Exercises, Techniques, Compensations

Maneuvers/Exercises

 
 

To close vocal cords prior to the swallow.

 

For dysphagia accompanied by reduced or late vocal cord closure or delayed pharyngeal swallow.

 

Changes timing of PES opening, duration and timing of hyoid excursion and laryngeal closure, timing of BOT movement.  Closes vocal cords earlier in the swallow, prolonging hyolaryngeal excursion before and during swallow.

 

Logemann recommends 10x/day x5 min with 5-6 swallows each time.  (Frymark et al 2009)

 

Research shows:

  • 13/15 subjects with CVA showed abnormal cardiac findings (Chaudhuri et al 2005)
  • laryngeal elevation was prolonged until postswallow exhalation was completed.  6/8 people had increased hyoid/laryngeal elevation after inhalation.  5/8 swallows with visible movement of arytenoid cartilage and vocal fold closure (Bulow et al 1999)
 
 

For early closure at the entrance to the airway.

 

Facilitates timing and extent of laryngeal closure at specific levels of the larynx.

 

For dysphagia secondary to reduced closure of the airway entrance, with increased PES relaxation pressure and duration of hyoid excursion and laryngeal movement, with decreased time between PES opening and onset of hyoid movement and BOT movement time between PES opening and the onset of vocal fold adduction and laryngeal closure (Frymark et al 2009)

 

Research shows:

  • 13/15 subjects with CVA showed abnormal cardiac findings (Chaudhuri et al 2005)
  • increased extent and duration of tongue base motion to the posterior pharyngeal wall, max laryngeal elevation and laryngeal vestibule/true vocal fold closure with increased bolus clearance (Logemann 2006)
 
 
 

To assist in laryngeal elevation.

 

 The Mendelsohn is an exercise of resistance/endurance to increase tongue-base/pharyngeal wall pressure and contact duration with increased supra hyoid constriction and PES opening.

 

The Mendelsohn can be used to:

  • increase timing of laryngeal elevation
  •  increase peak pharyngeal pressure
  •  increase PES opening duration
  •  increase duration of laryngeal elevation
  •  facilitate clearance of residue

Evidence shows:

  • sustaining laryngeal elevation for 1.5 seconds or more with increase in sub mental muscle group (anterior belly of digastric, mylohyoid and geniohyoid) (Ludlow et al 2007)
  • increased extent and duration of tongue base motion to the posterior pharyngeal wall with max laryngeal elevation and laryngeal vestibule/true VF closure with increased bolus clearance (Logemann 2006)
 

Masako Technique-Increases anterior motion of the posterior pharyngeal wall at the level of the tongue base.

 

Resistive exercise.

 

The Masako should not be used with any bolus.

 

Increases:

  • anterior motion of the posterior pharyngeal wall at the level of the tongue base
  • strength of tongue base and pharyngeal constriction
  • efferent (motor) drive of tongue base
  • pharyngeal clearance
 

Shaker

To assist in laryngeal elevation and cricopharyngeal opening.

 

Exercise of resistance/endurance to increase laryngeal anterior excursion and opening of the PES.

 

Increases efferent drive of hyolaryngeal excursion and PES opening.

 

Targets the anterior belly of the digastric, mylohyoid, geniohyoid (hyoid elevation muscles).

 

Research shows:

  • decreased post-deglutitive aspiration from decreased PES opening and enduring effect in maintaining oral nutrition (Easterling 2002)
  • significant effects to swallowing (as did traditional therapy) with reduced post swallow aspiration (Logemann et al 2009)
 

Increase strength of the overall swallow.

 

Exercises of resistance and endurance to increase tongue base retraction, lingual propulsive force, oral pressure, duration and extent of hyoid movement and laryngeal vestibule closure, duration of pharyngeal pressure and PES relaxation.

 

Can add various bolus textures to increase resistance and strengthening.

 

Research shows:

  • increased force-generating ability for swallowing muscles (Frymark et al 2009)
  • evidence of early elevation of the hyoid at initiation of the effortful swallow (Bulow et al 1999)
  • increased motoric output (activation) of submental swallowing muscles (Sapienza et al 2008)
  • heightens pre-swallow sensory input (Logemann 2006)
  • combined with NMES is resistive with increased extent of laryngeal excursion in post-stroke patients (Park et al 2012)
 

Exercise

 

Lingual exercise with resistance (tongue depressor)/Iowa Oral Performance Instrument

 Lingual exercise with resistance SwallowStrong Device (Formerly the MOST)

Research shows:

  • 8 weeks of training, 3 sets, 10 reps 3x/day using IOPI, lingual strength increased, improved swallow with liquid bolus with reduced Penetration/Aspiration scores (Robbins et al 2008) (Robbins et al 2005)
  • 3 groups, 1 with no exercise, 1 with tongue depressor and 1 with IOPI.  Exercise 5 days/week for 1 month, 10 reps 5x/day for lateralization, propulsion and elevation.  Change in both exercise groups with little difference between IOPI/tongue depressor.  No change in endurance. (Lazarus et al 2003)
  •  
  • 8 weeks lingual training, isometric exercises using IOPI with increased isometric and swallowing pressure, increased airway protection.  2 subjects with increase lingual mass.  (Robbins et al 2007)
 

Mastication exercises

 

Use changes in:

texture

viscosity

temperature

sour

 

Weighted bolus

 

Add viscosity and use challenging bolus

 

 

Back of tongue exercises

 

Pull tongue straight back

Yawn and hold tongue at most retracted state

Gargle and hold tongue at most retracted state

(From Jeri Logemann’s book)

 

Oral manipulation exercises:

 

cheese cloth with bolus, toothetter, sucker, gauze (resistive to increase coordination)

 

Suck Swallow

 

Increases the speed of initiation of the pharyngeal swallow

 

May want to have the person suck a thick bolus through a straw, such as applesauce, thickened liquids, yogurt or pudding.

 
 

Postures

 

Chin Tuck

 

To assist in closing the airway by narrowing airway.  Also varies pressures in pharynx and PES during the swallow, duration of timing of swallowing events and displacement of anatomical structures during the swallowing.

 

Research shows:

  • More aspiration with chin tuck than with NTL or HTL, however more adverse affects with thickened liquids (dehydration, UTI, fever) (Robbins and Hind 2008)
  • Significant change in pharyngeal contraction pressure, duration of pharyngeal contraction pressure, larynx to hyoid bone distance, hyoid to mandible distance before the swallow with decrease in angle between mandible to posterior pharyngeal wall, angle between epiglottis to PPW of trachea, width or airway entrance, distance from epiglottis to PPW.  (Frymark et al 2009)
  • Effective in 72% of patients, but may be contraindicated in those with weak pharyngeal contraction pressure as it decreases pharyngeal contraction pressure and duration (Robbins et al 2005) (Lazarus et al 2003)
 

Head Turn

 

Closes the weak side of the swallow directing the bolus to the stronger side.  Also decreased PES resting pressure on side opposite of rotation and increased anterior/posterior opening diameter.

 

Research shows:

  • decrease in PES resistance to bolus flow and prolongation of PES opening providing bolus more time to clear from pharynx.  (Frymark et al 2009)
 

Head Back

 

Uses gravity assistance to help with lingual deficits.

 

To assist in oral phase (must have functional airway protection and functional triggering of the pharyngeal swallow).

 

Side Lying

 

To help clear pharyngeal residue by altering gravity.

 

May help to clear pharyngeal residue.

 

Before the person sits upright, have cough to clear final residue.

 

Sensory Stimulation Techniques-

 

Tactile Thermal Stimulation

 

Thermal Gustatory Treatment

 

Deep Pharyngeal Neuromuscular Stimulation.

 
 

Therapy Techniques

Pharyngocise

CTAR (Chin Tuck Against Resistance)

 

Tips to Remember in Therapy:

 

Murray, Larson and Logemann 1998 found:

 

    Lip Strength:

    It takes very little lip strength to maintain a small liquid bolus.

    Increase in muscle activation as bolus size increases.

    Simple lip contact with spoon or cup=decreased muscle activation.

    Straws=increased activation.

 
 Tongue:
 

     General tongue movement patterns for bolus transport is quite

              stereotypical.

 

      Timing of movements may vary, movement pattern remained the same.

 

      Tongue presses against the hard palate segmentally and sequentially.

 

     Timing for lingual movements for continuous swallow-differed      substantially from movement timing in discrete swallows.

 

      Full contact of the tongue with the palate not seen in all continuous swallows.

 

Laryngeal Protection:

 

     3-Tiered Protection of the airway:

         Inversion of epiglottis over laryngeal aditus.

         Closure of false vocal folds.

         Closure of true vocal folds.

Pudding and a Straw

                                                                                

Picture from: http://www.busymomboutique.com

Haven’t you always wanted a very simple exercise that will work and strengthen the entire swallowing mechanism using resistance?  I do as well.  I have an exercise that I use all the time with my patients.  I am usually chastised by my co-workers when having patients use this exercise.  Patients give me a strange look until they try it.

This exercise has no fancy name.  I call it……..Pudding with a Straw.  It is exactly as the name implies.  The patient drinks pudding through a straw.

So first, let’s look at the evidence…….  I take into account that, from reading research…..I know using a straw increases labial activation.  A thicker, heavier bolus can add resistance to the swallow and can actually increase the movements both orally and pharyngeally with the swallow.   Using an effortful swallow increases sensory input to the swallowing mechanism.  Swallowing is a sub maximal event as a whole, but when the patient focuses and purposefully uses a more effortful swallow, there is an increase in the muscle contraction of the entire swallowing mechanism.

I take all of this into account and then try the method myself, to see what I feel.  When I drink pudding through a straw, not a Panera smoothie straw, not a regular drinking straw, a cocktail straw/coffee stirrer size straw, I can feel a difference.  My lips purse together with increased effort.  My tongue retracts and tightens, my jaw tightens.  I then suck enough pudding through the straw to swallow and use an effortful swallow.  At one time, I have incorporated straw use with a safe consistency bolus for most, an effortful swallow and a weighted bolus.  I have also used the entire swallowing structure.

I believe it is important and necessary that we look at the swallowing mechanism as a whole, a process, rather than 4 parts.  It’s great to break the swallowing system down into phases for descriptive purposes, but every part of the swallow is connected in some manner and every part of the swallow deserves some attention.

Now, keep in mind, not every patient can start at the level of a small cocktail straw/coffee stirrer or even the pudding.  I can modify the straw by either using a larger diameter straw (Panera smoothie straws seem to be the largest I’ve found at this point).  Regular drinking straws also work very well.  Not only can I change the diameter of the straw, I can change the size of the straw by cutting it in half or in thirds.  The shorter the straw, the easier the task.

Now, keep in mind, the viscosity of pudding can be varied as well.  Many times I will use a thickened liquid or applesauce for patients that are not able to start with pudding.  I may work up to yogurt, without the fruit.  Then with the pudding, in my experience, I have found that sugar-free pudding seems to be the thinnest, followed by home-made, then Snack Pack pudding.  Snack Pudding, the chocolate seems to be the lesser viscous, followed by butterscotch, with vanilla having the thickest viscosity.  Room temperature vs. refrigerated also makes a difference.  Room temperature pudding is a little less tedious for the patients, while with the refrigerated, I’m also adding the temperature aspect to my sensory portion of therapy, in addition to the difficulty of the task.

I don’t write a goal for the patient sucking pudding through a straw.  We may be working on lingual strengthening, pharyngeal strengthening, tongue base retraction, labial seal.  I don’t write my notes as “the patient was able to drink a Snack Pack cup of refrigerated chocolate pudding.”  We were working on using an effortful swallow, straw sucking for increased labial seal, weighted bolus for resistance.

Now I do time my patients and keep track of the time.  I will time the patient to see how long it takes to complete the task.  As the patient gains strength with the task, the time should decrease.  You can also use e-stim or sEMG with your patient as they are completing the task.

I don’t stress if the patient needs the entire session time to complete the task.  This is what I want them to do!!  I want the patient to use an effortful swallow.  I want to apply the rules of neuroplasticity and use a specific swallowing task, applying resistance and specificity.  My patient is swallowing, using both an effortful swallow with a focus of tongue to palate contact and using a weighted bolus with the thick pudding.

I challenge you to try this exercise.  Try the vanilla with the coffee stirrer/cocktail straws and feel what the exercise does for you!

Clark, H.M. (2005).  Therapeutic exercise in dysphagia management: Philosophies, practices and challenges.  Perspectives in Swallowing and Swallowing Disorders, 24-27.

 

Robbins, J.A., Butler, S.G., Daniels S.K., Diez Gross, R., Langmore, S., Lazarus, C.L., et al. (2008). Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. Journal of Speech, Language, and Hearing Research, 51, S276-300.

 

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:  251-265.

 

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

 

Lazarus, C. Logemann, J.A., Huang, C.F., and Rademaker, A.W. (2003). Effects of two types of tongue strengthening exercises in young normals. Folia Phoniatrica et Logopaedica, 55, 199-205.

 

Robbins, J.A., Gangnon, R.E., Theis, S.M., Kays, S.A., Hewitt, A.L., & Hind, J.A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatric Society, 53, 1483-1489.

 

Wheeler-Hegland, K.M., Rosenbek, J.C., Sapienza, C.M.  (2008). Submental sEMG and Hyoid Movement During Mendelsohn Maneuver, Effortful Swallow, and Expiratory Muscle Strength Training.  Journal of Speech, Language and Hearing Research, 51, 1072-1087.

 

Burkhead LM.  Applications of Exercise Science in Dysphagia Rehabilitation.  Perspectives on Swallowing and Swallowing Disorders (Dysphagia) June 2009; 18: 43-48.

 

Park JW, Kim Y, Oh JC, Lee HJ.  Effortful Swallow Training combined with Electrical Stimulation in Post Stroke Dysphagia:  A Randomized Controlled Study.  Dypshagia (2012).  DOI: 10.1007/S00455-012-9403-3.

 

Bulow M, Olsson R, Ekbert O.  Videomanometric Analysis of Supraglottic Swallow, Effortful and Non Effortful Swallow and Chin Tuck in Healthy Volunteers.  Dysphagia.  (1999); 14(2):  67-72.  DOI: 10.1007/PL00009589.

CTAR (Chin Tuck Against Resistance)

Yoon W.L., Khoo JKP, Liow SJR. Chin Tuck Against Resistance (CTAR):  New Method for Enhancing Suprahyoid Muscle Activity Using a Shaker-Type Exercise. Dysphagia (2014) 29: 243-248.

I was beyond excited to pick up my newest edition of the Dysphagia journal. I’ve never said I wasn’t a nerd. There was an article in the journal about chin tuck against resistance. I’ve always used what I call Modified Shaker exercises. My patients are generally elderly. Most have heart conditions or COPD. They are unable to do the Shaker as it was intended.
Most of my patients either use the Neckline Slimmer (available on Amazon) which offers 3 different levels of resistance through springs. They complete exercises exactly as if they were completing the Shaker, but don’t have to lie on the floor and struggle to get up.

This article looked at using Chin Tuck Against Resistance (what I would call a Modified Shaker) to improve activation of the suprahyoids.

Look at patients with dysphagia from Pharyngoesophageal Segment (PES) dysfunction, we look at strengthening the suprahyoid muscles. These muscles assist in hyolaryngeal excursion and therefore play a part in esophageal opening.

CTAR vs Shaker:  Both have a component of isometric versus isokinetic. The isometric portion fo the Shaker is holding the head up for 1 minute with a minute rest x 3 repetitions. The difference is, with CTAR, the patient is holding a 12 cm inflatable rubber ball and performing a chin tuck against it while seated. The Shaker the patient is lying flat on the floor and lifting their head only as if they were looking at their toes.

The isokinetic portion is 30 repetitions of up and down head movement 3 times.

This study used 40 healthy individuals (20 male, 20 female) 21-39 years of age. All participants completed the Shaker and CTAR both isometric and isokinetic as indicated above. Data was collected over one session.

What the researchers found:

CTAR:  The Chin Tuck Against Resistance was less strenuous than the traditional Shaker, with increased sEMG values during isometric and isokinetic movement. There was a significant increase for the isometric portion of the exercise. These patient had greater muscle activation using the rubber ball and a chin tuck!

Effort was required for the chin tuck, but not for the release.  The authors felt is might benefit to have the patient release compression of the ball slowly.

There was greater muscle activation for the isokinetic movement than for the isometric movement during the traditional Shaker. The Shaker also yielded considerable greater effort to lower the head to the mat.

“Clinical trials are now needed, but the CTAR exercises appear effective in exercising the suprahyoid muscles and could achieve therapeutic effects comparable to those of Shaker exercises, with the potential for greater compliance by patients.”

Overall, CTAR was an effective in exercising suprahyoid muscles in healthy participants.

This looks promising in giving us an alternative for our patients for the Shaker exercise!!

Product Review-TheraSip Swallowing Trainer

I think a lot of us dysphagia therapists or swallowologists are always looking for “what more can I do for my patients.”  I think that often. 

One of my favorite things to do is to browse through the medical catalogs and see what’s new or what’s out there and how much does it cost.  

There are many items that I use in therapy.  They mostly consist of straws, pudding, thickener (yes thickener) and tongue depressors.  There is one company that makes amazing tools that I use with all my patients.  

TheraSip is an amazing straw system.  If you haven’t seen it yet, it’s a set of microresistant straws.  That means they start at about the size of a coffee-stirrer and get progressively smaller.  There are three straws with a set of larger diameter straws in which the microresistant straws can fit to increase labial seal with the straw.

I will often use the small cocktail straws or coffee stirrers with pudding, applesauce or thickened liquids.  I like the TheraSip straws because they allow my patients to drink water.  They limit the amount they get at one time during the therapy session while working the oropharyngeal musculature.  Combine that with an effortful swallow and bam, you have one effective treatment. 

The straws can also be used during the Modified Barium Swallow Study (MBSS).  You can test the effectiveness of the small straw and the amount allowed by the straw to see if that might allow your patient to safely consume thin liquids.




These straws are available through several therapy supply companies and cost around $60 for the set.  You can also buy replacement straws at a lower cost.  I typically don’t use the larger straws and focus on the microresistant straws, so I could save a little money buying only the replacement straws.

The straws also come with a tube so that you can measure the amount of liquid the patient consumes per sip.  These straws can be used during the MBSS to measure effectiveness and safety with the smaller sips.  

Evidence has shown us that we have increased labial muscle activation with straw sucks.  One of our exercises that we have available to use with patients utilizes the patient imagining that they are sucking something very thick through a small straw and then swallowing.  This allows you to actually have the patient suck through a small straw and swallow creating a more functional swallow exercise for the patient.

Evidence also tells us that exercises should be movement specific and that if a patient’s goal is swallowing, they should be swallowing throughout the session.  This allows the patient to do so by activation of all muscles of the swallow starting with the oral muscles activated by the actual movement of the straw suck and ending with an effortful swallow of the bolus.