I-PRO.  Nope, it’s not a new app for the iPad.  It stands for Isometric Progressive Resistance Oropharyngeal Therapy.

Isometric is a sustained movement.  Wikipedia:

  • Isometric exercise, a form of resistance exercise in which one’s muscles are used in opposition with other muscle groups, to increase strength, for bodybuilding, physical fitness, or strength training.”
Our field has definitely moved in the direction of exercise-based dysphagia therapy investigating resistance, intensity, repetitions.
Evidence has shown us that resistance has a huge impact on our exercise.  Look at sticking your tongue out 10 times, compared to pushing your tongue against a tongue depressor 10 times.  Weight lifters don’t build muscle or strength by simply moving their arms up and down.  They add weight and continue to increase that weight.
I’ve been reading articles by Dr. Joanne Robbins for a while.  She has compared exercises using the Iowa Oral Performance Instrument or (IOPI).   Her research consistently looks at subjects given 8 weeks of therapy or exercise.  She’s researched patients using the IOPI vs. no exercise and found that those patients given a regimen of exercise for the tongue using resistance increased tongue mass (as measured by MRI), tongue strength (as measured by the IOPI) and actually lowered Penetration/Aspiration scores, meaning decreased penetration and/or aspiration.
In another study, she found that there was no difference in using the IOPI vs. using a standard tongue depressor, pushing the tongue against the depressor elevated, anterior and lateral (both sides).
Dr. Robbins has also created her own lingual strengthening device called the MOST (Madison Oral Strengthening Therapeutic) which is now called SwallowStrong.  This device works much like the IOPI, however provides various sensors, exercising different areas of the tongue (the IOPI utilizes a single bulb.)
I was excited to find this article:

Juan JHind JJones CMcCulloch TGangnon RRobbins J.  Case Study:  Application of Isometric Progressive Resistance Oropharyngeal Therapy Using the Madison Oral Strengthening Therapeutic Device.   Top Stroke Rehabil. 2013 Sep-Oct;20(5):450-70. doi: 10.1310/tsr2005-450

I-PRO is definitely a (new?) tool for your dysphagia toolbox!

This study looked at a single patient.  A 56 year old female, 27 months s/p CVA.  This patient had undergone behavioral interventions (“swallow-specific maneuvers (eg, supraglottic swallow), swallowing sensory stimulation/enhancement (eg, thermal stimulation), postural strategies (eg, head turn), and dietary modification”), UES dilatations and G-Tube with expectoration of saliva.   She also had outpatient services including, as the authors state “traditional dysphagia therapy and an intensive, daily home practice program including swallowing-specific maneuvers (eg, Mendelsohn), range of movement exercises, and electrical stimulation (E-stim) during saliva swallowing tasks.”

Following traditional therapy:  Video Fluorscopic Swallow Study (VFSS) was completed to see the anatomy and physiology of the swallow, looking at 12 swallows and 4 bolus consistencies.  Patient was observed with liquid pooling on the vocal folds, liquid pooling in the pyriform sinus, minimal right-sided UES opening, aspiration of liquids and decreased lingual strength as measured by the IOPI.

The patient then was introduced to 8 weeks of I-PRO Therapy with a focus on the anterior and posterior tongue, followed by 5 weeks of detraining and 9 weeks of I-PRO maintenance with decreased frequency.

During the 8 weeks of I-PRO, the patient completed 10 lingual press exercises (anterior and posterior portions of the tongue) 3x/day, 3 days/week.

Detraining included 5 weeks of no lingual strengthening.   After the detraining session, patient was found to have decreased isometric pressure with reduced UES oepning.

A 9 week program of I-PRO Therapy followed the detraining, which included a less intense I-PRO program.   After the maintance program, anterior lingual pressure returned to the same level that it was after the 8 weeks of intervention.

 Quality of Life was measured using the SWAL-QOL, a diet inventory was completed, lingual pressures and volumes were measured pre and post therapy.
Post I-PRO therapy, the patient went from total NPO with expectoration of saliva to a full, unrestricted oral diet, lingual pressure and volume increased with transference to increased swallowing pressure, post-swallow residue was decreased per follow-up VFSS, UES and pharyngeal pressures increased with increased UES opening (as measured by manometry) and quality of life increased.
The patient had improved swallow safety, increased to oropharyngeal intake.
Exercise needs to count for our patients.  According to exercise science literature, 10 reps, 3 times/day, 3 days/week for 8 weeks is what is recommended.
Can’t afford the devices ranging from roughly $900-$2500??  Invest in some tongue depressors to add to that toolbox!  We all have those anyway, right??

4 thoughts on “I-PRO

  1. Hi, I’m a CF SLP who works for a company that has yet to purchase an IOPI or MOST for me. I have been prescribing isometric tongue-palate exercises and have improvised by having the patient use a toothette wrapped in a pill crushing bag (the toothette is too abrasive if bare) and placing this contraption in the same positions that are used with IOPI bulbs. Not optimal – but it is what I have available. My question is how is a tongue depressor typically used for these exercises? I’ve experimented on myself and the tongue depressors unsurprisingly cause pain if I squeeze them between my tongue and palate, and they are too bendy if I hold them in my hand and push against them (although, granted, I have a stronger tongue than do my patients who need to do lingual exercises). Anyway – just curious how other SLPs are doing this… If you have some advice, it would be appreciated.

    1. The MOST was renamed the SwallowStrong and was discontinued last year. When I use a tongue depressor I don’t have the patient squeeze it between the tongue and the palate. I just have them push up against it with the tongue, which has not caused any pain in any of my patients using the exercise. I hope this helps!

  2. I have my patients press against either a tongue depressor or into the bowl of a spoon for lingual resistance. When patients are weaker, sometimes the bowl of the spoon helps them stabilize where they are pointing their tongue, and everyone has spoons at home/ can access them in the hospital… I focus on extension + force against the spoon, and I provide assistance as needed or train caregivers to help if needed. Sometimes having the patient perform these in front of a mirror is helpful cueing, or they need to prop their elbow on a table to maintain the position. I cue them to sit upright (many slump), then do this series:

    1) press straight ahead into the spoon, hard. My usual goal per rep is 5-10 seconds, depending on their strength. I work on getting the tip of the tongue beyond the lips without drooping while pressing against the spoon. I have them relax and swallow between each rep, then do that up to 10-20 times (depending on the person’s stamina and coordination – they may start at 5 seconds x 5 reps if need be…).

    2) Place the spoon or tongue depressor at the corner of the mouth (on the outside of the mouth) and press the tongue tip hard against it. Same assessment re: how many seconds/ how many reps. They often need cues not to scoot the spoon toward the middle of the mouth, where it is easier.

    3) Same thing on the other side of the mouth.

    4) Hold the spoon or tongue depressor sideways along the upper lip (flipped so that the back of the spoon points up toward the ceiling) and gently open the jaw/ press up against the spoon. Assess for seconds/ reps. This is their baseline for exercises outside of therapy, and I ask them to try to do them 3 x day, increasing time and reps as able to 10 seconds and 10-20 reps.

    I then have them gently open the jaw and forcefully lick the palate front-to-back. (Back-to-front is mostly just laying down your tongue). They have to maintain the jaw opening as they push back. This is a big tell about compensating for base of tongue weakness.

    Occasionally a person will complain about jaw tension while doing these – if so, we intersperse with some gentle jaw stretching/ exaggerating saying “Wow”, etc.

    I have always found these exercises very effective at showing me and the patient/ family whether their strength or stamina and/ or coordination are improving, and I have never seen a set of exercises that challenges quite this range of movement. I realize this is anecdotal, and I do follow the literature/ discussions/ debates about what we do!

    I hope that is helpful…

Leave a Reply