An active interest in exercise science and rehabilitation was almost inevitable for Lori Burkhead, PhD, CCC-SLP, on both a personal and professional level. Dr. Burkhead, an assistant professor in the Department of Otolaryngology at the Medical College of Georgia, in Augusta, is the sister of a world record holder in amateur bench press and has spent years working closely with occupational and physical therapists in rehab hospitals.
The constant exposure to exercise science eventually caused her to rethink her approach to dysphagia rehabilitation. "It baffled me that as a speech pathologist I was being asked to work on strength and to do strength training for dysphagia, yet I never received any training for that in my graduate school studies," she said. "So I decided there was some merit in going back and learning these principles to see what may or may not apply to dysphagia."
Dr. Burkhead found that many of the principles of strength training and exercise physiology had direct application to her work with the dysphagia population. She began to use evidence-based concepts from the physical therapy and exercise science literature to hone a more physiologically-based outlook on dysphagia assessment and rehabilitation.
Speech-language pathologists have a number of very effective, evidence-based exercises at their disposal for addressing dysphagia. However, if the exercises are not performed with the proper amount of repetition or intensity, they have little effect on improving patient outcome. Clinicians need to push patients-sometimes slightly out of their comfort zone-in order to see improvements in swallowing.
"As a helping profession, we frequently don't want our patients to be in discomfort, so we don't push them hard enough," Dr. Burkhead said. "We end up doing a couple repetitions of a Mendelsohn, an effortful swallow, or other exercises that are fundamentally good but not done to the intensity needed. We do not know the exact number of repetitions or sets of an exercise that might be the 'magic formula'-we just need to watch the patient and push them beyond their normal capacity."
Part of the problem in ensuring effective dysphagia therapy outcomes is the limited therapy time speech-language pathologists have, combined with their wide range of clinical demands. In addition to dysphagia, they generally are expected to work with patients on speech, language, communication and cognition, often in very limited time increments. Trying to squeeze in a few dysphagia exercises while working on a host of other speech and language issues does not bode well for improving swallowing function, Dr. Burkhead said.
Instead, clinicians should reprioritize therapy to meet the patient's greatest needs, she suggested. "Dysphagia is a priority for most patients. The overwhelming majority of patients who have the ability to communicate with us indicate that they prefer to work on their swallowing rather than communication, which might surprise some people."
If swallowing is the patient's priority, the speech-language pathologist can set aside more time in therapy to focus intensely on it. When dysphagia is resolved or the patient is able to eat something safely, speech and language goals can become more prominent. In fact, many of the strengthening exercises for dysphagia have concurrent benefits for speech.
"Just because speech-language pathologists can address so many things doesn't mean we should address them all at once," Dr. Burkhead noted. "We have to focus on the most important things first, do them correctly, then focus on the other deficits."
Intensive exercise therapy for dysphagia is not ideal for all patients, she cautioned. Exercise will not benefit people with certain conditions, such as chronic degenerative neuromuscular diseases like amyotrophic lateral sclerosis (ALS) and myasthenia gravis. In those populations intense exercise can cause extreme fatigue and worsen function. "Exercise is a great thing, but in the appropriate population and with the appropriate person," she said.
Not surprisingly, an exercise-based treatment approach is most effective when started early, even with patients in the ICU. Muscle deconditioning sets in quickly, but early intervention can lessen its severity.
Speech-language pathologists should advocate for their presence in the ICU. They should educate doctors and nurses that-much like physical therapy interventions for sitting balance and range of motion in intensive care-recovery of mouth and throat function requires early intervention as well.
It's often simply a matter of changing popular perception, Dr. Burkhead said. "No one would ever dream of walking into the ICU and saying to a patient, 'OK, get up and walk. If you fall down, we'll deal with it then.' Yet, they will extubate a patient in the ICU, put a food tray in front of them, and say, 'Let's see if you can eat. If you choke and cough, we'll deal with it then.'"
Speech-language pathologists can begin working on range-of-motion and gentle exercises for the mouth and throat to prevent deconditioning. "We need to be involved in the ICU to do simple things like putting a one-way speaking valve on a tracheostomy patient so they are getting airflow up through the upper airway, activating the muscles for speech and swallowing."
Her concern about preventing deconditioning stems from a concept in physical therapy literature known as a vicious loop. Patients who grow weak become more prone to falling. After falling once, they are more prone to fall again. They may be placed on bed rest, thus growing even weaker than before the initial fall.
Dr. Burkhead proposes that vicious loops exist in dysphagia as well. "When we put in an NG or PEG tube, keep patients NPO, and tell them not to swallow, they have less opportunity to swallow," she explained. "Then they become more deconditioned and have to stay on the PEG tube longer, getting weaker as the dyspghagia worsens. Hence goes the vicious loop. It's something we need to be mindful of so we can start working with patients even if they can't swallow but one food consistency or even just ice chips."
Dr. Burkhead also cited findings in the skeletal limb literature. Studies have shown a 40 percent decrease in force-generating capacity for strength among healthy individuals after spending a week in bed.1"If a healthy person is 40 percent weaker, think of how much worse that would be for the sick or the elderly. That's our patient population," she said. "It's reasonable to extrapolate from the limb literature that this is likely happening in the mouth and throat."
Deconditioning has serious effects on oropharyngeal and laryngeal muscles.
Among the various therapy tools available to speech-language pathologists, one of the most underused is surface electromyography (sEMG). This biofeedback technique enables patients to see what their muscles are doing by observing a waveform on a computer screen. A harder swallow causes the waveform to surge higher on the screen. Dr. Burk-head suggests setting a visual cue as a goal on the screen and challenging the patient to swallow hard enough for the waveform to reach the goal. "Then keep increasing that goal so the patient has to swallow harder and harder to reach it," she said.
Focusing on intensity helps patients meet goals faster and is more cost-effective, according to research by Michael Crary, PhD, CCC-SLP, of the University of Florida Health Science Center, on the use of biofeedback paired with exercise.2
ost speech-language pathologists don't have sEMG equipment, Dr. Burkhead noted, but most occupational and physical therapists do and could partner with them to use this equipment for swallow strengthening.
Other evidence-based exercise treatments in dysphagia therapy include expiratory muscle strength training (EMST), the Shaker exercise, and use of the Iowa Performance Oral Instrument (IOPI) for lingual strengthening techniques,3 hich have been studied in stroke, head and neck cancer, and other populations.
Dr. Burkhead is developing an exercise using variations of tongue and jaw positions to increase intensity during an effortful swallow. "My theory is that if we alter the position of the jaw and tongue, we can alter the intensity of the effortful swallow and try to strengthen muscles by increasing the challenge of swallowing," she explained.
Exercise principles are also helpful cornerstones of swallowing assessment. "As a field, we've started to realize that we have to look more at endurance," Dr. Burkhead said. "We need to look at fatigue and how that affects the swallow. We need to look at pill swallowing, different textures of food, and mixed textures of food and be mindful of what the physiologic components of swallowing are. It's not just strength-it's speed, endurance and coordination."
1. Bloomfield, S.A. (1997). Changes in musculo-skeletal structure and function with prolonged bed rest. Medicine & Science in Sports & Exercise, 29 (2): 197-206.
2. Crary, M.A., Carnaby Mann, G.D., Groher, M.E., et al. (2004). Functional benefits of dysphagia therapy using adjunctive sEMG biofeedback. Dysphagia, 19 (3): 160-4.
3. Robbins, J.A., Kays, S.A., Gangnon, R.E., et al. (2007). The effects of lingual exercise in stroke patients with dysphagia. Archives of Physical Medicine and Rehabilitation, 88 (2): 150-58.
• Burkhead, L.M., Sapienza, C.M., Rosenbek, J.C. (2007). Strength-training exercise in dysphagia rehabiliation: Principles, procedures, and directions for future research. Dysphagia, 22 (3): 251-65.
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• Lori Burkhead, PhD, firstname.lastname@example.org
Alyssa Banotai is a Senior Associate Editor at ADVANCE. She can be reached at email@example.com.