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Strengthening the Swallow

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Strengthening the swallow must involve increasing the efficiency of the valves as well as the muscles. Speech-language pathologists most frequently use active exercise to treat speech and swallowing disorders. The two main types of active exercises are strength training and stretching.

Clinicians need to consider established philosophies and principles of exercise. Strength is defined as the ability to produce force against resistance. Some oral-motor assessment protocols suggest range-of-motion tasks, which involve stretching rather than resistance.1 Resistance exercises must be designed according to the type of loss (lack of tone or spasticity). There is some question about the efficacy of strength training with patients experiencing spasticity, but active exercise with patients who have high or low levels of tone can be beneficial if exercise principles are understood and applied appropriately.

Resistance exercises used to strengthen muscles must have specificity (relevant to the behavior treated), provide for overload, and increase in intensity to ensure that overload is maintained. When treating dysphagia, exercises should involve swallowing movements. The exercise should tax muscles beyond their typical use. As the training sessions continue, the intensity of these exercises should increase in order to ensure that the muscles continue to be taxed beyond typical use.

There are a number of resistance exercises in swallowing treatment. Typically, the Masako maneuver taxes the pharyngeal constrictors by anchoring the tongue by the teeth anteriorly. The effortful swallow overloads the swallowing musculature beyond its normal use, and the individual swallows with greater effort than normal. The palate provides resistance as the tongue tip presses against it to initiate the swallow. The Shaker exercise uses the weight of the head as resistance and provides overload by holding the position.

Commercial products are available that emphasize resistance exercise. The Ora-Light® system incorporates holding resistance against the tongue with tools designed to isolate a variety of oral muscle groups.

The use of continuous positive airway pressure (CPAP) provides resistance against velar elevations during swallowing and exerts resistance for the treatment of hypernasality.2 The levels of air pressure can be increased, allowing for overload and its maintenance.

The IOPI (Iowa Oral Performance Instrument) can provide measurements of tongue strength and provides both resistance and overload. This device uses an air-filled bulb, which the tongue presses against. Recordings of strength are digitally shown. The IOPI offers feedback and the ability to increase intensity to insure that overload is maintained. It also measures and monitors fatigue. Lingual exercise using the IOPI increased the strength of swallowing pressures in normal elderly individuals.3

The micro-resistance straws, which are part of the TheraSIP Swallowing Trainer™, provide resistance by requiring an "effortful suck" (working the lips, tongue retraction, velopharyngeal closure and the glossopharyngeal valve) against the force of water drawn through microscopic interior straw diameters. In addition to resistance, this device stresses the significance of using an effortful swallow with very small boluses. Research supports the use of small boluses with the effortful swallow.4This tool offers three micro-resistance straws of varying difficulty to provide the important increase in intensity necessary for maintaining overload. Specificity is also an important part of this device, which strongly employs swallowing as part of its exercise.

Neuromuscular electrical stimulation (NMES) applies low-voltage electrical currents to muscle tissue, causing contraction of muscle fibers. NMES does not induce gains of physical strength in normal adults.5The best results are obtained when NMES is paired with resistance training and/or with functional activities such as swallowing.6The role of active exercise is critical to the success of NMES.

Therapists planning a program for an individual with swallowing problems need to ask several questions: Do the exercises involve swallowing movements? Do the exercises tax the muscles of the swallow beyond their typical use? Can the exercises be increased in intensity to insure that overload is maintained?

More important than these questions is the diagnostic question regarding the individual's type and nature of neuromuscular loss. For patients with progressive disease, programs must be designed carefully to prevent fatigue.

There has been considerable controversy regarding the appropriateness of resistance training with spasticity. Traditionally, it is believed that resistance training further decreases range of motion and possibly increases spasticity. However, this is not substantiated by research, which has found that spastic muscle groups should be stretched with range-of-motion exercises or relaxed using stretch prior to applying resistance exercises.7A conservative approach should be taken when using resistance training for any spastic muscle groups, specifically avoiding high-intensity training. Stretch or relaxation exercises may be helpful prior to or following resistance drills. Most importantly, strengthening programs for individuals with high tone will not eliminate spasticity but should not worsen it.

Other resistance exercises are designed to increase respiratory strength for improved ability to protect the airway. Respiratory incentive inspirators offer resistance on inhalation, and instruments such as the Breather®use resistance on both inhalation and exhalation.

One of the best sources for examining neuromuscular treatments is "Neuromuscular Treatments for Speech and Swallowing: A Tutorial," by Heather Clark, PhD, CCC-SLP, associate professor in the Department of Language, Reading & Exceptionalities at Appalachian State University in Boone, NC.8Dr. Clark clearly explains exercise physiology and its application to neuromuscular treatment. All clinicians who treat dysphagia should have a working knowledge of various types of exercise, as well as the ability to make appropriate application of exercise principles to neuromuscular dysfunction. This insures that they establish differential treatment programs for each individual with swallowing dysfunction rather than relying on cookbook therapies or a one-size-fits-all approach.

In the treatment of swallowing disorders, evidence suggests that the same principles of exercise science used to strengthen large muscle groups can be used to help restore strength to the oral muscles involved in swallowing and speech. Individualized plans for treating dysphagia should include a variety of active exercises employing range-of-motion, stretch, relaxation, NMES and resistance exercises tailored for the individual needs of each patient.

References

1. Clark, H.M. (2006). Therapeutic exercise in dysphagia management: Philosophies, practices and challenges. The Role of Therapeutic Exercises in the Treatment of Dysphagia, 31-35.

2. Kuehn, D.P., Imrey, P.B., Tomes, L., et al. (2002). Efficacy of continuous positive airway pressure for treatment of hypernasality. Cleft Palate-Craniofacial Journal, 39: 267-77.

3. Robbins, J., Gangnon, R.E., Theis, S., et al. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatrics Society, 53: 1483-89.

4. Witte, U., Huckabee, M.L., Doeltgen, S.H., et al. (2008). The effect of effortful swallow on pharyngeal manometric measurements during saliva and water swallowing in healthy participants. Archives of Physical Medicine and Rehabilitation, 89: 822-28.

5. Currier, D.P., Mann, R. (1983). Muscular strength development by electrical stimulation in normal individuals. Physical Therapy, 63: 915-20.

6. Mysiw, W.J., Jackson, R.D. (1996). Electrical stimulation. In R.L. Braddom (ed.), Physical Medicine and Rehabilitation (pp. 464-90). Philadelphia: W.B. Saunders.

7. Lockette, K.F. (1995). Resistance training with stretch bands: Modifying for disability. In P.D. Miller (ed.), Fitness Programming and Physical Disability. Champaign, IL: Human Kinetics.

8. Clark, H.M. (2003). Neuromuscular treatments for speech and swallowing: A tutorial. American Journal of Speech-Language Pathology, 12: 400-15.

Kathleen Smead is director of the Speech & NeuroRehabilitation Center Inc., in Pensacola, FL, and developer of the TheraSIP Swallowing Trainer. She can be contacted at ksmead@cox.net.




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