 621-749, Korea. E-mail: jisu627@hanmail.net Search for more papers by this author First published: Tongue function can affect both the oral and pharyngeal stages of the swallowing process, and proper tongue strength is vital for safe oropharyngeal swallowing.

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Research suggests the actual effectiveness of the effortful swallow is highly variable among patients.

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Affiliations

1. Communicative Sciences and Disorders, The University of Montana, 32 Campus Drive, Missoula, MT, 59812-9968, USA

Laurie Slovarp, Lauren King & Catherine Off

2. Speech and Hearing Science, Arizona State University, 975 S. Myrtle Ave, P.O. Box 870102, Tempe, AZ, 85287-0102, USA

Julie Liss

Corresponding author

Correspondence to Laurie Slovarp.

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Slovarp, L., King, L., Off, C. et al. A Pilot Study of the Tongue Pull-Back Exercise for Improving Tongue-Base Retraction and Two Novel Methods to Add Resistance to the Tongue Pull-Back. Dysphagia 31, 416-423 (2016). https://doi.org/10.1007/s00455-016-9693-y
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Keywords

Deglutition

Deglutition disorders

Dysphagia

Tongue-base retraction

Electromyography

Effortful swallow

Tongue pull-back

Strength training

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A Pilot Study of the Tongue Pull-Back Exercise for Improving Tongue-Base Retraction and Two Novel Methods to Add Resistance to the Tongue Pull-Back - Dysphagia

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This pilot study investigated the tongue pull-back (TPB) exercise to improve tongue-base retraction as well as two methods to add resistance to the TPB.

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Unassistive use of the tongue pull-back exercise is not any more helpful for improving tongue-base retraction than typical swallowing.

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Access options

Buy single article

Instant access to the full article PDF.

US$ 39.95

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Author information

Affiliations

1. Communicative Sciences and Disorders, The University of Montana, 32 Campus Drive, Missoula, MT, 59812-9968, USA

Laurie Slovarp, Lauren King & Catherine Off

2. Speech and Hearing Science, Arizona State University, 975 S. Myrtle Ave, P.O. Box 870102, Tempe, AZ, 85287-0102, USA

Julie Liss

Corresponding author

Correspondence to Laurie Slovarp.

About this article

Cite this article

Slovarp, L., King, L., Off, C. et al. A Pilot Study of the Tongue Pull-Back Exercise for Improving Tongue-Base Retraction and Two Novel Methods to Add Resistance to the Tongue Pull-Back. Dysphagia 31, 416-423 (2016). https://doi.org/10.1007/s00455-016-9693-y
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Get shareable link

Keywords

Deglutition

Deglutition disorders

Dysphagia

Tongue-base retraction

Electromyography

Effortful swallow

Tongue pull-back

Strength training

# data[].attributes.attachment_link.title
A Pilot Study of the Tongue Pull-Back Exercise for Improving Tongue-Base Retraction and Two Novel Methods to Add Resistance to the Tongue Pull-Back - Dysphagia

# data[].attributes.attachment_link.description
This pilot study investigated the tongue pull-back (TPB) exercise to improve tongue-base retraction as well as two methods to add resistance to the TPB.

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Research suggests performing swallowing exercises prior to chemoradiation for treatment of head and neck cancer increases improvements in post-treatment swallowing function.

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Objectives/Hypothesis: Swallowing dysfunction is a devastating complication of chemoradiation therapy (CRT) for head and neck squamous cell carcinoma. We have previously demonstrated that pretreatment swallowing exercises improve posttreatment swallowing-related quality of life. This study evaluates the effect of pretreatment swallowing exercises on posttreatment swallow function as measured by videofluoroscopy.

Study Design: Retrospective case control.

Methods: Eighteen patients with advanced squamous cell carcinoma of the oropharynx, hypopharynx, and larynx treated at University of Alabama at Birmingham with CRT were included in the study. Nine patients received pretreatment swallowing exercises prior to CRT, and nine patients received swallowing exercises during routine posttreatment management. Approximately 3 months after completing treatment, standard videofluoroscopy examinations were conducted. Outcomes measured by the videofluoroscopy examinations included hyoid elevation, epiglottis inversion, tongue base movement, cricopharyngeal opening, and Rosenbeck aspiration score. Percutaneous endoscopic gastrostomy (PEG) tube use was assessed at 12 months after treatment.

Results: Epiglottis inversion was better maintained ( P = .05) in patients receiving pretreatment swallowing therapy. The position of the tongue base during swallowing was also significantly closer to the posterior pharyngeal wall ( P = .025) for patients receiving pretreatment exercises. PEG tube removal rates did not significantly differ between groups.

Conclusions: Performing pretreatment swallowing exercises produces measurable improvements in posttreatment swallowing function in patients who undergo organ-preservation CRT for head and neck cancer. This study provides an initial foundation for the development of noninvasive, cost-effective, evidence-based interventions in this group of vulnerable patients.

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Pretreatment Swallowing Exercises Improve Swallow Function After Chemoradiation

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Objectives/Hypothesis: Swallowing dysfunction is a devastating complication of chemoradiation therapy (CRT) for head and neck squamous cell carcinoma. We have previously demonstrated that pretreatment swallowing exercises improve posttreatment swallowing-related quality of life. This study evaluates the effect of pretreatment swallowing exercises on posttreatment swallow function as measured by videofluoroscopy.

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Research finds tongue strengthening exercises to be effective in increasing strength and thickness of oropharyngeal muscles in the elderly population.

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Monitoring Editor: Xu Qian.

Abstract

Background

Tongue strengthening exercise (TSE) is a remedial method for the training of swallowing-related muscles in the oropharyngeal phase. However, clinical evidence of its effectiveness is insufficient.

Methods

To investigate the effect of TSE on the oropharyngeal muscles associated with swallowing in older adults, in this study, 40 elder adults living in the community were recruited and assigned to 2 groups. The experimental group performed a TSE with a 1-repetition maximum resistance level of 70%. The exercise was divided into an isometric and isotonic part. The control group did not perform an exercise. We measured the muscle strength and thickness of the tongue and suprahyoid muscles using an Iowa Oral Performance Instrument and ultrasonography.

Results

The experimental group showed a statistically significant increase in tongue muscle strength and thickness in the oral phase ( P = .001 and <.001, respectively). In the pharyngeal phase, the experimental group showed a statistically significant increase in the mylohyoid and digastric muscles (suprahyoid muscles) ( P  = .045 and .019, respectively). The control group showed no statistically significant changes.

Conclusion

TSE is effective in increasing the strength and thickness of the oropharyngeal muscles of elder adults and is recommended for those who are vulnerable to swallowing difficulties.

Keywords: older, sarcopenia, strength, swallowing, tongue

1. Introduction

Sarcopenia occurs during the normal aging process, results in a reduction of muscular volume and size, and leads to muscle weakness. The elderly may undergo physiological changes of skeletal muscle, which reduce physical activity and result in negative impacts, such as falls; these changes may also affect the muscles associated with swallowing and cause swallowing difficulty in the elderly, which is called presbyphagia. Therefore, exercise of the muscles related to swallowing in elderly people who are vulnerable to sarcopenia is important.

The tongue is a skeletal muscle and a representative soft-tissue structure of the stomatognathic system of the oral cavity. The role of the tongue in oropharyngeal swallowing is extensive and essential to normal swallowing function. The tongue is involved in mastication, manipulation, and formation and transport of the food bolus to the tongue base during the oral phase of the swallowing process. However, the strength and endurance of the tongue muscles are significantly reduced in the elderly compared to younger adults, because these muscles are affected by sarcopenia. As a result, various problems can occur, such as lateral sulcus residue, poor bolus formation and mastication during the oral phase, and vallecular residue and aspiration during the pharyngeal phase.

Tongue strengthening exercise (TSE) is a therapeutic exercise aimed at enhancing the swallowing function by improving tongue muscle strength. Several previous studies have demonstrated the efficacy of TSE. Robbins et al demonstrated an increased tongue strength in 10 elder adults who performed TSE for 8 weeks; the increase in tongue thickness was measured by magnetic resonance imaging. However, the Robbins et al study had a very small number of subjects and no control group. Recently, Van den Steen et al reported a significant increase in tongue muscle strength after TSE application for 8 weeks in a healthy older adult; however, the effect of TSE on the thickness of the tongue and other muscles associated with swallowing was not determined, because only tongue muscle strength was measured. Studies related to TSE are lacking and the effects remain unclear. Therefore, this study investigated the effect of TSE on the oropharyngeal muscles of elder adults living in the community.

2. Methods

2.1. Participants

A total of 40 community-dwelling elder adults living in 2 senior citizen's centers in the Busan territory of South Korea were enrolled in this study. This study was conducted from September 2018 to December 2018. The inclusion criteria were as follows: age > 65 years, able to independently perform activities of daily living, > 24 point score on the Mini-Mental Status Examination-Korean version, tongue pressure >30 kilopascal (kPa), and normal range of tongue motility (e.g., protrusion, lateralization). The exclusion criteria were as follows: history of speech or swallowing deficits, severe visual impairment, parafunctional sucking and biting habits (finger sucking, lip, cheek, and object biting, bruxism, and nail biting), smoker, and person with a specific hobby (e.g., wind instrument player). The subjects' general characteristics are shown in Table . Ethical approval was obtained from the Inje University Institutional Review Board before conducting the experiment (INJE 2018-09-002-001).

Table 1

2.2. Tongue strengthening instrument

This study employed a TPS system for the TSE (TPS 100, Cybermedic Inc, Iksan, South Korea). The TPS system is a tongue muscle exercise device designed for resistance training. The TPS system consists of a pressure sensor, air-bulb, and display (e.g., tablet PC, smartphone) for the resistance training, and the pressure sensor and tablet PC are connected by a Bluetooth interface. The external force applied to the pressure sensor is automatically displayed on the Tablet PC screen in kPa (Fig. ).

2.3. Intervention

A total of 40 older adults were divided between an experimental group (n = 20) and a control group (n = 20). The experimental group performed TSE using the TPS system. The 1-repetition maximum (1-RM) was measured for all subjects before training to determine their baseline resistance value. To measure the 1-RM, a pressure sensor was placed between the tongue and the palate of each subject in both groups, and they were asked to press their tongue as strongly as possible against the sensor. The experimental group then performed TSE by applying70% of their 1-RM baseline measurement.

The exercise performed by the experimental group was divided into an isotonic and isometric type. The isotonic type was performed by repeating the contraction and relaxation of the tongue muscle 30 times at 3 sets per day. The isometric type was a state of contraction of the tongue muscle maintained for 30 seconds for a total of 3 sets. The control group did not perform an exercise.

2.4. Outcome measurement

Tongue strength was measured using the TPS system. The measurement was performed by placing the air-bulb between the tongue and the palate and then pressing the bulb firmly with the tongue. The average value of 3 consecutive measurements was recorded.

The thickness of the tongue and suprahyoid muscle was measured using a portable ultrasonography device (SONON300L, Healcerion, Seoul, Korea) with a 10 MHz and linear- and convex-array transducer. Tongue thickness was determined by measuring the distance between the upper and lower surfaces of the tongue muscles in the center of the plane perpendicular to the Frankfort horizontal plane of the frontal session. The vertical distance was measured from the surface of the mylohyoid muscle to the dorsum of the tongue. Suprahyoid muscle measurements were performed by positioning the transducer between the hyoid bone and the chin and visualizing the image on a tablet PC. The suprahyoid muscle measurements included the measurements of the anterior bellies of the digastric and the mylohyoid muscles. The digastric muscle measurements were obtained from the upper to the lower boundary of the fascia covering the muscle at the broadest point perpendicular to the mylohyoid muscle. The mylohyoid muscle measurements were recorded below the measurement point of the digastric muscle, from the upper to the lower boundary of the fascia covering the muscle (Fig. ). Ultrasonographic measurement of muscle thickness was performed by an experienced rehabilitation physician.

2.5. Data analysis

Participant characteristics were analyzed using the statistical software program SPSS Statistics 20 (IBM Corporation, US). Descriptive statistics were presented as means with standard deviations. The Shapiro-Wilk test was used to check normality of the outcome variables. To evaluate the intervention effects, the paired t test was used to compare the outcome measures before and after the intervention in each group. The independent t test was used to compare the changes in the outcome measures between groups. The effect sizes (Cohen d) of changed scores between the experimental and control groups were calculated. An effect size of 0.2, 0.5, and 0.8 represented a small, moderate, and large effect, respectively.

3. Results

3.1. General characteristics of subjects

Data from a total of 40 patients were analyzed. No significant differences in the baseline characteristics were observed between the 2 groups ( P  > .05). The flowchart of the study is shown in Figure . The general characteristics of the subjects are shown in Table .

3.2. Tongue muscle strength

Table 2

3.3. Tongue muscle thickness

3.4. Thickness of the mylohyoid muscles

Table 3

3.5. Thickness of the digastric muscles

4. Discussion

Maintaining and improving the strength of the oropharyngeal muscles is important for safe swallowing in the elderly. Therefore, we investigated the effect of TSE on the oropharyngeal muscles of elder adults living in the community. We measured the tongue strength and thickness in the oral phase using the Iowa Oral Performance Instrument and ultrasonography. The tongue muscle strength and thickness of the elder adults in the experimental group significantly increased by 18% and 5%, respectively; however, no significant changes were observed in the control group. Therefore, TSE is an effective method to increase the tongue strength and thickness of the elderly.

A reasonable loading value is one of the important factors in resistance training. Recently, Van den Steen et al conducted a study using TSE at 60%, 80%, and 100% of the 1-RM value in a group of healthy elder adults; all groups showed a significant increase in tongue muscle strength, but100% 1-RM was the most effective. TSE at 100% of the 1-RM is likely to result insubstantial muscle fatigue and noncompliance, because the exercise must be performed with a constant maximum effort. Therefore, this study was performed at 70% of the range that is generally accepted as optimal for resistance training. As a result, we were able to confirm that the range we chose increased tongue muscle strength as well as the range in previous studies. This study also measured the change in tongue thickness, which was not reported in previous studies. We confirmed by using ultrasonography that TSE induces physiological changes, including tongue thickness and muscle strength. Resistance exercise of skeletal muscle increases the number of myofibers and results in increased muscle hypertrophy and cross-sectional area. The results of our study confirm that the tongue muscle is responsive to resistance training.

Interestingly, this study confirms that TSE is an effective method to increase suprahyoid muscle thickness in the pharyngeal phase. The experimental group demonstrated a significant increase in both the digastric and mylohyoid muscle thickness. Yoshida et al in the sEMG study demonstrated that tongue press exercise induces activation of the suprahyoid muscles. Muscle activation is a recruitment of motor units by peripheral nerves. High amplitudes on the sEMG value represent an increase in the number of recruited motor units or an increased discharge rate of motor units. Therefore, the induction of muscle activation most likely induces muscle physiology changes, such as muscle strength and muscle thickness, and the results of our study support this concept. The tongue muscles and suprahyoid muscles are attached to the hyoid bone below the chin and are partially integrated. Therefore, contraction of the tongue muscles, such as the genioglossus and hyoglossus muscles, and the suprahyoid muscles, such as the digastric muscle and the myolyoid muscle, during TSE may be associated. For this reason, TSE is thought to positively influence changes in both the suprahyoid and tongue muscles.

5. Conclusion

In conclusion, TSE is an effective method to increase the thickness of the suprahyoid and tongue muscles and increase tongue muscle strength in the elderly. We propose TSE for elder adults who are vulnerable to swallowing difficulties.

Acknowledgment

This work was supported by the BB21+ project in 2018.

Author contributions

Data curation: Sang-Hoon Jung.

Formal analysis: Sang-Hoon Lee.

Funding acquisition: Jong-Bae Choi, Young-Jin Jung.

Investigation: Sang-Hoon Lee, Sang-Hoon Jung.

Supervision: Jong-Bae Choi.

Writing - original draft: Ji-Su Park, Young-Jin Jung.

Writing - review & editing: Ji-Su Park.

Young-Jin Jung orcid: 0000-0003-0169-2865.

Footnotes

Abbreviations: 1-RM = 1-repetition maximum, TSE = tongue strengthening exercise.

How to cite this article: Park JS, Lee SH, Jung SH, Choi JB, Jung YJ. Tongue strengthening exercise is effective in improving the oropharyngeal muscles associated with swallowing in community-dwelling older adults in South Korea. Medicine. 2019;98:40(e17304).

This work was supported by Dongseo University, "Dongseo Cluster Project" Research Fund of 2019 (DSU-2019002).

The authors have no conflicts of interest to disclose.

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Tongue strengthening exercise is effective in improving the oropharyngeal muscles associated with swallowing in community-dwelling older adults in South Korea: A randomized trial

# data[].attributes.attachment_link.description
Monitoring Editor: Xu Qian. Tongue strengthening exercise (TSE) is a remedial method for the training of swallowing-related muscles in the oropharyngeal phase. However, clinical evidence of its effectiveness is insufficient. To investigate the effect of TSE on the oropharyngeal muscles associated with swallowing in older adults, in this study, 40 elder adults living in the community were recruited and assigned to 2 groups.

# data[].attributes.body
Purpose: To improve base of the tongue movement and strength in order to better propel the bolus.

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Effortful and Mendelsohn maneuver swallows significantly alter the pharyngoesophageal pressure profile. Faster opening of the upper esophageal sphincter may facilitate bolus transfer during maneuver swallows; however, reduced proximal esophageal contractility during Mendelsohn maneuver swallows may impair bolus flow and aggravate dysphagic symptoms.

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To produce an effortful swallow patients are instructed to swallow normally while squeezing their throat and tongue muscles very hard throughout the process.

# data[].attributes.body
A technique to open the upper esophageal sphincter (UES) by extending the duration of laryngeal elevation.

# data[].attributes.body
Purpose: To improve labial strength to keep the bolus in the oral cavity and in preparing the bolus for transfer.

# data[].attributes.body
This study reported that among 17 head and neck cancer survivors, 16 participants showed a continual improvement in their chin tuck, jaw opening, and anterior strength after 6-8 weeks. The researchers assert that this indicates OMEs can provide an effective tool to improve swallowing function long-term.

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Only a minority of exercises prescribed for patients with dysphagia have sufficient evidence for long-term improvement in swallowing

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Evidence suggests that the Masako maneuver may not benefit patients with increased pressures of the tongue base to the pharyngeal wall.

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Purpose

To compare the effects of the tongue-hold swallowing maneuver on pharyngeal pressure generation in healthy young and elderly research volunteers.

Method

Sixty-eight healthy research volunteers (young, n = 34, mean age = 26.8 years, SD = 5.5; elderly, n = 34, mean age = 72.6 years, SD = 4.8; sex equally represented) performed 5 noneffortful saliva swallows and 5 tongue-hold swallows each. Amplitude and duration of pharyngeal pressure were investigated during both swallowing conditions with solid-state pharyngeal manometry at the level of the oropharynx, hypopharynx, and upper esophageal sphincter (UES).

Results

At both pharyngeal levels, tongue-hold swallows produced lower peak pressure compared with saliva swallows. During tongue-hold swallows, UES relaxation pressure was increased in the elders, whereas the younger group displayed a trend toward reduced relaxation pressure. Elderly individuals produced pressure longer during control swallows in the oropharynx and hypopharynx than young individuals.

Conclusions

The tongue-hold maneuver affects oropharyngeal and hypopharyngeal pressure in the young and elders in similar ways, whereas effects on UES peak relaxation pressure differ between age groups. Reduced pharyngeal peak pressure and increased UES relaxation pressure underscore the notion that tongue-hold swallows should not be performed when bolus is present. Long-term training effects remain to be investigated.

References

Burkhead, L. M., Sapienza, C. M., & Rosenbek, J. C. (2007). Strength-training exercise in dysphagia rehabilitation: Principles, procedures, and directions for future research.22, 251-265.Dysphagia,

Butler, S. G., Stuart, A., Wilhelm, E., Rees, C., Williamson, J., & Kritchevsky, S. (2010). The effects of aspiration status, liquid type, and bolus volume on pharyngeal peak pressure in healthy older adults.Dysphagia. Advance online publication. doi:10.1007/s00455-010-9290-4

Youmans, S. R., Youmans, G. L., & Stierwalt, J. A. G. (2009). Differences in tongue strength across age and gender: Is there a diminished strength reserve?,24, 57-65.Dysphagia,

# data[].attributes.attachment_link.title
Pharyngeal Pressure Generation During Tongue-Hold Swallows Across Age Groups

# data[].attributes.attachment_link.description
To compare the effects of the tongue-hold swallowing maneuver on pharyngeal pressure generation in healthy young and elderly research volunteers. Sixty-eight healthy research volunteers (young, n = 34, mean age = 26.8 years, SD = 5.5; elderly, n = 34, mean age = 72.6 years, SD = 4.8; sex equally represented) performed 5 noneffortful saliva swallows and 5 tongue-hold swallows each.

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Types: Tongue Resistance Exercises, Base of Tongue Exercises, Tongue Range of Movement (ROM) Exercises.

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Purpose: To improve airway closure and prevent aspiration.

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1. Protrude your tongue slightly from your mouth.
2. Hold the tongue gently with your teeth.
3. Swallow while keeping your tongue protruded.
4. Relax/repeat trials.