Measuring Lingual Range of Motion

For so long, we have focused on lingual strength and range-of-motion.

The Iowa Oral Performance Instrument (IOPI),  the SwallowStrong and the Tongue Press have all been developed to give us visual and numeric strength measurements of the tongue.

We finally have a measurement scale for lingual range of motion.

C.L. Lazarus, H. Husaini, A.S. Jacobson, J.K. Mojica, D. Buchbinder, K. Okay, M.L. Urken.  Development of a New Lingual Range-of-Motion Assessment Scale, Normative Data in Surgically Treated Oral Cancer Patients.  Dysphagia (2014) 29:489-499.

This study compared results in treated surgical patients vs. healthy patients.   36 patients s/p oral tongue surgery with significantly decreased tongue range-of-motion and 31 healthy individuals.

The scale was validated by correlating range-of-motion with performance status, oral outcomes and patient-related Quality of Life.

The scale was made to define lingual deficits.  This is a tool that can be used for baseline and post surgery tongue range-of-motion and to track changes over time with recovery and therapy.

Lingual protrusion was measured using the Therabite jaw range-of-motion measurement discs.

Protrusion Scores:  (100) Normal:  > or = 15 mm past the upper lip margin

(50)   Mild-mod:  >1mm but <15mm pasat the upper lip margin

(25)   Severe:  Some movement but unable to reach upper lip margin

(0)     Total:  No movement

Lateralization Scores:  based on ability of the tongue to touch the commissures of the mouth.  Measure both right and left side.
(100)  Normal:                      able to fully touch the corner of the mouth.
(50)    Mild-Moderate:  50% reduction of movement to corner of the mouth                                                in either direction.
(25)    Severe:  >50%           reduction in movement.
(0)      Total:                          No movement.

Elevation Scores:    

(100)  Normal:  complete tongue tip contact with the upper alvoelar                                       ridge.
(50)    Moderate:  tongue tip elevation but no contact with the upper                                       alvoelar ridge.
(0)      Severe:  No visible tongue tip elevation

Total Scores were assigned by adding the protrusion score+ right lateralization score + left lateralization score + elevation score divided by 4.

Scores were 0-100:      

0=severely impaired/totally impaired
25=Severly impaired
50=mild-moderate impairment
100=normal

During this study, tongue strength was measured using the Iowa Oral Performance Instrument.

Jaw range-of-motion was measure using the Therabite jaw range-of-motion measurement discs.

Saliva flow was measured using the Saxon test where the patient was asked to chew a sterile 4×4 piece of gauze for 2 minutes then spit the gauze in a cup.  The gauze was weighed before and after mastication.

The Performance Status Scale was used to determine diet type, speech uderstandability, impact of surgery on ability to eat socially.

Quality of Life was measured using the Eating Assessment Tool-10 (EAT-10), MD Anderson Dysphagia Inventory (MDADI) and Speech Handicap Index (SHI).

The study found that lingual range-of-motion can negatively affect all aspects of a patient’s life and correlates with performance and quality of life.

Lingual Strengthening Using Resistance

Research by Dr. Lazarus and Dr. Robbins has focused heavily on lingual strengthening.  Many of these research articles have proven to us that lingual strengthening using resistance such as an IOPI does increase not only tongue strength and at times, tongue mass, but also improves the overall swallow.  This same research has also shown us that using a tongue depressor is just as effective as a more expensive device.

 The nice thing about these more expensive devices, such as the Iowa Oral Performance Instrument, or IOPI is that they allow visual representation of strength, but also allows you to visually set a goal for your patient.  The IOPI is a box that is attached to a tongue bulb.  The bulb is pushed between the tongue and the palate, the cheeks and the teeth or the lips and the teeth.   It gives you a visual line showing the amount of effort exerted with a number representation.  This not only allows you to track where the patient functions during that session, giving you measurable outcomes to report to insurance, but it also allows you to set a goal for your patient to try to beat.

 Dr. Robbins created a device similar to the IOPI called the Madison Oral Strength Trainer (MOST).  This device has a 5 point piece that fits on the palate with 5 pressure sensors to measure lingual strength with your patient.  This device will cost you nearly $2000.   The MOST is connected to a laptop to track progress and strength of your patient.

 The creator of TheraSip, those wonderful micro resistant straws I recently blogged about, has created a device called the Tongue Press.  It does not have a fancy computer with it to track or collect data regarding your patient’s strength or progress.  This is a very simple device with 2 clear plastic tubes which can be filled with water, with a red level in the top tube with bulbs on both ends.  After the device is set per instructions (included with the device) the patient puts the tongue bulb between the tongue/palate, lips/teeth or cheek/teeth and squeezes.  Strength can be measured by movement of the red level.  The nice part of this device…..it costs a mere $20.

 While the computers are always nice to have and very functional, if you don’t have $1000-$2000 to spend on a device, you can always use tongue depressors for lingual strengthening or the new Tongue Press.

 The main thing we need to remember is to utilize evidence based practice in our therapy.  There is plenty of evidence base regarding lingual strengthening that we can incorporate into our therapy.

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

 Robbins, J.A. (2003, March).  Oral strengthening and swallowing outcomes.  Perspectives on Swallowing and Swallowing Disorders, 12, 16-19.