Rethinking the Importance of Skill Training for Dysphagia

Several years ago, I went to an ASHA Convention and attended a talk that addressed whether it is better to train skill or strength when working with patients with dysphagia. I found the idea rather intriguing, especially when considering the possible advantages and disadvantages of focusing on one over the other, rather than focusing on both equally.

Recently, I was invited to speak at the Alaska Speech Language and Hearing Association Convention. Part of my talk was about skill versus strength training. Throughout the course of my research for that presentation, it occurred to me that while both are vital to swallowing, skill training may prove beneficial in areas where strength training fails.

The Limits of Strength Training

When talking about strength training, it’s helpful to start with some basic definitions:

• Strength is the ability to produce force against resistance.
• Weakness is the reduced ability to produce force.
• Fatigue is weakness that becomes evident during sustained force production or over repeated trials.

As it relates to swallowing, strength cannot be the only means of assessment. We need to also assess and treat neuromuscular coordination, precision, timing, reaction speed, and motor movement planning.

Typically, when we describe weakness in the laryngeal and pharyngeal structures, we are inferring a weakness from the reduced range of motion of the structures. Reduced range of motion can be derived from many factors, not weakness alone.

Strengthening may not be the best approach for swallowing rehabilitation as swallowing does not require maximal muscle contraction and weakness may not be the underlying generation of adequate force.^1,2 We may also have potential adverse effects from strength training, including fatigue, increased muscle tone, and detraining effects following treatment.

There are few means available to us to measure the strength of the laryngeal and pharyngeal structures. We can measure the force of the tongue with a tool such as the Iowa Oral Performance Instrument^® or the Tongueometer™.

We also need to evaluate the treatment strategies that we use to “strengthen the swallow.” Many do not incorporate the principles of exercise, including:

• Individuality—Exercise should be specific to the individual completing the training.
• Specificity— Exercise should be specific to the client’s needs and capabilities.
• Overload— Exercise should overload the body for a positive adaptation to occur.
• Progression— Exercise needs to continually overload the body if positive adaptations are to continue to take place.
• Adaptation— The body becomes accustomed to a particular exercise through repeated exposure and can modify based on increased and decreased physical demands.
• Recovery— Rest and recovery are required to allow the body time to adapt to exercise.
• Reversibility (Use/Disuse)— Adaptations from exercise will be lost if left unused.

If you’re primarily focused on strength training and you find that your patient is not progressing as expected, you may consider this quote: “Does the error lie with the clinician and the clinical inaccuracy of the diagnosis to improper selection of rehabilitation approaches?”³

The Influence of Skill Training

Huckabee and MacCrae stated “Skill-based training can be defined at a basic level as the acquisition of skill through functional repetition and refinement of movement patterns, task challenge and feedback.” The goal of skill training as it pertains to swallowing is to improve the precision of swallow muscle contraction by developing conscious control of timing and strength. With skill training, increasing levels of difficulty and proficiency are required at each level before moving to the next.³

Current rehabilitation approaches for swallowing impairment are limited by a general lack of specificity to associated pathophysiology, with many of our practices focusing on increasing strength of muscle activation. Skill training has been documented to influence greater gains than strength training alone. Additionally, skill training has been found to influence greater strength.⁴

Skill-based training is defined as having three elements:

• Specificity of practice (actually practicing swallowing)
• Task challenge with increased demand
• Feedback (typically through use of sEMG)

Skill-Based Exercises

When a patient practices a dysphagic swallow with no adaptation to the task, progress is unlikely. The use of skill-based training has been studied in patients with Parkinson’s disease,5 patients with head and neck cancer,6 and patients who have not been successful with traditional treatment.⁷ All studies showed improvements not only in swallowing, but also in retention of that progress in follow-up studies.

The following exercises have been found to influence swallowing both with and without using an actual swallow. Many of these exercises are available through MedBridge’s HEP library.

Skill-based swallowing exercises incorporating the swallow:

• Effortful swallow
• Tongue-hold maneuver (Masako)
• Mendelsohn maneuver
• McNeill Dysphagia Therapy Program (MDTP)

Skill-based swallowing exercises without a swallow:

• Head-lift exercise (Shaker)
• Expiratory muscle strength training (EMST)
• Lingual exercises

Other promising programs include:

• The Intensive Dysphagia Rehabilitation Program (IDR)
• MD Anderson Boot Camp

To learn more about exercises that support swallowing therapy for dysphagia, check out this course, Dysphagia and the Older Adult: Exercise in Swallow Rehabilitation, by MedBridge instructor Angela Mansolillo, MA/CCC-SLP, BCS-S.