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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

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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.

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NSOMES-To Use Them or Not to Use Them…..That is the Debate

This topic may seem a little off the dysphagia path, but it’s not, trust me.  I have actually thought a lot about NSOMES in my therapy as of late.  Not only does NSOME, at least in my eyes, stand for Non-Speech Oral Motor Exercises, I also use the term for Non SWALLOWING Oral Motor Exercises.  This was the March topic for the SLP Chat, which was a very interesting conversation.  I also went to a session on NSOME’s at our state convention, which actually turned into an artic course using core vocabulary which upset me immensely since I was hoping to learn a little more about NSOME’s.

 

 

First, let’s start with these exercises.  What are they?  Non-speech (swallowing) imply that these are movements that are not concurrent with producing sounds or swallows.  These are the typical stick out your tongue 10 times, move your tongue from corner to corner of your mouth.  These are actions that we use to “strengthen” the speech/swallowing mechanism by having our patients move the articulators.

 Now I’m switching to all swallowing-hey that’s what my blog is about.  It’s my blog!!  So, anyway, who hasn’t been to a facility and observed the SLP there.  What do they usually do for swallowing exercises.  Stick out your tongue, try to touch your nose with your tongue, move your tongue from corner to corner of your mouth, stick out your jaw…….all of these 10 times, 3 times a day.  So, 30 times total.  How many of these patients truly get better with only these exercises??  In my experience, very few.

 Robbins, et al wrote a very good article about neural plasticity in swallowing.  I actually reviewed that article in an earlier blog.  One principle is that plasticity is experience specific, or that to make neural changes (i.e. to the swallowing mechanism) the experience has to be specific to the actual movement.  So, to improve the swallowing mechanism, you have to practice swallowing.  To make neural changes to the swallowing system, the patient has to SWALLOW!  What a novel idea.

 Dysphagia therapy is quickly moving to a very exercise-based therapy.  No, not the typical stick out your tongue exercises.  When you exercise the swallowing system, there are very few researched techniques, however they do exist.  With all the changes in therapy and in insurance, healthcare, now is most definitely the time to move to evidence-based practice, if you haven’t already jumped on board.  I have my list of exercises that I use that are swallowing-specific and have evidence to support them.

 Tongue exercises using resistance, i.e. tongue depressor or IOPI.  Robbins et al looked at the IOPI 10x/3xday against the tongue tip, blade and dorsum with improvement with swallowing.  (Robbins, J.A., Gangnon, R.E., Theis, S.M., Kays, S.A., Hewitt, A.L., &amp; Hind, J.A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatric Society, 53, 1483-1489.)  Lazarus, et al looked at the IOPI vs. a tongue depressor and found that the tongue depressor exercises worked just as well as the IOPI exercises.  (Lazarus, C. Logemann, J.A., Huang, C.F., and Rademaker, A.W. (2003). Effects of two types of tongue strengthening exercises in young normalsFolia Phoniatrica et Logopaedica, 55, 199-205.)  So, I have my patients use a tongue depressor and push their tongue against it using protraction, elevation, depression and lateralization, 10x each, 5x/day, 5 days/week.

 

 

 

 Mendelsohn Maneuver uses resistance with swallowing.  You can continually add resistance if you have the capability to use sEMG with your patients, which unfortunately I do not have at this time.  With the Mendelsohn, you not only have resistance, but the entire exercise involves the act of swallowing, therefore it is a relevant exercise to improve the swallow.  (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.) (Frymark T, Schooling T., Mullen R., Wheeler-Hegland K., Ashford J., McCabe D., Musson N., Hammond C.S. (2009).  Evidence-based systematic review:  Oropharyngeal dysphagia behavioral treatments.  Parts I-V.  JRRD, 46, 175-222.) 

The Masako technique is a little bit questionable with therapy.  Yes, it does involve a swallow, however, how often do you swallow with your tongue sticking out???  This exercise should be used with caution, and should never be the only exercise you use, but may be a good exercise paired with another exercise to improve tongue base retraction.  So, possibly have the patient use the Masako and then the Mendelsohn??   (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.)

 The Shaker exercise offers not only resistance using the head as weight, but repetition of the exercise.  Logemann and Eastering both have research for the Shaker exercise available, however use caution with this exercise, particularly for cardiac patients.  I have been to a conference where I learned the Neckline Slimmer (https://www.buynecklineslimmer.com/) using the highest resistance spring can do the same as the Shaker without the strain on the patient.  However, be careful with this as there is no research out there to support this.  The Slimmer can be purchased at many stores including Walgreens and Bed Bath and Beyond.

 The effortful swallow uses an actual swallow with the added resistance by producing force with the swallow.  You have to have the patient not only “swallow hard” but an important component of the effortful swallow is to forcefully push the tongue against the palate, therefore creating pressure for the swallow.  (Bulow, M., Olsson, R. &amp; Ekberg, O. (1999). Videomanometric analysis of suprglottic swallow, effortful swallow, and chin tuck in healthy volunteers. Dysphagia, 14, 67-72.)  (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.) (Frymark T, Schooling T., Mullen R., Wheeler-Hegland K., Ashford J., McCabe D., Musson N., Hammond C.S. (2009).  Evidence-based systematic review:  Oropharyngeal dysphagia behavioral treatments.  Parts I-V.  JRRD, 46, 175-222.)

 There are also exercises that I use that are “swallowing-based” such as changing the consistency, texture, weight of the bolus, one of my favorite exercises (you’d know this if you read my previous blog posts) is having the patient suck pudding through a straw and then change to a smaller straw as the patient progress.  This not only has the person swallow but strengthens the oral phase of the swallow through sucking, which is a natural motion of swallowing (we all use a straw at some point).  Mastication exercises are good, if the patient is not appropriate for an actual bolus, I use a mesh baby feeder or cheese cloth.  Any exercise you can have the patient complete that adds resistance or complication to their natural swallow is what we need.  Remember, evidence-based can also be what YOU trial, track and possibly research.  

 Now, there are times that I do use NSOME’s, I know, right, gasp.  I find that STRETCHING the articulators/swallowing mechanism is quite good for patients that have been through radiation therapy, for example.  If they are unable to move the articulators to the maximum benefit, yes, I will combine oral stretches/massage/myofascial release to the mix (above exercises) for maximum benefit.

 

 Will tongue exercises, jaw exercises, etc work outside of the context of swallowing/speech, I really don’t think they will.  You have to train the muscles to do what they’re supposed to do for function.  To do that, you HAVE to combine exercise/therapy with the intended movement.  You cannot rehabilitate speech without using speech and you cannot rehabilitate swallowing without having your patient swallow, even if it is only their own secretions.  Make certain that what you are doing is working for your patient, if the tongue exercises don’t seem to be changing anything, by the data you track, change what you are doing!  We are therapists adn are trained to use a variety of techniques.  If you are uncertain about where to go next, ask.  Don’t be afraid to ask questions.  

 When having your patients exercise, whether it be the speech or swallowing system, look to your physical therapist for ideas.  They exercise their patients, however they relate the exercise to the actual act (i.e. walking) and combine the exercises with the act of walking.  They don’t have their patients do leg exercises and send them home expecting them to walk with more efficiency.  They also exercise their patients with walking and make it more difficult (without the walker).  

 Remember when using Swallowing Oral Motor Exercises, use plenty of repetition, add resistance and make it worth your and your patient’s time!