The role of exercise programs for dysphagia patients

Degree of pharyngeal deformation caused by pharyngeal endoscopic submucosal dissection is associated with the incidence of aspiration pneumonia

Background and study aims  Endoscopic submucosal dissection (ESD) is one of the most minimally invasive treatments for superficial squamous cell cancer of the pharynx. However, aspiration pneumonia (AsP) associated with postoperative deformity of the pharynx may occur. The purpose of this study was to investigate the frequency of AsP and the degree of pharyngeal deformity after pharyngeal ESD. Patients and methods  This was a retrospective observational study of patients who underwent pharyngeal ESD at Okayama University Hospital between 2006 and 2017. The degree of pharyngeal deformation was assessed using the pharyngeal deformation grade (PDG). The primary endpoint was the frequency of AsP as a long-term adverse event. Results  Among the 52 patients enrolled, nine developed aspiration pneumonia, with a 3-year cumulative incidence of 9.0 % (95 % confidence interval [CI], 3.3 %-22.0 %). There were 16, 18, 16, and two patients that had PDG 0, 1, 2, and 3, respectively. Patients with a history of radiotherapy, as a treatment of head and neck cancer (44.4 % vs. 11.6 %; P  = 0.02) and the high PDG group (PDG 2 and 3) (77.8 % vs. 25.6 %; P  = 0.005) had a significantly higher incidence of AsP. The 3-year cumulative incidence rate of AsP after ESD in the high PDG group was significantly higher than that in the low PDG group (PDG 0 and 1) (23.9 % [95 %CI, 9.2.-49.5%] vs. 0 %; P  = 0.03). Conclusions  The incidence of aspiration pneumonia in the long-term course after pharyngeal ESD was revealed. The incidence of aspiration pneumonia may be associated with pharyngeal deformity, but further studies are needed.

Is the proprioceptive neuromuscular facilitation technique superior to Shaker exercises in swallowing rehabilitation?

PURPOSE

This prospective study was planned to investigate whether the combined isotonic technique of proprioceptive neuromuscular facilitation (PNF) is superior to Shaker exercises in improving the function of swallowing muscles.

METHODS

Fifty individuals (30 females and 20 males; mean age 68 ± 3.89 years) with swallowing difficulties were separated into two groups randomly. The treatment groups were Shaker and PNF groups, which performed these exercises three times in a week for6 weeks. Swallowing difficulties were determined with the Turkish version of the eating assessment tool (T-EAT-10). The 100 ml-water swallow test was used to measure capacity, volume, and speed of swallowing. Contraction amplitude changes used as a universal measurement of motor unit activity during the muscle action were measured with superficial electromyography.

RESULT

After 6 weeks of exercise training, T-EAT-10 scores decreased in both groups (p < 0.001). Water swallowing capacity and volume improved in both groups (p < 0.001). There was no change in swallowing speed in both groups (p > 0.05). Maximal voluntary contraction values of suprahyoid muscles were higher in PNF than the Shaker group (p < 0.05).

CONCLUSION

Both the types of exercise can be used in the rehabilitation of swallowing difficulties. However, the PNF technique increased the contraction amplitude values that occur during maximum contraction more than the Shaker exercises. Different functional evaluations are needed to determine the effectiveness of PNF on swallowing difficulty.

Cervical isometric exercises improve dysphagia and cervical spine malalignment following stroke with hemiparesis: a randomized controlled trial

BACKGROUND

Hemiparesis following stroke can cause cervical spine scoliosis, kyphosis or hyperlordosis. These abnormal cervical alignments can contribute to dysphagia. The benefit of cervical isometric exercises to improve swallowing has not been previously studied.

AIM

To evaluate the use of cervical isometric exercises in dysphagic adult patients with cervical spine alignment disorders due to hemiparesis after stroke.

DESIGN

A randomized controlled trial.

SETTING

University Hospital, PMR Department.

POPULATION

Dysphagic adult patients with hemiparesis after stroke in the rehabilitation phase.

METHODS

In addition to the standard physical and speech therapy therapeutic approach for 12 weeks, cervical isometric exercises were conducted by a group of patients (experimental group). Patients had cervical spine radiographs in erect (sitting or standing) position coronal and sagittal C2-C7 Cobb angle and a videofluoroscopic swallowing study to evaluate deglutition (0=normal, 1=penetration, 2=aspiration) at 2 time points (at the beginning and at the end of the therapeutic program).

RESULTS

Seventy consecutive patients with hemiparesis of a mean (SD) age of 52±15 years were included in the study and were randomized in 2 groups. Thirty-seven of them (experimental group) conducted cervical isometric exercises in addition to their therapeutic program. At the last follow-up, patients had improved (P<0.001) cervical alignment, in both coronal and sagittal plane, and deglutition. Patients who conducted cervical isometric exercises (experimental group) had more pronounced correction (P<0.001) of cervical alignment in both planes and achieved greater improvement (P<0.05) of deglutition too, than patients who did not conduct such exercises (control group).

CONCLUSIONS

Dysphagic adult patients with hemiparesis after stroke in the rehabilitation phase who underwent cervical isometric strengthening exercises showed more significant correction of cervical alignment and more pronounced improvement in deglutition compared to patients who did not include cervical isometric exercises in their therapeutic program.

CLINICAL REHABILITATION IMPACT

The additional use of cervical isometric exercises in hemiparetic stroke patients with dysphagic symptoms lead to more pronounced improvement of their swallowing function compared to such patients who are subjected to speech therapy only. Furthermore, these exercises are shown to be beneficial for cervical spine alignment too.

The Sequence of Swallowing Events During the Chin-Down Posture

PURPOSE

This study investigated the effect of the chin-down posture on the sequence of swallowing events in healthy adults.

METHOD

Sixteen healthy participants performed 45 5-ml thin liquid swallows during videofluoroscopy: 5 neutral head position, 30 chin-down posture, and then 10 neutral head position. Eight swallowing events were measured: the time of hyoid burst, bolus head in the pharynx, bolus tail in the pharynx, laryngeal vestibule closure (LVC), upper esophageal sphincter (UES) opening, bolus head in the UES, bolus tail exiting the pharynx, and laryngeal vestibule opening (LVO).

RESULTS

Our key finding is that LVC was one of the first 3 swallowing events in 69% of neutral swallows and in 78% of chin-down swallows (p = .006). Also, LVO occurred last in 14% of chin-down swallows but never occurred last in the preceding neutral swallows (p ≤ .001). Thus, in chin-down swallows, LVC occurred earlier and LVO occurred later.

CONCLUSIONS

The chin-down posture may be beneficial for individuals with delayed onset of LVC and reduced duration of the LVC. Future studies are needed to examine this effect in individuals with dysphagia.

Mechanisms of airway protection during chin-down swallowing

PURPOSE

This study examined the effects of chin-down swallowing on laryngeal vestibule closure. It also investigated the technique's rehabilitative impact, by assessing the stability of effects across multiple trials and aftereffects in neutral swallows on cessation of the technique.

METHOD

Duration of laryngeal vestibule closure (dLVC) was measured with videofluoroscopy in 16 healthy participants (mean = 33.2 years, 9 men). Participants swallowed 40 times: 5 head-neutral swallows (N1), then 30 chin-down swallows, followed by 5 head-neutral swallows (N2). The first 5 chin-down swallows were categorized as early posture swallows (P1) and the last 5 as late posture swallows (P2). Within-participant comparisons determined the effects of the maneuver on dLVC during and after execution.

RESULTS

The study found that dLVC increased during chin-down swallows (N1 to P1, p = .018). This increase remained stable throughout 30 repetitions (P1 to P2, p = .994). On return to neutral, dLVC returned to baseline (N1 to N2, p = .875).

CONCLUSIONS

This study demonstrated increased dLVC during chin-down swallowing, offering a possible mechanism responsible for previously reported reduced aspiration during the technique. As aftereffects were not evident after multiple chin-down swallows, the maneuver appears to offer more compensatory benefit than rehabilitative value for patients with dysphagia.

Adherence to preventive exercises and self-reported swallowing outcomes in post-radiation head and neck cancer patients

BACKGROUND

To reduce the risk of long-term swallowing complications after radiation, swallowing exercises may be helpful. Both the rate of adherence to swallowing exercises and its impact on future swallowing function are unknown.

METHODS

In all, 109 patients with oropharyngeal cancer beginning radiation were tracked for 2 years to determine adherence to swallowing exercises. Participants completed the MD Anderson Dysphagia Inventory (MDADI) 1-2 years after treatment, to assess self-reported swallowing function. Adherence, demographics, tumor, and treatment variables were multivariably regressed onto the MDADI physical subscale score.

RESULTS

In accord with speech pathologist documentation, 13% of the participants were fully adherent and 32% were partially adherent. Adherence was associated with the Physical MDADI Subscale score in the multivariate model (p = .01).

CONCLUSIONS

The majority of patients with head and neck cancer are nonadherent to swallowing exercise regimens and may benefit from supportive care strategies to optimize their adherence.

Differential effects of targeted tongue exercise and treadmill running on aging tongue muscle structure and contractile properties

Age-associated changes in tongue muscle structure and strength may contribute to dysphagia in elderly people. Tongue exercise is a current treatment option. We hypothesized that targeted tongue exercise and nontargeted exercise that activates tongue muscles as a consequence of increased respiratory drive, such as treadmill running, are associated with different patterns of tongue muscle contraction and genioglossus (GG) muscle biochemistry. Thirty-one young adult, 34 middle-aged, and 37 old Fischer 344/Brown Norway rats received either targeted tongue exercise, treadmill running, or no exercise (5 days/wk for 8 wk). Protrusive tongue muscle contractile properties and myosin heavy chain (MHC) composition in the GG were examined at the end of 8 wk across groups. Significant age effects were found for maximal twitch and tetanic tension (greatest in young adult rats), MHCIIb (highest proportion in young adult rats), MHCIIx (highest proportion in middle-aged and old rats), and MHCI (highest proportion in old rats). The targeted tongue exercise group had the greatest maximal twitch tension and the highest proportion of MHCI. The treadmill running group had the shortest half-decay time, the lowest proportion of MHCIIa, and the highest proportion of MHCIIb. Fatigue was significantly less in the young adult treadmill running group and the old targeted tongue exercise group than in other groups. Thus, tongue muscle structure and contractile properties were affected by both targeted tongue exercise and treadmill running, but in different ways. Studies geared toward optimizing dose and manner of providing targeted and generalized tongue exercise may lead to alternative tongue exercise delivery strategies.

Speech and myofunctional exercise physiology: a critical review of the literature

PURPOSE

To analyze the scientific literature about the physiology and effects of exercises used in the treatment of oral myofunctional disorders.

RESEARCH STRATEGY

The methodology used followed the concepts of the Cochrane Handbook and involved question formulation related to the topic of investigation, identification and selection of the studies, and a critical evaluation of the selected articles.

SELECTION CRITERIA

Papers were selected on PubMed database using the following keyword combinations: "physiology exercise AND speech, language and hearing science", "exercise physiology AND speech therapy", "exercise physiology AND myofunctional therapy", and "physiology exercise AND swallowing therapy". Only papers written in English and published between the years of 2000 and 2010 were included in the analysis.

DATA ANALYSIS

Manuscripts were analyzed according to their objectives, research design, participants, inclusion of a control group, assessment criteria, therapeutic proposal, results and existence about physiology of the chosen exercises.

RESULTS

One hundred and eight studies were identified, out of which 38 had access to the full text and were directly related to the investigated topic. The articles were classified as clinical trials and experimental research, case studies, literature reviews and theoretical articles, letters to the editor and critical analyses.

CONCLUSION

This review concluded that there is a lack of knowledge about the effects of the myofunctional exercises used by clinicians. Also there is a lack of scientific evidence to determine the frequency at which they should be performed. Generally, the articles investigate the efficacy of treatment programs without inquiring whether the included exercises are individually effective.

The effect of age and tongue exercise on BDNF and TrkB in the hypoglossal nucleus of rats

Age-associated changes in tongue musculature may contribute to dysphagia. One possible treatment is tongue exercise. Exercise induces synaptic plasticity by increasing neurotrophic factors in spinal cord and limb musculature. However, effects of exercise on neurotrophic factors in the cranial sensorimotor system are unknown. Our purpose was to examine the effects of age and exercise on brain-derived neurotrophic factor (BDNF) and its receptor TrkB in the rat hypoglossal nucleus. Young, middle-aged, and old rats were assigned to exercise or no-exercise control conditions. Exercise animals were trained to perform a tongue press task for 8 weeks. Samples from the hypoglossal nucleus were analyzed for BDNF and TrkB immunoreactivity. Baseline maximum tongue forces were similar in all age groups and increased significantly following exercise. BDNF immunoreactivity did not show a significant decrease with age in control group. However, in the exercise group, BDNF was significantly increased in young animals. TrkB immunoreactivity decreased significantly with age in control group, but did not change with exercise. BDNF and TrkB immunoreactivity levels were positively correlated with exercise in young and middle aged animals, but were negatively or weakly correlated with exercise in old animals and with a lack of exercise in no-exercise controls. Tongue exercise was associated with increased tongue forces in rats at all ages. While increases in BDNF and TrkB levels associated with exercise may play a role in mechanisms contributing to increased tongue forces in young and middle-aged rats, other mechanisms may be involved in increased tongue forces observed in old rats.

Anatomical variations in stylopharyngeus muscle insertions suggest interindividual and left/right differences in pharyngeal clearance function of elderly patients: a cadaveric study

The stylopharyngeus plays a critical role in the clearance of the piriform recess. We dissected 78 sides of the pharynx from 55 donated cadavers and observed histology of another seven sides of the pharynx from seven cadavers. The stylopharyngeus consistently comprised (1) a descending muscle bundle surrounding the piriform recess and (2) an additional short sheet inserting into the tonsillar bed. Histologically, the former bundle connected to a thick fascia providing the lateral glossoepiglottic fold, extending along the submucosa of the piriform recess, and covering the thyroid cartilage, whereas the latter sheet intermingled with other pharyngeal wall muscles at and near the tonsillar bed. Notably, in 44.4% of female specimens, the additional sheet occupied a greater proportion in cross section than the descending muscle bundle. Given the different directions, the additional sheet seemed to check clearance function of the descending bundle for the piriform recess. Thus, particularly in women, interindividual differences in pharyngeal clearance were likely to depend on whether the additional sheet is strong or weak. Chin down in combination with tilting and rotating the head may represent effective exercises of the stylopharyngeus that could compensate for the disadvantages of additional insertion.

Dysphagia: implications for older people

This review opens with an outline definition of dysphagia, its causes, and why it is vital that people involved in the health care of older people should be aware of it. A brief consideration of prevalence is followed by an overview of assessment options. We conclude with a section on management.

Tongue measures in individuals with normal and impaired swallowing

PURPOSE

This investigation sought to add to the extant literature on measures of normal tongue function, to provide information on measures of tongue function in a group of individuals with oral phase dysphagia, and to provide a comparison of these 2 groups matched for age and gender.

METHOD

The Iowa Oral Performance Instrument was utilized to measure tongue function (strength and endurance) in a group of individuals with normal (N=200) and impaired (N=50) swallowing. The peak measure of 3 encouraged trials was recorded as participants' strength, and 50% of their peak was sustained as long as possible for endurance.

RESULTS

Results for the control group supported previous investigations wherein greater tongue strength was found in males than in females and in the youngest versus oldest groups. The experimental group demonstrated a similar trend in strength for gender. When matched for age and gender, the experimental group demonstrated significantly lower strength. Significant differences were not revealed on measures of tongue endurance.

CONCLUSIONS

We were able to extend the normative database on tongue function and document reduced tongue strength in a group of individuals with dysphagia. The findings provide evidence that in this group, tongue weakness coincided with signs of dysphagia, adding justification for tongue-strengthening protocols.

Strength-training exercise in dysphagia rehabilitation: principles, procedures, and directions for future research

Dysphagia rehabilitation, historically, has focused a great deal on various compensations during swallowing to prevent aspiration and/or improve safety and efficiency. Exercise, in general, has been a part of the dysphagia rehabilitation landscape. However, heightened discussions in the field regarding best practices for exercise training, particularly strengthening, raise more questions than answers. The intent of this paper is to (1) explore the overriding principles of neuromuscular plasticity with regard to strength training, (2) evaluate how current exercise-training interventions in dysphagia rehabilitation correspond to these principles, and (3) postulate directions for future study of normal and disordered swallowing and determine how to incorporate these principles into dysphagia rehabilitation.