Introduction

In swallowing rehabilitation, one of the most debated questions is: Should we train skill or strength?

At an ASHA Convention several years ago, this debate highlighted the question of whether dysphagia therapy should primarily target muscle strength or motor skill learning. Since then, growing evidence suggests that the answer is not either/or—it’s both.

In this post, I’ll break down the difference between skill and strength training in swallowing therapy, examine the research, and explore what this means for clinicians.

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Why Both Skill and Strength Matter in Dysphagia Therapy

Swallowing requires much more than strength. As clinicians, we assess and treat:

• Neuromuscular coordination
• Precision of movement
• Timing
• Reaction speed
• Motor planning

As Huckabee & Lamvik Gozdzikowska (2018) pointed out, lack of patient progress may reflect not just the patient, but the accuracy of our diagnosis and selection of rehabilitation strategies.

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The Limits of Compensatory Strategies

Historically, dysphagia management emphasized compensations. However, Zimmerman et al. (2020) highlighted that compensatory techniques often provide only temporary effects and suffer from poor adherence. The shift toward rehabilitative therapy aims to produce lasting functional improvements.

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Strength Training in Swallowing

• Strength = ability to produce force against resistance
• Weakness = reduced ability to produce force
• Fatigue = weakness that becomes evident over time or repetitions

Strength training in swallowing therapy has limits:

• Swallowing does not require maximal contraction (Burkhead et al., 2007; Langmore & Pisegna, 2015).
• Adverse effects can occur: fatigue, increased tone, and detraining (Moldover & Borg-Stein, 1994; Clark, 2003; Baker et al., 2005).
• Measurement tools are limited—though tongue strength can be measured with IOPI or Tongueometer.

Many traditional “strength” exercises do not meet principles of exercise science such as progression, overload, and specificity.

Strength-based training may be beneficial for Lower Motor Neuron damage, sarcopenia, and in some cases of Upper Motor Neuron damage.

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Skill Training in Swallowing

Skill training focuses on motor learning—improving precision, coordination, and timing of the swallow.

According to Huckabee & MacCrae (2016):

“Skill-based training can be defined at a basic level as the acquisition of skill through functional repetition and refinement of movement patterns, task challenge and feedback.”

Skill-based training emphasizes:

• Specificity of practice – actual swallowing tasks
• Task challenge – increasing demand at each level
• Feedback – often via sEMG

Studies show skill training produces greater gains than strength alone, and may even build strength through precise practice (Huckabee & Macrae, 2014).

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Evidence for Skill Training

Skill-based swallowing therapy has been studied in:

• Parkinson’s disease (Athukorala et al., 2014)
• Head and neck cancer (Martin-Harris et al., 2015)
• Patients resistant to traditional therapy (Carnaby & Crary, 2010)

These studies consistently demonstrate improvements in swallowing function and, importantly, retention of progress over time. Skill training can also increase cortical activation.

Patients with Apraxia of Swallowing may benefit from skill-based training.

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Examples of Swallowing Exercises

Strength-based exercises with swallowing:

• Mendelsohn Maneuver
• Effortful Swallow
• Tongue-Hold Maneuver (Masako)

Strength-based exercises without swallowing:

• Pitch Glide
• Shaker (Head-Lift Exercise)
• Expiratory Muscle Strength Training (EMST)
• Lingual strengthening using resistance
• Chin Tuck Against Resistance (CTAR)
• Jaw Opening Against Resistance (JOAR)

Skill-based exercises with swallowing:

• Effortful Swallow
• Tongue-Hold Maneuver (Masako)
• Mendelsohn Maneuver
• McNeill Dysphagia Therapy Program (MDTP)

Skill-based exercises without swallowing:

• Shaker (Head-Lift Exercise)
• Expiratory Muscle Strength Training (EMST)
• Lingual exercises

Other programs:

• Intensive Dysphagia Rehabilitation Program (IDR)
• MD Anderson Boot Camp

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Takeaway for SLPs

The debate between skill vs. strength training should not be framed as a competition. Both have roles in swallowing rehabilitation.

• Strength training may be appropriate in select cases, but should follow exercise science principles.
• Skill training, grounded in motor learning, is often more specific and effective for long-term outcomes.

As clinicians, we need to consider when, how, and why to use each approach—choosing therapy that matches the patient’s pathophysiology, goals, and ability to benefit.

Are you ready for a deeper dive with even more resources available? Join the Dysphagia Skills Accelerator today. You will get so many great tools with new tools being added all the time! Click here to join now!

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References

Crary, M. A., Carnaby, G. D., LaGorio, L. A., & Carvajal, P. J. (2012). Functional and physiological outcomes from an exercise-based dysphagia therapy: a pilot investigation of the McNeill Dysphagia Therapy Program. Archives of physical medicine and rehabilitation, 93(7), 1173-1178.

Sia, I., Carvajal, P., Lacy, A. A., Carnaby, G. D., & Crary, M. A. (2015). Hyoid and laryngeal excursion kinematics–magnitude, duration and velocity–changes following successful exercise‐based dysphagia rehabilitation: MDTP. Journal of Oral Rehabilitation, 42(5), 331-339.

Carnaby, G. D., LaGorio, L., Silliman, S., & Crary, M. (2020). Exercise‐based swallowing intervention (McNeill Dysphagia Therapy) with adjunctive NMES to treat dysphagia post‐stroke: A double‐blind placebo‐controlled trial. Journal of oral rehabilitation, 47(4), 501-510.

Crary, M. A., & Carnaby, G. D. (2014). Adoption into clinical practice of two therapies to manage swallowing disorders: exercise based swallowing rehabilitation and electrical stimulation. Current opinion in otolaryngology & head and neck surgery, 22(3), 172.

Crary, M. A. McNeill Dysphagia Therapy Program–10 years of research experience with an exercise based dysphagia rehabilitation approach.

Carnaby-Mann, G. D., & Crary, M. A. (2010). McNeill dysphagia therapy program: a case-control study. Archives of physical medicine and rehabilitation, 91(5), 743-749.

Clark, H. M. (2003). Neuromuscular treatments for speech and swallowing.

Clark, H. M. (2005). Food for Thought: Therapeutic Exercise in Dysphagia Management: Philosophies, Practices, and Challenges. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 14(2), 24-27.

Robbins, J., Butler, S. G., Daniels, S. K., Gross, R. D., Langmore, S., Lazarus, C. L., … & Rosenbek, J. (2008). Swallowing and dysphagia rehabilitation: translating principles of neural plasticity into clinically oriented evidence.

Huckabee, M. L., & Macrae, P. (2014). Rethinking rehab: Skill-based training for swallowing impairment. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 23(1), 46-53.

Athukorala, R. P., Jones, R. D., Sella, O., & Huckabee, M. L. (2014). Skill training for swallowing rehabilitation in patients with Parkinson’s disease. Archives of Physical Medicine and Rehabilitation, 95(7), 1374-1382.

Zimmerman, E., Carnaby, G., Lazarus, C. L., & Malandraki, G. A. (2020). Motor learning, neuroplasticity, and strength and skill training: moving from compensation to retraining in behavioral management of dysphagia. American Journal of Speech-Language Pathology, 29(2S), 1065-1077.

Huckabee, M. L., & Lamvik-Gozdzikowska, K. (2018). Reconsidering rehabilitation for neurogenic dysphagia: Strengthening skill in swallowing. Current Physical Medicine and Rehabilitation Reports, 6(3), 186-191.

Burkhead, L. M., Sapienza, C. M., & Rosenbek, J. C. (2007). Strength-training exercise in dysphagia rehabilitation: principles, procedures, and directions for future research. Dysphagia, 22(3), 251-265.

Langmore, S. E., & Pisegna, J. M. (2015). Efficacy of exercises to rehabilitate dysphagia: a critique of the literature. International journal of speech-language pathology, 17(3), 222-229.

MOLDOVER, J. R., & STEIN, J. (1994). Cardiopulmonary physiology. In The physiological basis of rehabilitation medicine (pp. 127-147). Butterworth-Heinemann.

Baker, S., Davenport, P., & Sapienza, C. (2005). Examination of strength training and detraining effects in expiratory muscles.

Martin-Harris, B., McFarland, D., Hill, E. G., Strange, C. B., Focht, K. L., Wan, Z., … & McGrattan, K. (2015). Respiratory-swallow training in patients with head and neck cancer. Archives of physical medicine and rehabilitation, 96(5), 885-893.

Malandraki, G. A., & Hutcheson, K. A. (2018). Intensive therapies for dysphagia: implementation of the intensive dysphagia rehabilitation and the MD Anderson Swallowing Boot Camp Approaches. Perspectives of the ASHA Special Interest Groups, 3(13), 133-145.

Malandraki, G. A., Rajappa, A., Kantarcigil, C., Wagner, E., Ivey, C., & Youse, K. (2016). The intensive dysphagia rehabilitation approach applied to patients with neurogenic dysphagia: a case series design study. Archives of Physical Medicine and Rehabilitation, 97(4), 567-574.

Hutcheson, K. A., Kelly, S., Barrow, M. P., Barringer, D. A., Perez, D. P., Little, L. G., … & Lewin, J. S. (2015). Offering more for persistent dysphagia after head & neck cancer: The evolution of boot camp swallowing therapy. Age, 28, 82.

Burkhead, L. M. (2009). Applications of exercise science in dysphagia rehabilitation. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 18(2), 43-48.