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

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.


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??

Respiratory Muscle Strength Training

I recently went to an interesting course on respiratory muscle strength training, and by recently I mean 2 months ago!

 I found the course very interesting. It was taught by Christine Sapienza. Respiratory muscle strength training has strong implications for dysphagia, is easy to implement and really fairly affordable.

 Inspiratory strength training works on the muscles of inspiration the diaphragm, the intercostals. Inspiration involves contractions of the diaphragm and external intercostals, which increase intrathoracic volume and decreased volume in pressure.

 Respiration is a recoil from inspiration. Exhalation involves relaxation of the inhalation muscles, recruitment of abdominal and internal intercostals to force air out of the lungs.

 An incentive spirometer is not the same device used as in respiratory muscle strength training (rmst). The spirometer is commonly used after surgery, to remove anesthesia from the body, encourage sustained inhalation and to help to open the airway.

 Resistive trainers such as “The Breather” are also typically not used because they only offer resistance on 5 levels.

 Pressure Threshold Devices are recommended for RMST. There are devices for inspiratory muscle strength training and for expiratory muscle strength training (IMST, EMST).

 In dysphagia, EMST was found not only to increase greater force with the cough, enabling the patient to produce a more productive cough forcing material from the airway, but also was found to increase hyolaryngeal excursion and velar closure.

 EMST is not recommended for those on supplemental oxygen, those with COPD or people with untreated GERD.

 The Aspire 150 device is the one that was recommended during the course, as it is the device that was used during the study. The Aspire 150 is is found on the Aspire website and is relatively inexpensive at $39.95 each.  The patient used the device 5 times, 5 times a day for 5 weeks.

 You can find “A Primer on Inspiratory Muscle Strength Training“, giving further information on IMST.   The the Power Lung Sport Trainer, the Threshold Inspiratory Muscle Strength Trainer are examples of IMST devices.

 When focusing on EMST and IMST in your therapy, you want to find a pressure threshold device to achieve maximum results similar those found in the research as referenced below.  Resistive devices usually offer 5 levels of resistance, or 5 holes/notches which to increase the device.  The Pressure Threshold Devices offer more.  Resistive devices are:  Expand-a-Lung, The Breather, PFlex and BreathBuilder.

 RMST is also indicated for voice disorders, bilateral vocal fold paralysis, professional voice users, sedentary elderly, Parkinson’s Disease (PD), Multiple Sclerosis (MS), Progressive Supranuclear Palsy (PSP), stroke, healthy elderly.  RMST can also be used for ventilator weaning.

 For more information on RMST please read the following:

 EMST and Parkinson’s Disease

Parkinson’s Disease and EMST


EMST with MS

A large number of articles regarding RMST

EMST on Cough and Swallow

EMST Swallowing and PD

 Sapienza, C.M., Davenport, P.W., &amp; Martin, A.D. (2002).  Expiratory muscle training increases pressure support high school band students.  Journal of Voice, 16, 495-501.

 Burkhead, L.M., Sapienza, C.M. &amp; Rosenbek, J.C. (2007).  Strength-Training Exercise in Dysphagia Rehabilitation:  Principles, Procedures and Directions for Future Research.  Dysphagia 22, 251-265.

 Sapienza, C.M. (2008).  Respiratory Muscle Strength Training Applications.  Current Opinion in Otolaryngology &amp; Head and Neck Surgery, 16, 216-220.

 Pitts, T. et al.  (2009).  Impact of Expiratory Muscle Strength Training on Voluntary Cough and Swallow Function in Parkinson’s Disease.  Chest, 135(5), 1301-1308.

 Wheeler-Hegland K.M., Rosenbek J.C. &amp; Sapienza, C.M. (2008).  Submental sEMG and Hyoid Movement During Mendelsohn Maneuver, Effortful Swallow, and Expiratory Muscle Strength Training.  JSLHR 51, 1072-1087.