Choosing Exercises for Dysphagia Treatment: An Evidence-Based Approach
Helping to rehabilitate someone with dysphagia so the person can eat and drink safely and in the most effective means can be quite a rewarding experience.
When choosing the most appropriate exercise routine or plan of care for each patient, we have to keep several things in mind. First, we need an accurate assessment to determine the physiology and dysfunction of the swallow. This includes a complete clinical swallow evaluation with a complete history and chart/records review, brief cognitive exam, oral motor exam, and a thorough cranial nerve exam.
We can then make the appropriate recommendation for an instrumental exam, whether it be FEES or VFSS to determine the pharyngeal physiology.
The Principles of Neuroplasticity
When we are creating a dysphagia treatment plan, we need to be mindful not only of the swallowing physiology and dysfunction—whether it be sensory or motor driven—but we also need to remember the principles of neuroplasticity and exercise physiology.
The principles of neuroplasticity should drive our therapy plan. These principles include:
- “Use it or lose it”
- “Use it and improve it”
- Experience specificity
- Repetition
- Intensity
- Duration
- Salience
- Patient’s age
- Transference
- Interference
We also need to be mindful that when we are rehabilitating the swallow, we need to have the patient practice swallowing. This means including exercises that are swallow-driven. Exercises such as repeating words that begin with /k/ or /g/ or tongue movements are not swallow-driven.
We also need to make sure that we are increasing the repetition and intensity of the prescribed exercise. Think about the principle of “use it or lose it” and how it relates to those patients who are strict NPO.
The Principles of Exercise Science
When we prescribe exercises for our patients, are we using exercise science? Exercise science principles include:
- Individuality
- Trainability
- Specificity
- Progression
- Overload
- Variety
- Rest
- Adaptation
- Recovery
- Reversibility
- Maintenance
- Ceiling
Not every patient will require exercises for strengthening since not every patient with dysphagia has a strength issue. But when you are working to strengthen swallowing muscles, you should incorporate the following in your exercise plan:
- Resistance
- Speed
- Repetition
- Intensity
- Load
- Pacing
- Fatigue
Exercises need to progress and require resistance and intensity to increase strength. Simple range-of-motion exercises such as sticking out your tongue with no resistance do not lead to increased swallow strength.
Exercise Plans for Swallowing Concerns
Often, exercise programs or pages of exercises are passed down in a facility and used for years with no adaptation to current evidence or changes to individualize the exercises to suit the patient’s needs.
Try these exercise plans for the following swallowing issues, featuring exercises available in MedBridge’s HEP library.
Sensory Aspect of Swallowing
- Carbonated beverages, which may increase speed of the swallow through sensation
- Changes in flavor, which may increase sensory input of the swallow, driving the motor output
- External pressure to the cheek or to the tongue, for example by using a spoon
- Changes in temperature
- Changes in texture
- Changes in the size of the bolus, which may increase load of the bolus, thereby increasing the sensory component of the swallow, which many elderly patients need. Increased bolus size may also help to drive the UES opening.
Decreased Labial Closure
- Labial press, by holding a tongue depressor between the lips during swallowing exercises
- Straw drinking, decreasing the size of the straw to make the task more difficult
Decreased Lingual Control
- Lingual exercises with resistance using the IOPI, the Tongue-O-Meter, or tongue depressors
- Effortful swallow, in which the patient swallows as hard as they can while squeezing the pharyngeal muscles as tightly as possible
- Base-of-tongue exercises, including yawning, pretending to gargle, pulling the tongue straight back in the mouth
- Lingual exercises with resistance, such as pushing the tongue out, up, and to each side against a tongue depressor
Reduced Velopharyngeal Closure
- Expiratory muscle strength training (EMST) using a pressure threshold device, such as the EMST 150, in which the patient follows a protocol provided with the device
Reduced Hyolaryngeal Excursion
- Chin tuck against resistance (CTAR) using a 12-cm ball, the Phagiaflex, or a rolled towel. Have the patient push their chin down against the tool and hold for one minute, then rest for one minute, and repeat this three times. You can also have the patient push down repetitively 30 times.
- Shaker maneuver, in which the patient lies flat on their back and holds their head up, holding the pose for one minute, resting for one minute, and repeating this three times. The patient can also repetitively lift their head 30 times.
- Effortful swallow
- Mendelsohn maneuver, by having the patient hold their Adam’s apple up for as long as possible after completion of the swallow to keep the airway closed after the swallow. View this during VFSS to ensure accuracy of completion of the exercise.
- Jaw opening against resistance (JOAR), in which a tool is held in CTAR or the patient holds their hand under their jaw. Have the patient open their mouth as wide as possible for a count of 10 and then close the mouth for a count of 10. Complete five repetitions, two times a day, for four weeks.
- Pitch glide, in which the patient starts at a low pitch and slowly increases their pitch to the highest level and holds for several seconds
Reduced Laryngeal Closure
-
- Super supraglottic swallow, in which the patient takes a deep breath, holds their breath after the inhale, and bears down while swallowing hard and coughing immediately following the swallow
- EMST
Reduced Pharyngeal Contraction
- Effortful swallow
- CTAR
- Shaker
- Mendelsohn maneuver
Reduced UES/PES (Pharyngoesophageal segment) Opening
- Shaker
- Effortful swallow
- Mendelsohn maneuver
- CTAR
- JOAR
There are also several treatment protocols requiring specialized training that will guide you in decision making as to when to use the protocol and who would most benefit from it. These programs include:
- The Effective Swallowing Protocol™ by Ampcare
- Lee Silverman Voice Treatment
- The McNeill Dysphagia Therapy Program
- Neuromuscular electrical stimulation (VitalStim, Guardian, eSwallow)
There is also research supporting Pharyngocise for patients with head and neck cancer.
Regularly addressing and updating your exercise prescription techniques based on the most current evidence will help keep you practicing at the top of your license and providing your patients with the best chances to regain lost function.
- Burkhead, L. M. (2009). Applications of exercise science in dysphagia rehabilitation. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 18(2), 43–48.
- Burkhead, L. M., Sapienza, C. M., & Rosenbek, J. C. (2007). Strength-training exercise in dysphagia rehabilitation: Principles, procedures, and directions for future research. Dysphagia, 22(3), 251–265.
- Carnaby-Mann, G., Crary, M. A., Schmalfuss, I., & Amdur, R. (2012). "Pharyngocise": Randomized controlled trial of preventative exercises to maintain muscle structure and swallowing function during head-and-neck chemoradiotherapy. International Journal of Radiation Oncology Biology Physics, 83(1), 210–219.
- Clark, H. M. (2003). Neuromuscular treatments for speech and swallowing: A tutorial. American Journal of Speech-Language Pathology, 12(4), 400–415.
- Clark, H. M. (2005). Therapeutic exercise in dysphagia management: Philosophies, practices, and challenges. Perspectives in Swallowing and Swallowing Disorders, 14(2), 24–27.
- Crary, M. A., Carnaby, G. D., LaGorio, L. A., & Carvajal, P. J. (2012). Functional and physiological outcomes from an exercise-based dysphagia therapy: A pilot investigation of the McNeill Dysphagia Therapy Program. Archives of Physical Medicine and Rehabilitation, 93(7), 1173–1178.
- 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 Phoniatrice et Logopaedica, 55(4), 199–205.
- Logemann, J. A. (2005). The role of exercise programs for dysphagia patients. Dysphagia. 20(2), 139–140.
- McCoy, Y., & Wallace, T. (2018). The Adult Dysphagia Pocket Guide: Neuroanatomy to Clinical Practice. Plural Publishing: San Diego, CA.
- Pitts, T., Bolser, D., Rosenbek, J., Troche, M., Okun, M. S., & Sapienza, C. (2009). Impact of expiratory muscle strength training on voluntary cough and swallow function in Parkinson disease. Chest, 135(5), 1301–1308.
- Robbins, J. A., Butler, S. G., Daniels, S. K., Diez Gross, R., Langmore, S., Lazarus C. L., & Martin-Harris, B., et al. (2008). Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. Journal of Speech, Language and Hearing Research, 51(1), S276–S300.
- Robbins, J. A., Gangnon, R. E., 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(9), 1483–1489.
- Sapienza, C. M. (2008). Respiratory muscle strength training applications. Current Opinion in Otolaryngology & Head and Neck Surgery, 16(3), 216–220.
- Sapienza, C. M., Davenport, P. W., & Martin, A. D. (2002). Expiratory muscle training increases pressure support in high school band students. Journal of Voice, 16(4), 495–501.
- Wheeler-Hegland K. M., Rosenbek J. C., & Sapienza, C. M. (2008). Submental sEMG and hyoid movement during Mendelsohn maneuver, effortful swallow, and expiratory muscle strength training. Journal of Speech, Language, and Hearing Research, 51(5), 1072–1087.
