USING EXERCISE-BASED TREATMENTS IN

DYSPHAGIA INTERVENTIONLORI BURKHEAD MORGAN, PHD, CCC-SLP

DEPARTMENT OF NEUROLOGY, MEDICAL COLLEGE OF GA AT AUGUSTA UNIVERSITY

DISCLOSURES

Financial

Paid educational consultant for Passy-Muir (but receives no royalties nor any financial benefit from discussing the

company’s products)

Financial compensation from Vanderbilt for this presentation

Nonfinancial

None

LEARNING OUTCOMES

Describe the structure and muscle fiber type associated with oropharyngeal musculature

Name two changes occurring in muscle with both conditioning and deconditioning

Define at least two theoretical principles that an “activity” must incorporate to be considered “exercise”

Identify at least two evidence-based treatments for swallowing rehabilitation that incorporate exercise science

principles

FOOD IS MEANT FOR MORE THAN EATING

START AT THE BEGINNING

NEUROMUSCULAR DEVELOPMENT

HOW MUSCLES WORK

SKELETAL MUSCLE COMPOSITION

Type I

Type II

IIa

IIb

Whole muscle contains blend with a predominance of one type

Slow-twitch, fatigue-resistant

Fast-twitch, fatigable

Adaptable, more efficient Type II fiber

Best force generation, but inefficient

OROPHARYNGEAL MUSCLE COMPOSITION

Type II is predominant

Type I, IIa, IIb, and hybrid fibers

Unique architecture

Regional differences in proportion and diameter of fiber types

Complex arrangement

(Kent, 2004)

OROPHARYNGEAL MUSCLE COMPOSITION

Muscular hydrostat

Tongue

Kier & Smith (1985)

Pharynx?

Kairaitis (2010)

MUSCULAR HYDROSTAT

Composed entirely of muscle with complex, three-dimensional fiber

arrangement

Maintains constant volume, as a fluid-based muscle structure

Shape alteration is dependent on redistribution of hydrostatic tissue pressure

Mechanical effect depends upon integrated activity of other muscles within the

organ

(Kairaitis, 2010)

WHY DO WE CARE?

Do contemporary exercise principles apply to these unique structures?

In what ways can we maximize function of these muscles?

FOR MORE DETAIL

Burkhead, Sapienza, & Rosenbek (2007)

FOR MORE DETAIL

March 2017, Perspectives of the ASHA Special Interest Groups

MUSCLE RESPONSE TO DECONDITIONING AND

CONDITIONING Conditioned:

John Burkhead – world record bench

press, 515 lbs.

Deconditioned:

Muscle-wasting, cachexia

DECONDITIONING

Peripheral

Atrophy

Loss in cross-sectional area

Decreased size

Force-generating capacity (“strength”)

Fiber-type shift

More easily fatigued

Sarcopenia

Age-related reduction in muscle fibers

Preferentially affects Type II

Central

Decreased neural activation

(“drive”)

Decrease in number of motor units

Remodeling of motor units

DECONDITIONING

Muscle atrophy & deconditioning

4-6 weeks bed rest (young, healthy) – up to 40% decrease in strength (Bloomfield,

1997)

Ill & elderly even more susceptible (Urso et al., 2006)

Canu, M. et al, 2019

“Vicious Loops”

in Sarcopenia

“VICIOUS LOOPS” IN DYSPHAGIA?

Decreased swallow

frequency

Deconditioning

Exacerbation of

dysfunction

Swallow

frequency/min

Normals 3

Dysphagia, - asp 1.16

Dysphagia, + asp .71

(Murray et al., 1996)

Dysphagia – NPO

“VICIOUS LOOPS” IN DYSPHAGIA?

Decreased

swallow frequency

Deconditioning

Exacerbation of

dysfunction

Swallow

frequency/min

Normals 3

Dysphagia, - asp 1.16

Dysphagia, + asp .71

(Murray et al., 1996)

Dysphagia – NPO

FUNCTIONAL RESERVE

The proportion of potential force-generating capacity in relation to the

effort required to perform a certain task

SARCOPENIA Age-related reduction in skeletal muscle mass

~0.5-1% loss in healthy individuals > 50 years old

Can be prevented or reversed by EXERCISE!

DECONDITIONING AND

NONFUNCTIONAL FUNCTION

Synkinesis

Involuntary movements that accompany voluntary movements

Results from rewiring of misfiring nerves

Functional decompensation (Crary, 1995)

Compensatory gestures that interfere with (rather than help) swallowing function

Excessive throat-clearing, tongue-pumping, etc.

CONDITIONING

Peripheral

Hypertrophy

Increased cross-sectional area

Increased force-generating capacity

Fiber-type shift

Increased endurance

Central

Increased neural activation (“drive”)

Increased number of motor units

4-8 weeks

6-12 weeks

***PLASTICITY***

Cortical reorganization

Blood flow changes

Peripheral muscle changes

IDENTIFY PHYSIOLOGY TO

TREAT PHYSIOLOGY

HISTORY OF DYSPHAGIA EVALUATION

Look, Listen, Feel

Much like phenology?

Imaging

Ultrasound

Scintigraphy

Videofluoroscopy

FEES

Manometry

HRM

MOST COMMONLY AVAILABLE OROPHARYNGEAL

EVALUATION TOOLS

Videofluoroscopy Endoscopy

EVALUATION:

PAST AND PRESENT PERSPECTIVES

PAST PRESENT

One test is superior to others Different techniques provide unique

information, can be complementary

Purpose of exam to document

aspiration

Purpose of exam to assess physiology

to determine compensations & Tx

options

SLP “domain” = lips to UES Swallowing is synergistic & influenced

by other systems (i.e., respiration,

esophageal function)

Are we using our instrumental swallowing

assessments as tools or weapons?

ARE PATIENTS “PUNISHED” FOR “FAILURE”?

“The patient failed the swallow test”

Pass vs. fail mentality

“Banished” to altered textures

“Punished” for physiologic disorder/disease

PURPOSE OF INSTRUMENTAL EXAMS?

PURPOSE OF EVALUATION

Underlying cause of dysfunction

Effect of compensations (temporary)

Method/manner of intake

Texture modifications

Effect of treatment techniques (long-term)

Ability to perform

Effectiveness of techniques

PROBLEM-BASED TREATMENT

Start with physiologically based assessment

What is causing the underlying problem?

Speed

Strength

Coordination

Movement pattern

Detective vs. Reporter

INSTRUMENTAL EXAMINATION

FEES

More specific visualization of structures

Portability (advantage in ICU, etc.)

No time limit for assessing therapeutic interventions

Videofluoroscopy

Broader view of overall swallow

Visualization of oral phase & hyolaryngeal excursion

Visualization of esophagus

DO OUR TOOLS BIAS US?

MBSS

FEES

Bedside/clinical exam

WNL OROPHARYNGEAL SWALLOW…

OR IS IT??

MBSS FINDINGS

PRESENTED WITH NECK MASS,

C/O COUGH WITH SWALLOW

FEES WNL

MBSS DETERMINES EXTENT OF

CERVICAL OSTEOPHYTES

MBSS AND FEES?

When one exam yields unusual findings that cannot be fully appreciated

When both esophageal and oropharyngeal symptoms are reported

When one exam does not answer all clinical questions

TAKE-HOME MESSAGE

EACH exam has different strengths

Choice of exam should be based on clinical question

Both may be warranted

Don’t just diagnose disorder –

think physiology!

• Coordination

• Speed

• Endurance

• Strength

• Various conditions

EVALUATION: LESSONS FROM

PHYSICAL REHABILITATION

Ambulation Swallowing

Leg strength/ROM O-P-L strength/ROM

Standing, balance Dry swallow, cough, breath-

hold

Few steps Few bites/sips

Greater distance, speed Greater volume, rate

Variety of terrain Variety of consistency &

situation

THE BIGGEST LESSON

FROM PHYSICAL REHABILITATION

One successful step ≠ ambulation

One successful swallow ≠ eating

WHAT ABOUT THE

CLINICAL/BEDSIDE EXAM?

CLINICAL/BEDSIDE EXAM

Value

Assess readiness, attentiveness, overall status

Examine structure/ROM

Observe with oral trials

It is NOT

Physiologic assessment (!!!!)

Assessment of airway compromise

Reliable

DEALING WITH CONSTRAINTS

Mobile FEES services/equipment

Mobile MBSS vans

Structured bedside screening/assessment tools

MASA

TORR-BSST

Yale Swallow Protocol

3-OUNCE WATER TEST

Been in the literature previously

Studied by Leder et al. (2008) in a different way as the “3-

Ounce Water Challenge”

Drink ALL at once without stopping

Fail = risk for aspiration, instrumental test recommended

Cannot or refuses to perform test

Stops/starts to complete ingestion of full amount

Coughs or chokes on water at any time

3-OUNCE WATER TEST

Clinical utility of the 3-ounce water swallow test (Suiter & Leder, 2008)

Concurrent FEES with 3-oz. water test, 3,000 pts, referral-based sample

96.5% sensitivity

48.7% specificity

51.3% false positive rate

Failure doesn’t necessarily mean patients cannot tolerate liquids

May result in over-referral

VALID ITEMS FOR SCREENING DYSPHAGIA RISK IN

PATIENTS WITH STROKE

Systematic review of four databases: 1985-March 2011

Search terms:

Eligibility

Homogenous stroke population

Comparison to instrumental exam

Clinical exam without equipment

Outcome measures of dysphagia or aspiration

Validity of screening items

Studies that met criteria evaluated for:

Methodology

Sensitivity, specificity, predictive capability(Daniels, Anderson, & Willson, 2012)

CVA Stroke deglutition disorders Dysphagia

VALID ITEMS FOR SCREENING DYSPHAGIA RISK IN

PATIENTS WITH STROKE

Total documents sourced = 832

Documents meeting criteria = 16

Inconsistent protocol methods across studies

Water swallows of various methods employed in most studies, but non-swallow

items also included

(Daniels, Anderson, & Willson, 2012)

VALID ITEMS FOR SCREENING DYSPHAGIA RISK IN

PATIENTS WITH STROKE

Cough & wet voice in response to a water swallow test appear to be ESSENTIAL

predictors of aspiration and should be part of a clinical screening

However, significant dysphagia can exist without aspiration, and lead to decreased

nutrition, hydration, quality of life

Conclusion: A cluster of swallowing and non-swallowing features may be the best to

achieve optimal sensitivity & specificity in the clinical screen

(Daniels, Anderson, & Willson, 2012)

ASSOCIATED INFLUENCES

Esophagus

Respiratory system

ESOPHAGEAL INFLUENCE

Esophageal disorders can

be perceived as pharyngeal

Esophageal dysmotility can

influence pharyngeal

function

DOING A COMPLETE FLUORO EXAM

Is Visualization Complete?

A-P view

Esophagus scan

Is Investigation Complete?

Compensatory maneuvers

Volume & texture trials

Introduction of a fatigue condition

Pill swallowing

• IV-D of the American College of Radiology (ACR) Practice Parameter Document

(2017) indicates:

✓ “An esophagram may be required.”

• Intro of the same document:

✓ “…a complete study may also include spot films…and an esophagram, as

symptoms of dysphagia are often poorly localized.”

ESOPHAGEAL EVALUATION IN MBSS

Section D-2 of ACR Practice Parameters:

✓ “…may need to be prematurely terminated if the patient demonstrates severe

aspiration (…below the sternal notch)…and does not respond to protective or

therapeutic maneuvers.”

Section D-3 of ACR Practice Parameters:

✓ “When aspiration does occur, the effect of maneuvers to limit or prevent

aspiration may be assessed.”

PREMATURE CESSATION OF MBSS

Section D-1 of ACR Practice Guidelines:

“If aspiration occurs, the patient’s response to aspiration and ability to

clear the aspirated materials and his or her response to the protective

and therapeutic maneuvers should be assessed wherever possible.”

PREMATURE CESSATION OF MBSS

RESPIRATION & SWALLOWING

Interrelated & Tightly Coordinated

Shared neural substrates

Central pattern generator (three “arms”) (Doty, Richmond, & Storey, 1967)

Peripheral inputs (input)

Interneurons (organization)

Motoneurons (output)

Structural & functional interdependence

Voice

Airway protection

Swallowing

RESPIRATION & SWALLOWING

Role of Subglottic Air Pressure & Lung Volume

Gross, Steinhauer, Zajac, & Weissler (2006)

Direct subglottic air pressure measured during normal swallowing (healthy single subject)

Gross et al. (2012)

Confirmed presence of deglutitive subglottic pressure generated by lung recoil

RESPIRATION & SWALLOWING

Swallowing-Breathing Coordination Training

30 HANC pts, chronic dysphagia

Respiratory-swallow training via biofeedback improved:

Coordination/phase patterning

Laryngeal-vestibular closure

BOT retraction

Pharyngeal clearance

Airway protection

(Martin-Harris et al., 2015)

THERAPEUTIC EXERCISE:

EXERCISE VS. ACTIVITY

NOT THIS

MASLOW’S LAW OF THE HAMMER

“I suppose it is tempting, if the only

tool you have is a hammer, to treat

everything as if it were a nail.”

Abraham Maslow,

American psychologist (1908-1970)

EXERCISE: WHAT IS IT?Strength, Timing, Coordination, ROM (Burkhead, Sapienza, & Rosenbek, 2007)

Intensity

• Overload principle

(> 60% MVC)

• Progressive resistance

• Volume & frequency of exercise

Specificity

• Do practiced tasks mimic

or relate to target

movements?

MOTOR LEARNING: WHAT IS IT?

Process for learning voluntary control of more automatic physiological processes

If swallowing is a sensory motor task, is motor learning part of retraining swallow

behaviors?

SURE!

MOTOR LEARNING

Performance is temporary

Learning is permanent change due to practice

Consistent, intense practice

MOTOR LEARNING

Cognitive Stage

Associative Stage

Autonomous Stage

Understanding task

Refining movement pattern

Developing independent,

transferable skill

Three-Stage Model

(Fitts & Poser, 1967)

WHAT QUALIFIES AS EXERCISE?

Exercise is activity that challenges the body beyond

its typical level of activity

Exercise that does not force the neuromuscular system beyond usual activity will not elicit an adaptation

Resistance training recruiting 60-75% effort is required to achieve the greatest improvement

AS YOUR MUSCLES GET STRONGER, THE

CHALLENGE MUST ALSO INCREASE TO

ELICIT CONTINUED IMPROVEMENT!

STRENGTH DEFINED

The force-generating capacity of a muscle

Lifting a heavy weight

Swallowing a large bolus of peanut butter

ENDURANCE DEFINED

The ability to continually produce force over a period of time

Marathon runner

Eating a meal

POWER DEFINED

Combination of strength & speed

Ability to exert force quickly in a “burst”

Jumping, sprint start

Strong, forceful BOT retraction

SPEED DEFINED

Maximal velocity achieved (how fast one can go!)

Sprinter

Swallowing liquids

COORDINATION DEFINED

All of the previous components mentioned working in

concert to efficiently and effectively perform functional

tasks

• Basketball player in a game

• Ballet dancer performing

• My husband ingesting a rack of ribs & a beer

SO HOW DO WE PROCEED?

Best judgment – based on literature, knowledge, experience, & common sense

Know limitations of the clinical and instrumental exam

SO HOW DO WE PROCEED?

Weigh risks vs. benefits

Risk of malnutrition/dehydration vs. aspiration

Pt wishes/QOL vs. risks of eating/drinking with dysphagia

Risks of NPO vs. risks of feeding

You may not be able to to eliminate risk, but how can you best minimize

patient risk/maximize safety?

ONCE THE PROBLEMS ARE IDENTIFIED…

PROBLEM-BASED TREATMENT

Start with physiologically based assessment

What is causing the underlying problem?

Speed

Strength

Coordination

Movement pattern

Detective vs. Reporter

REMEMBER….

THE CHALLENGE

• Critically evaluate & implement findings from research to solve

clinical problems

• Provide the best patient care possible

• Treatment must be both time-efficient & cost-efficient

EVIDENCE-BASED PRACTICE

Treatment should be based on:

• Best available evidence

• Patients wishes

• Clinician knowledge & experience

EXERCISE?

What?

Who?

Why? How?

When?

Which?

“BORROWING”

FROM PHYSICAL THERAPY &

ATHLETICS

THINK OUTSIDE THE BOX

…or the cage

SPECIFICITY

Work toward the end goal by working on movements and movement patterns you

wish to improve

“Best treatment for swallowing is swallowing”

Or is it?

IS INTENSE STRENGTHENING OUR ONLY HAMMER?

Studentbranding.com

NON-SWALLOWING EXERCISES

Expiratory Muscle Strength Training (EMST)

Chin Tuck Against Resistance (CTAR)

Lee Silverman Voice Treatment (LSVT)

Shaker Head Lift, Recline Exercise

Isometric Lingual Strengthening• IOPI

• SwallowSTRONG

EXERCISE: WHAT?

“Direct” vs. “indirect” exercises

Direct exercise

• Mendelsohn

• Effortful swallow

• Tongue hold swallow

(Masako)

• Etc.

Indirect exercise

• Shaker head lift

• Recline

• EMST

• Lingual

strengthening

SKILL VS. STRENGTH?

Maybe both?

Stronger muscles move more quickly (power)

Must have some base of strength for movement first

BRIDGING STRENGTH TRAINING AND FUNCTIONAL

PRACTICE

Historically common in PT/OT

Isolated training ➔ integrated movement

E.g., leg extensions ➔ gait training

Most effective in the weakest patients

SKILL-BASED TRAINING

Premise:

Swallowing utilizes submaximal strength

Integrated movements

Precision/speed/coordination

Specificity would underscore skill training concept

SKILL TRAINING

Targeted lingual precision, not just strength

Varying degrees of lingual pressures

(Steele et al., 2013)

SKILL TRAINING

Two main conclusions:

Tongue responds to task specificity (precision vs. strength)

To elicit carryover, perhaps training should include

integrated swallowing tasks

(Steele et al., 2013)

SKILL TRAINING

Swallowing-Breathing Coordination Training

30 HANC pts, chronic dysphagia

Respiratory-swallow training via biofeedback improved:

Coordination/phase patterning

Laryngeal-vestibular closure

BOT retraction

Pharyngeal clearance

Airway protection

(Martin-Harris et al., 2015)

SKILL TRAINING

Biofeedback in Swallowing Skill Training (BiSSkiT)

Uses sEMG biofeedback to train varying motor patterns that mimic eating

Goal altered based on pt performance

(Athukorala et al., 2014)

SEMG BIOFEEDBACK

One of the oldest evidence-based practices in dysphagia rehabilitation

(Haynes, 1976)

Outcomes superior with biofeedback when compared with “traditional” treatment alone

(Sukthankar et al., 1994; Crary, 2004; Huckabee & Cannito, 1999)

INTENSITY

There is no magic number

Work to challenge status quo

Strengthening: > 60% 1RM

Other parameter: Habit or motor pattern?

Eat 3x/day, exercise 3x/day??

EXERCISE: WHEN?

The sooner the better

“Use it or lose it” principle

(Kleim & Jones, 2008)

Early intervention can improve diet tolerance, airway protection, & overall nutrition**

(Emstahl et al., 1999; Carnaby et al., 2006)

Pre-treatment exercise beneficial in H&N cancer

(Kulbersh et al., 2006; Carroll et al., 2008)

EXERCISE: WHEN??

“OUR PATIENTS ARE TOO SICK”

If you do nothing, you will improve nothing

Function may only get worse as you “wait” for the patient to “get better”

Remember the concept of “vicious loops”

MAJOR CULPRITS IN THE ICU PATIENT

Systemic inflammatory response syndrome

Critical illness myopathy

Critical illness polyneuropathy

HR > 90 bpm

Body temperature, 36 or > 38°C

WBC count, 4000 cells/mm3

SIRS + infection = sepsis

Systemic Inflammatory Response

Syndrome (SIRS)

SIRS

Occurs in adults and children

Up to 50% of ICU pts on vent have SIRS

50-70% of those pts develop diffuse myopathy and polyneuropathy

SIRS

Results in:

Muscle weakness

Difficulty weaning from the ventilator

CRITICAL ILLNESS MYOPATHY (CIM)

& POLYNEUROPATHY (CIP)

Usually co-occurring

Presents as ventilator-weaning difficulty

Seen in 25-63% of pts on vent > 1 week

Sensorimotor with motor predominance

Limbs & respiratory muscle affected most

Cranial nerves usually spared

CRITICAL ILLNESS MYOPATHY (CIM)

Diffuse weakness

Diagnosed with EMG studies & biopsy

Type II muscle atrophy or undergo necrosis

“OFFENDERS” SPECIFICALLY IMPACTING

COMMUNICATION & SWALLOWING

Deconditioning

Endotracheal intubation

Tracheostomy

Ventilator dependency

DECONDITIONING NEGATIVELY IMPACTS STRUCTURE &

FUNCTION

Muscle atrophy

Reduced force-generating capacity

AKA “strength”

Lower endurance

WHAT ABOUT COMMUNICATION & SWALLOWING

IN THE ICU?

Intubation

Tracheostomy

Ventilator dependency

NPO

ENDOTRACHEAL INTUBATION

Bypasses use of upper airway

Disuse atrophy

Desensitization

Trauma to mucosa, particularly larynx

Cuff over inflation is common

AIRFLOW CHANGES WITH TRACHEOSTOMY

Airflow bypasses upper airway

Deflated cuff and/or fenestration can facilitate some upper airway airflow

AIRFLOW

NORMAL LARYNX (FOR REFERENCE)

Granuloma

Subglottic Stenosis

Glottic & Subglottic Trauma

POST-INTUBATION ULCERATION

WHAT CONTRIBUTES TO STRUCTURAL DEFICITS?

Prolonged intubation (>2 weeks)

Can happen quickly, not just in long-term intubation

(Whited, 1984; Colice, 1992; De Larminat et al., 1995)

Trauma due to movement/friction

INCIDENCE & PREVALENCE

Laryngotracheal injury in 95% (39/41) of previously intubated patients

(Stauffer, Olson, & Petty, 1981)

Dysphagia as high as 56% (27/48), with nearly half those pts aspirating silently

(Ajemian et al., 2001)

BUT WE CAN DO SOMETHING…

ARE OUR PATIENTS “TOO SICK”?

If you do nothing, you will improve nothing – function commonly gets

worse as you “wait” for the patient to “get better”

LESSONS FROM PHYSICAL THERAPY

Early intervention

ROM and facilitation are precursors to rehabilitating functional movement

EXERCISE: WHEN?

The sooner the better

Muscle atrophy & deconditioning

4-6 weeks bedrest = ~40% decrease in strength

(Bloomfield, 1997)

Ill & elderly even more susceptible

(Urso et al., 2006)

FIRST THINGS FIRST…

Restore the system to the most “normal” condition as possible

Passy-Muir Valve use (in-line ventilator use or trach alone)

APPROACHING ASSESSMENT

WITH EXERCISE PRINCIPLES IN MIND

“Hey, what do you say we

get this fella up for nice

walk? Yeah… I bet that

would feel good to

stretch in those legs! If

he falls, we can call PT

for a consult!”

Orthopedics?

“Give it a shot” mentality

Instrumental assessment not just a tool for

diagnosis of dysphagia – think physiology!

• Coordination

• Speed

• Endurance

• Strength

• Various conditions

EXERCISE: WHO?

What conditions would exercise NOT be appropriate for?

Traditionally taught to compensate for deficits rather than treat in

degenerative neuromuscular disease

Working to fatigue in such systems could prove detrimental

EXERCISE?

Disease states we used to treat only with compensation we are learning now

may respond to some forms of exercise

Strengthening in PD

Moderate exercise in ALS

Whole body moderate aerobic exercise benefits

Potential moderate bulbar muscle exercise benefits

(Plowman, 2015)

FUTURE DIRECTIONS IN

EXERCISE APPLICATIONS

Moderate exercise where we once thought it was “taboo”?

Skill vs. strength training?

Further investigation in applicability of modalities in conjunction with

physiologically sound exercise?

USEFUL THERAPEUTIC TOOLS

SEMG BIOFEEDBACK

The most effective, evidence-based tool available!

Detects muscular activity, provides graphic representation

Teaches control and challenges effort

(Huckabee & Cannito, 1999; Crary, 1995)

Effortful swallow Mendelsohn

SEMG – THE EVIDENCE

One of the oldest evidence-based practices in dysphagia rehabilitation

(Haynes, 1976)

Outcomes superior with biofeedback when compared with “traditional” intervention

alone

(Sukthankar et al., 1994; Crary, 2004; Huckabee & Cannito, 1999)

SEMG – THE EVIDENCE

Effective in a variety of populations

More cost-effective than “traditional” tx (faster recovery in fewer visits)

(Crary et al ., 2004)

HOW TO DO IT: SEMG BIOFEEDBACK

Use a smoothed, rectified signal

Obtain/observe baseline resting rate

Head neutral, relaxed

Address tension as necessary (e.g., massage, stretching, cuing)

Obtain amplitude of 3-5 baseline swallows

Determine training target based on goals

SEMG RESOURCES

Synchrony Dysphagia Solutions by ACP

Equipment “rental” along with clinician training & ongoing support

SEMG RESOURCES

Prometheus Group

sEMG alone can be used as

handheld device or coupled to a

monitor using gaming software.

SEMG GENERAL GUIDELINES

A great place to start:

Basic Concepts of Surface Electromyographic Biofeedback

in the Treatment of Dysphagia:

A Tutorial

(Crary & Groher, 2000)

LINGUAL STRENGTHENING DEVICE RESOURCES

IOPI (Iowa Oral Performance Instrument)

www.iopi.info

Swallow Strong

Formerly known as the MOST (Madison Oral Strengthening Therapeutic device)

Swallowsolutions.com

ISOMETRIC LINGUAL STRENGTHENING

Lingual strengthening*

Train at >60% of maximal effort for strengthening effect

Provides biofeedback on performance

ANOTHER LINGUAL STRENGTHENING OPTION

• Swallow Strong

(Next generation of the MOST-Madison

Oral Strengthening Therapeutic device)

• Mouthpiece with sensors coupled to

visual output device

LINGUAL STRENGTHENING –

THE EVIDENCE

8-week progressive resistance exercise with IOPI in older, healthy volunteers

100% increased their isometric pressures and also oral pressure during swallowing

tasks

5.1% volume increase in tongue bulk on MRI

(Robbins et al., 2005)

LINGUAL STRENGTHENING –

THE EVIDENCE

10 stroke pts with dysphagia 51-90 y.o. (6 acute, 4 chronic)

8-week progressive resistance with IOPI

10 reps, 3x/day, 3 days/wk at 60% on week 1, then 80% on weeks 2-8

All increased isometric pressures and oral swallowing pressures

Airway protection improved with liquids

Tongue volume increased on two subjects

(Robbins et al., 2007)

ISOMETRIC LINGUAL STRENGTHENING

Progressive Resistance Oropharyngeal Therapy Using the Madison

Oral Strengthening Therapeutic Device

(Juan et al., 2013)

Case study

56 y.o. female, 27 months s/p brainstem CVA

PEG dependent, expectorating saliva

“Traditional” treatment plus NMES in the home

ISOMETRIC LINGUAL STRENGTHENING

8 wks. Isometric Progressive Resistance Oropharyngeal Therapy (I-PRO)

10 reps anterior & posterior 3x/day, 3 days/wk.

5 wks. detraining

9 wks. maintenance (NO device)

Anterior & posterior tongue press to palate, 3 sets of 10, 3x/day, 1 day/wk.

ISOMETRIC LINGUAL STRENGTHENING

Isometric lingual pressures

Decreased some following detraining, with some rebound in anterior after

maintenance phase

Maximum oral pressures during swallowing

Some increases, particularly in anterior tongue

Bolus flow kinematics

Decreased residue, increased safety (PAS scores)

EMST – PRESSURE THRESHOLD DEVICE

EMST 150

www.EMST150.com

OTHER RESPIRATORY TRAINERS

The BreatherThreshold PEP

EMST – THE EVIDENCE

EMST compared to wet & dry swallows showed increased muscle activity

and hyoid excursion in healthy volunteers

EMST can improve muscle contraction as well as neuromuscular control of

suprahyoid muscle, which is important for laryngeal elevation/airway

protection

(Wheeler et al., 2007)

EMST – THE EVIDENCE

EMST can improve cough strength, pulmonary function, and vocal loudness as well as

swallowing function

(Troche et al., 2010; Pitts et al., 2009; Wingate et al., 2007; Chiara et al., 2006; Saleem et al., 2005)

WORKING OUT WITH EMST

3-5 sets of 10, 3-5 x/day at > 60% MEP

If unable to calculate 60% of MEP, can use perception of 6 on a 1-10 scale

(Morishita et al., 2013)

HOW TO DO THE SHAKER EXERCISES

Part 1: Sustained Hold

1. Lie flat on your back with no pillow under your head.

2. Lift your head to look at your toes.

3. Keep your shoulders flat on the floor/bed.

4. Hold this position for ___ seconds.

5. Release. Repeat 3 times and rest 1 minute between repetitions.

Part 2: Lift and Lower (same starting position as sustained hold)

1. Lift your head and look at your toes.

2. Let your head go back down with control.

3. Repeat 30 times.

4. Rest in between as needed.

5. Repeat 3 times a day. WARNING: Patients with neck problems (e.g., arthritis) may not be able to perform this exercise.

CHIN TUCK AGAINST RESISTANCE (CTAR)

Yoon, Khoo, & Rickard Liow (2014)

Seated upright

Press chin to chest against resistance

Alimed.com Alternativespeech.com

RECLINE EXERCISE

Head Lift Exercise performed at 45 degree angle vs. supine

Comparable outcomes

Easier to perform, reported more comfortable.

CTARCHIN TUCK AGAINST RESISTANCE(YOON ET AL., 2014; SZE ET AL., 2016)

ISO-SED (ISO Swallowing Exercise Device)

CTAR Ball

JOARJAW OPENING AGAINST RESISTANCE(WADA ET AL., 2012)

ISO-SED (ISO Swallowing Exercise Device)

LEE SILVERMAN VOICE THERAPY(LSVT)

ASHA, 2016

http://www.lsvtglobal.com/loud-certification

DOCUMENTATION

Clearly important

Should reflect function, not only

performance on exercises/tasks

DOCUMENTATION

We crave “numbers”

Numeric changes on certain measures may not translate to clinically

meaningful outcomes

Think about and document function in addition to “numbers”

EXAMPLE: “SKINNY FAT” CONCEPT

Who weighs more?

Who is more fit?

Who has better functional performance?

https://www.corehealthproducts.com/skinny-fat-to-lean-machine/

DOCUMENTATION

Intensity

Repetitions

Effort/resistance

DOCUMENTATION: INTENSITY

Depends upon the tool you are using

sEMG

Peak amplitude

Duration

Average amplitude

DOCUMENTATION: INTENSITY

Depends upon the tool you are using

EMST

Sets & reps against resistance

DOCUMENTATION: INTENSITY

Depends upon the tool you are using

Lingual strengthening

Peak pressure generated

Duration of pressure generation

Number of sets/reps completed at given goal

DOCUMENTATION: TYING IN FUNCTION

Repetitions

# of swallows in certain time frame if working on speed/initiation of swallow

Volume of food/liquid ingested safely

Factor of time?

Factor of volume?

DOCUMENTATION: TYING IN FUNCTION

If you do decide to document “numbers,” also document

functional gain or relate to eating/swallowing performance

DOCUMENTATION: TYING IN FUNCTION

Pt. able to ingest 4-oz. trial of

puree within 10 minutes

without oral residue and no

clinical s/s airway compromise.

DOCUMENTATION: TYING IN FUNCTION

Pt. triggered laryngeal elevation

within 1 second of attempt to

swallow tsp. of liquid on 6/10

trials. Cough observed only on

delinquent trials.

GOAL WRITING

Don’t focus on the device; however, targets measured by the device can be utilized

80% of effortful swallow attempts above threshold 3 μV above baseline peak

amplitude

Demonstrate increase in 3 kPa during 5 ml bolus pudding trials on 80% of attempts

GOAL WRITING

Although, best to focus on functional changes

Patient able to take 4-oz. trial of thin liquid without overt s/s of airway

compromise.

Patient able to ingest 4-oz. mechanical soft trial within 5 minutes with no oral

residue.

CASE EXAMPLES

Note the following:

Prior treatment had plateaued

Intensity and use of tools for progressively increasing resistance/challenge were key

in progress

Progress was dramatic in a relatively short period of time

CASE REPORT #1

60-y.o. man

Hx/o right CVA

Severe dysfunction,

silent aspiration

Pt carried “spit cup”

PEG dependent

1 yr. of IP & OP Tx

Referred for myotomy

CASE REPORT #1

• 8 weeks of intervention:

BOT and pharyngeal

strengthening & laryngeal

closure

• Used sEMG & NMES

• Pt resumed unrestricted

oral diet

• PEG removed

CASE REPORT #2

• Hx/o 2 left CVAs, DM, renal failure

w/ transplant, heart disease

• 4 months severe dysphagia

following C-spine surgery

• PEG dependent, frank aspiration

w/ ice chips

• In dysphagia tx 3x/wk at local

rehab

• Had ~1 yr Tx prior

CASE REPORT #2

• 16 weeks of intervention:

Oral & pharyngeal strength,

airway protection, timing

• Used EMST, isometric

tongue strengthening,

sEMG

• Unrestricted oral diet; chin

tuck with liquids

• PEG removed

FOOD IS MEANT FOR MORE THAN EATING

CELEBRATION OF CULTURE

Foodnavigator-usa.com

BE THAT MOTIVATOR FOR YOUR PATIENTS!

Encourage your patients!

Even the most motivated patients can do

juuuussst a little bit more if you push them

***REMEMBER***

STIMULUS MUST INCREASE IN PROPORTION TO STRENGTH FOR

CONTINUED IMPROVEMENT!

IN ALL THINGS…

Be a critical consumer of the research

Blend that with knowledge & experience

Look outside our field when necessary

i.e., When doing exercise, learn about “exercise”

Conduct focused, function-driven, purposeful treatment vs. “task-driven” treatment

THANK YOU FOR YOUR ATTENTION LORI_GATOR@YAHOO.COM