Posted on 2 Comments

Lingual Strengthening Using Resistance

Research 

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 can be just as effective as a more expensive device.

The tongue is often called the driving force in the swallow.

Exercise

One type of exercise we discuss in dysphagia is an isometric exercise.  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).

Another study (Juan et al) 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.
The devices

 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.

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 Tongue Press.

Remember

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.

References:

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.

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

Posted on 2 Comments

Measuring Lingual Range of Motion

Strength Vs. Range of Motion

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

Instruments for Measurement

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

The Research

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.

The Scale

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 intelligibility, 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.