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.

Gelmix Thickener

I was really excited to see Gelmix at the ASHA Convention this year.  I’ve heard a lot about Gelmix, but have never had the opportunity to try it until now!What is Gelmix?

Gelmix is a “healthy thickener” as it is USDA Organic.  Gelmix was formulated to thick breast milk, formula and other liquids.  Gelmix is also free from common allergens including:  gluten, corn, lactose, casein and soy.

Gelmix is made from Carob Bean Gum.  Carob Bean Gum is widely used for its gelling and thickening properties.  The other two ingredients in Gelmix are Organic Tapioca Maltodextrin and Calcium Carbonate.

Gelmix is activated in warm liquids, so you must warm the liquid prior to thickening it with Gelmix.

Gelmix can be used for term infants and children under 3 to thicken to a “light honey-thick consistency.”  For children over 3 and adults, Gelmix can be used to thicken liquids to a “spoon-thick consistency.”

Gelmix is contraindicated for infants under a gestational age of 42 weeks or under 6 pounds.  It also cannot be used with infants with suspected allergy to galactomannans.

Gelmix is available in an 8.8 oz jar (250 grams) which will thicken up to 624 fluid ounces for $29.99 or you can buy the “stick pack” which contain 5 stick, individual serving packets for $5.99.  Each stick will thicken 4 oz of liquid to nectar consistency.

The instructions for thickening with Gelmix:

  • Warm desired amount of liquid (between 100-120 degrees F for best results).
  • Sprinkle in Gelmix per usage instructions.
  • Mix well until Gelmix is completely dissolved.
  • Wait 5 minutes for the mixture to thicken and cool to a safe feeding temperature, mix again before serving.

Usage Instructions:

Infants and Children under 3:

  • Half Nectar:  Add 1 scoop for every 3-4 ounces of liquid.
  • Nectar-Thick:  Add 1 scoop for every 2 ounces of liquid.

(For infants and children under 3 years old, do not use more than one scoop Gelmix per 2 ounces of liquid.  To avoid gassiness, start with lowest concentration, particularly for infants 6-12 pounds.)

Adults and Children over 3:

  • Nectar-Thick:  Add 2 scoops per 4 ounces of liquid.
  • Honey-Thick:  Add 3-4 scoops per 4 ounces of liquid.
  • Spoon-Thick:  Add 4-5 scoops per 4 ounces of liquid.

Gelmix may gradually thicken over time.

Time for a Trial



Last night, I thought what a great time to try Gelmix and combine it with the #thickenedliquidchallenge.   I heated up my water and some milk.  I mixed the Gelmix in, per recommendations for honey thickened liquid.

 

I used a whisk to mix the thickener because when using a spoon, the water was extremely clumpy.  The milk actually became more of a pudding thick liquid.

The water was a little discolored, as with almost all thickened water.  The Gelmix really didn’t add a flavor to the water.

 

The milk was not discolored at all and had no added flavor.

The texture was another thing.  I am just not a honey-thickened liquid person.

I miserably failed the #thickenedliquidchallenge and will be donating to the National Foundation of Swallowing Disorders (NFOSD).

The Gelmix seems to be a good option for a more organic thickener, if you have access to heating your liquids.  It seems to be a great option for babies and would love to hear your thoughts on using Gelmix with babies!

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.

Research Tuesday Post-Effects of Barium Concentration

I finally got back into the swing of things with Research Tuesday.

My article for the month is:  Stokely S., Molfenter SM, Steele CM.  Effects of Barium Concentration on Oropharyngeal Swallow Timing Measures.  Dysphagia (2014) 29: 78-82.

This study was completed as prior studies suggest that various aspects of the swallowing process, including timing measures may vary depending on the concentration of barium presented to the patient.

Subjects:  20 healthy adults

Given:  3 non cued swallows of 5 ml of barium (“thin” 40% concentration and “ultrathin” 22% concentration).

Results:

Longer stage transition durations (“the interval between the bolus head crossing the ramus of the mandible and the onset of hyoid elevation) with the 22% concentration.

Longer pharyngeal transit times (“the interval between the bolus head crossing the ramus of the mandible and closing of the UES”) were observed with the 40% concentration.

Longer durations of UES opening with 40% concentration.

Results:  “For all temporal measures of interest (stage duration, pharyngeal transit time and duration of UES opening) significantly shorter duration were seen with the 22% concentration than with the 40% concentration.”

“The 22% w/v “ultrathin: solution may act more like a true thin fluid such as water than a 40% w/v solution.  Although lower concentrations of barium appear less opaque on fluoroscopy, the study by Fink and Ross together with our own use of a 22% w/v concentration for several years, suggests that this concentration is adequate for visualization.”

The barium we use will and does effect timing events in the swallow.  If the barium solution is more concentrated, we can expect longer timing events in the swallow.  We need to be aware of the barium we use and mix it according to manufacturer’s directions or use a standardized recipe when assessing the events of the swallow.

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!!

The Dysphagia Buy-In: Selling Your Services

My colleague Jonathon Waller, over at the Dysphagia Cafe posted recently. I LOVE his post. If you haven’t read it yet, you definitely need to. Dysphagia Therapy: More Rehabilitation and Less Compensation.

I think the reason I love this post, and asked him if he minded if I expanded on it, was because THIS IS MY LIFE!

I have definitely had the buy-in aspect. I live and work in Smalltown, Nowhere. People typically have not heard about this “dis-fay-gee-ah” thing.

I go into a room to work with a patient or they come to see me as an outpatient and they have NO idea why they’re there. They swallow just fine and have no problem speaking. Even though they cough and choke with every sip of water.

I find the majority of my evaluation is getting the person to “buy-in” to therapy. They’re not going to continue to come in for therapy if they don’t know what I’m doing.

Let’s face it, we’ve given ourselves a bad name at times. Have you ever had that patient that actually comes to you from another SLP with a 10 page list of exercises that they need to complete 10 times each, 3 times a day, including, but not limited to: stick your tongue out, up, side to side, say every /k/ and /g/ word known to man, stick out your jaw and hold it tensed for 5 hours……you get the picture. Now ask these people why they do these exercises and they have no idea.

I explain the swallowing system to the patient. These are muscles that we work with and when we don’t use those muscles or don’t use them as we’re supposed to, we lose the ability for those muscles to perform the way they are meant.

I often teach my patients, it’s like when you hurt your leg or ankle and limp for several days. You then create other problems because you are walking in a manner you were not meant.

I then teach them how I’m going to help. There’s homework. You don’t do your homework, you may not get better. There’s work to be done in my room. However, I can’t fix this in one session. Much like you can’t expect to go to the gym and after one day of lifting weights look like Arnold Schwarzenegger from the 80’s.

I ask them to give me 4-8 weeks along with the home-exercise program.

We use NO compensation in the therapy room. By using those compensations 100% of the time, we’re not teaching them to swallow without and building pathways FOR those compensations. (After all, who wants to tuck their chin, stand on their head and count to 25 when they swallow).

My patients EAT and DRINK in my therapy room. They don’t stick out their tongue at me or say “cook” with an emphasized /k/ sound. They SWALLOW.

Happy Swallowing Rehabilitation. P.S. I’m all for Swallow Pathologists, Dysphagiologists, anything that distinguishes us by what we do!! Maybe Dysphagia Rehabologists?? I say we put it to a vote!

I-PRO

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??