Chin Tuck Against Resistance (CTAR): New Method for Enhancing Suprahyoid Muscle Activity Using a Shaker-type Exercise

Advancing clinical understanding of surface electromyography biofeedback: bridging research, teaching, and commercial applications

INTRODUCTION

Expanding the use of surface electromyography-biofeedback (EMG-BF) devices in different therapeutic settings highlights the gradually evolving role of visualizing muscle activity in the rehabilitation process. This review evaluates their concepts, uses, and trends, combining evidence-based research.

AREAS COVERED

This review dissects the anatomy of EMG-BF systems, emphasizing their transformative integration with machine-learning (ML) and deep-learning (DL) paradigms. Advances such as the application of sophisticated DL architectures for high-density EMG data interpretation, optimization techniques for heightened DL model performance, and the fusion of EMG with electroencephalogram (EEG) signals have been spotlighted for enhancing biomechanical analyses in rehabilitation. The literature survey also categorizes EMG-BF devices based on functionality and clinical usage, supported by insights from commercial sectors.

EXPERT OPINION

The current landscape of EMG-BF is rapidly evolving, chiefly propelled by innovations in artificial intelligence (AI). The incorporation of ML and DL into EMG-BF systems augments their accuracy, reliability, and scope, marking a leap in patient care. Despite challenges in model interpretability and signal noise, ongoing research promises to address these complexities, refining biofeedback modalities. The integration of AI not only predicts patient-specific recovery timelines but also tailors therapeutic interventions, heralding a new era of personalized medicine in rehabilitation and emotional detection.

Effects of effortful swallowing against kinesiology taping resistance on the swallowing function in patients with poststroke dysphagia: A randomized controlled trial

BACKGROUND

A dysphagia rehabilitation method using kinesiology taping (KT) was recently introduced, and its potential for clinical efficacy was demonstrated by evaluating muscle activity and thickness. However, its effect on the swallowing function in patients with dysphagia remains unclear. This study aimed to investigate the effects of effortful swallowing against KT resistance on the swallowing function in patients with post stroke dysphagia.

METHODS

Thirty patients with poststroke dysphagia were recruited and randomly assigned to the experimental and placebo groups. In the experimental group, the KT was attached to the front of the neck (the hyoid bone between the sternum) with a tension of approximately 70% to 80%, and effortful swallowing was performed against the KT tension. In contrast, the placebo group performed effortful swallowing with KT applied at the same location without tension. The intervention was performed 30 times/day, 5 days/week for 6 weeks. The videofluoroscopic dysphagia scale (VDS) and penetration-aspiration scale (PAS) based on a videofluoroscopic swallowing study were used to analyze oropharyngeal swallowing function.

RESULTS

The experimental group showed statistically significant improvements in the oral and pharyngeal phases of the VDS (P = .029 and .007, respectively) and PAS (P = .034) compared with the placebo group. Effect sizes were observed for the oral (0.3) and pharyngeal phases (0.5) of the VDS and PAS (1.1).

CONCLUSION

This study demonstrated that effortful swallowing against resistance to KT is an effective therapeutic exercise for improving the swallowing function in patients with poststroke dysphagia.

Development of a tool for monitoring the jaw-opening pace and preliminary comparison the pace between young and old ages

OBJECTIVES

Studies have demonstrated that high-speed jaw-opening exercises are effective in improving swallowing function. However, there has been no objective tool available for monitoring jaw-opening pace. This study aimed to develop an objective tool for monitoring and validating jaw-opening pace and compare it between young and old ages from different age groups.

MATERIALS AND METHODS

A load cell plug-in jaw pad connected to an automatic recording and analysis system was used to record jaw-opening motions for offline analysis. We recruited 58 healthy volunteers from different age groups (20-39 y/o; 40-59y/o; 60-79y/o). During a 2-min recording session, each participant was instructed to fully open and close their jaw as quickly as possible while wearing a sensor. Bland-Altman plot, paired t-test and Pearson's correlation test were used to compare the number of jaw-opening motions between manual counting and automatic software analysis. The number of jaw-opening motions during the 2-min recording was compared between the three age groups.

RESULTS

Automated analysis of jaw-opening pace was efficient and equally comparable with the traditional manual counting method across the three age groups. A declining trend in jaw-opening pace among the old age group was found but with no statistically significant difference.

CONCLUSIONS

A jaw-opening motion monitoring tool with reliable automatic pace analysis software was validated in young and old ages. The jaw-opening pace demonstrated a tendency to decline with age.

CLINICAL RELEVANCE

This monitoring tool can also be used to provide visual feedback during jaw-opening motion training in pace control.

The Cost-Effectiveness of Chin Tuck Against Resistance Compared to Usual Care in Citizens with Oropharyngeal Dysphagia - An Economic Evaluation

Purpose

This study aims to evaluate the cost-effectiveness of chin tuck against resistance (CTAR) for citizens suffering from dysphagia compared to the standard municipal treatment in Denmark.

Patients and Methods

A cost-utility analysis, employing a municipal perspective, was conducted using cost data collected alongside clinical data of a randomized controlled trial evaluating the effect of CTAR training for citizens with dysphagia. The composition of the clinical randomized controlled trial, which included citizens with different diagnoses, means that participants had different disease courses. Ninety-two citizens from seven different Danish municipalities were enrolled, of whom 43 received standard care, and 49 received CTAR in addition to standard care. The effect outcome of the economic evaluation was quality-adjusted life years (QALY), estimated using the EQ-5D-5L questionnaire. Individual resource consumption of each citizen was determined based on the use of home care, home nursing care, physio- and occupational therapy, dietitian guidance, and hospital admissions. The incremental costs and QALYs between the intervention group (CTAR in addition to standard care) and standard care group were estimated using regression analysis, and sensitivity analyses were performed to investigate the robustness of the results.

Results

The base case analysis showed that the intervention group was dominant compared to the standard care group, with a decrease in incremental costs of £542.38 and an increase in incremental QALYs of 0.0118. All sensitivity analyses demonstrated similar findings as the base case analysis, supporting the robustness of the results.

Conclusion

This study found that the intervention group was the dominant alternative, hence being more effective and cost-saving, compared to the standard care group in a Danish municipality perspective with a three-month time horizon. This study adds to the scarce evidence on the cost-effectiveness of CTAR in a Danish clinical setting, but further studies should focus on estimating long-term cost-effectiveness.

Efficacy and safety of oropharyngeal muscle strength training on poststroke oropharyngeal dysphagia: a systematic review and meta-analysis

OBJECTIVES

To investigate how oropharyngeal muscle strength training affected the safety and performance of swallowing in patients with poststroke oropharyngeal dysphagia.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Cochrane Central Register of Controlled of Trials, Web of Science, PubMed, Embase databases and ClinicalTrials.gov were systematically searched, for publications in English, from database inception to December 2022.

ELIGIBILITY CRITERIA

Studies comparing the effect of oropharyngeal muscle strength training with conventional dysphagia therapy in patients with poststroke. Penetration-Aspiration Scale (PAS) and Functional Oral Intake Scale (FOIS) were assessed as the main outcomes.

DATA EXTRACTION AND SYNTHESIS

Two researchers independently screened the literature, extracted data and evaluated the quality of the included studies, with disagreements resolved by another researcher. The Cochrane risk-of-bias tool was used to assess the risk of bias. Review Manager V.5.3 was employed for the meta-analysis. Random effect models were used for meta-analysis.

RESULTS

Seven studies with 259 participants were included in this meta-analysis. The results showed that oropharyngeal muscle strength training could reduce PAS score compared with conventional dysphagia therapy (mean difference=-0.98, 95% CI -1.34 to -0.62, p<0.0001, I2=28%). The results also showed that oropharyngeal muscle strength training could increase FOIS score (mean difference=1.04, 95% CI 0.55 to 1.54, p<0.0001, I2=0%) and the vertical displacement of the hyoid bone (mean difference=0.20, 95% CI 0.01 to 0.38, p=0.04, I2=0%) compared with conventional dysphagia therapy.

CONCLUSION

In patients with poststroke oropharyngeal dysphagia, oropharyngeal muscle strength training can improve swallowing safety and performance.

PROSPERO REGISTRATION NUMBER

CRD42022302471.

Longitudinal changes in swallowing function after surgery and proactive swallowing therapy for oral cancer

BACKGROUND

This study aimed to describe and explore the longitudinal changes in swallowing function among patients with oral cancer who underwent surgery and proactive swallowing therapy from baseline to 1-year postoperation.

METHODS

We retrospectively studied 118 patients over a 4.5-year duration. Swallowing functional assessment including 10-item Eating Assessment Tool (EAT-10), Functional Oral Intake Scale (FOIS), M. D. Anderson Dysphagia Inventory, and Modified Barium Swallow Impairment Profile (MBSImP™) was performed at baseline, 1-month, 6-month, and 1-year postoperatively.

RESULTS

All swallowing parameters worsened 1-month postoperation. EAT-10, FOIS, and MBSImP™ oral and pharyngeal impairment scores improved significantly compared with 1-month postoperation at 6 months. Other swallowing parameters, except for weight, did not differ significantly from baseline at 6 months. The rate of tube-feeding dependency was 11.5% and 5.6% at 1 and 6 months postoperation, respectively.

CONCLUSIONS

Periodic swallowing functional assessments help delineate the longitudinal changes in swallowing functional outcomes.

Dosages of swallowing exercises in stroke rehabilitation: a systematic review

PURPOSE

To investigate the dosages of swallowing exercises reported in intervention studies on post-stroke dysphagia through systematic review.

METHODS

Five electronic databases were searched from inception until February 2022 with reference tracing of included studies. Studies were included, where adults with post-stroke dysphagia received rehabilitative, behavioural swallowing exercises, pre/post outcomes were reported, and intervention dosage was described in detail, including frequency, intensity, time, and type of exercise. Two reviewers independently screened studies and rated quality using ASHA Levels of Evidence tool. Data was tabulated and narratively described.

RESULTS

54 studies were included with a total 1501 participants. Studies included 28 randomised controlled trials, 8 non-randomised controlled trials, 12 pre/post studies, 3 retrospective case controls and 3 case studies. Results showed inconsistent reporting of intervention dosage, with intensity the least consistently reported dosage component. While swallowing intervention was most commonly provided five times per week for four weeks, there was a wide breadth of type, frequency, intensity and duration of swallowing exercises reported. Dosage under-reporting and variation was particularly observed in "standard care" co-interventions or control groups. Study strengths included following PRISMA guidelines, providing a comprehensive review of swallowing exercise methodology and dosages, and including non-English studies. The limitation was lack of meta-analysis due to the heterogeneity of included studies.

CONCLUSIONS

Dosages of swallowing exercises are inconsistently reported and vary significantly in post-stroke dysphagia studies. Results indicate the need for consistent and comprehensive dosage reporting in dysphagia studies, and for further research into evidence-based principles to optimise swallowing exercise dosages.

SYSTEMATIC REVIEW REGISTRATION NUMBER

131294.

Effects of chin tuck against resistance exercise on post-stroke dysphagia rehabilitation: A systematic review and meta-analysis

Background

Chin tuck against resistance (CTAR) exercise was introduced to substitute for the commonly used Shaker exercise for dysphagia rehabilitation. The effects of CTAR exercise in stroke survivors needs to be validated.

Objective

To investigate the effects of Chin tuck against resistance (CTAR) exercise on the swallowing function and psychological condition in stroke survivors compared to no exercise intervention and the Shaker exercise.

Materials and methods

The Cochrane Library, PubMed, Web of Science, EMBASE, CINAHL and four Chinese databases were searched for randomized controlled trails (RCTs) and quasi-RCTs from inception to February 2022.

Results

After screened and assessed the methodological quality of the studies, nine studies with 548 stroke survivors were included in the systematic review. 8 studies were included in the meta-analysis using RevMan 5.4 software. The mean difference (MD) or standardized mean difference (SMD) with 95% confidence intervals (CIs) were calculated. The results revealed that CTAR exercise is effective in improving swallowing safety (MD, -1.43; 95% CI, -1.81 to -1.06; P < 0.0001) and oral intake ability (SMD, -1.82; 95% CI, -3.28 to -0.35; P = 0.01) compared with no exercise intervention, CTAR exercise is superior to Shaker exercise in improving swallowing safety (MD, -0.49; 95% CI, -0.83 to -0.16; P = 0.004). The psychological condition in CTAR group is significant better than the control group (MD, -5.72; 95% CI, -7.39 to -4.05; P < 0.00001) and Shaker group (MD, -2.20; 95% CI, -3.77 to -0.64; P = 0.006).

Conclusions

Our findings support CTAR exercise as a superior therapeutic exercise for post-stroke dysphagia rehabilitation than Shaker exercise. More high-qualities RCTs from larger multicenter are needed to analysis the effects of CTAR exercise in patients with different type and phase of stroke and explore the optimal training dose.

Effects of Craniocervical Flexion on Suprahyoid and Sternocleidomastoid Muscle Activation in Different Exercises

This study aims to investigate the effects of craniocervical flexion (CCF) on the activation of suprahyoid and sternocleidomastoid (SCM) muscles in Shaker and Resistant Jaw Opening (RJO) exercises, and to compare the effects of these two exercises on the same muscles with the Chin Tuck Against Resistance (CTAR) exercise. The study recruited a total of 37 healthy participants (20 female and 17 male, mean age: 27.45 ± 7.32 years). All participants received craniocervical flexion training with the biofeedback pressure unit (Stabilizer™, Chattanooga Group Inc. USA). Shaker, Shaker with CCF, RJO, RJO with CCF and CTAR exercises were performed and surface electromyographic (sEMG) activations of the suprahyoid and SCM muscles were recorded. In addition, the maximum sEMG activations of suprahyoid and SCM muscles were recorded for the normalization procedure. CCF increased the effect of Shaker exercise on the suprahyoid muscle activation (p < 0.001); but this effect was not seen in RJO exercise (p > 0.05). Suprahyoid muscle activation was lower in Shaker exercise compared to RJO and CTAR exercises (p < 0.016). SCM muscle activation was greater in CTAR exercise compared to Shaker and RJO exercises (p < 0.016). The addition of CCF to the Shaker and RJOE exercises did not affect the ranking among the three exercises for both the suprahyoid and SCM muscles. The result of this study suggest that integration of CCF movement to the Shaker exercise would have a greater therapeutic effect. In addition, RJO exercise can be included in the rehabilitation program as an alternate to CTAR exercise.

Dysphagia in Intensive Care Evaluation (DICE): An International Cross-Sectional Survey

Dysphagia occurs commonly in the intensive care unit (ICU). Despite the clinical relevance, there is little worldwide research on prevention, assessment, evaluation, and/or treatment of dysphagia for ICU patients. We aimed to gain insight into this international knowledge gap. We conducted a multi-center, international online cross-sectional survey of adult ICUs. Local survey distribution champions were recruited through professional and personal networks. The survey was administered from November 2017 to June 2019 with three emails and a final telephone reminder. Responses were received from 746 ICUs (26 countries). In patients intubated > 48 h, 17% expected a > 50% chance that dysphagia would develop. This proportion increased to 43% in patients intubated > 7 days, and to 52% in tracheotomized patients. Speech-language pathologist (SLP) consultation was available in 66% of ICUs, only 4% reported a dedicated SLP. Although 66% considered a routine post-extubation dysphagia protocol important, most (67%) did not have a protocol. Few ICUs routinely assessed for dysphagia after 48 h of intubation (30%) or tracheostomy (41%). A large proportion (46%) used water swallow screening tests to determine aspiration, few (8%) used instrumental assessments (i.e., flexible endoscopic evaluation of swallowing). Swallowing exercises were used for dysphagia management by 30% of ICUs. There seems to be limited awareness among ICU practitioners that patients are at risk of dysphagia, particularly as ventilation persists, protocols, routine assessment, and instrumental assessments are generally not used. We recommend the development of a research agenda to increase the quality of evidence and ameliorate the implementation of evidence-based dysphagia protocols by dedicated SLPs.

Home-based intensive treatment of chronic radiation-associated dysphagia in head and neck cancer survivors (HIT-CRAD trial)

Background

Chronic radiation-associated dysphagia (C-RAD) is considered to be one of the most severe functional impairments in head and neck cancer survivors treated with radiation (RT) or chemoradiation (CRT). Given the major impact of these late toxicities on patients’ health and quality of life, there is a strong need for evidence-based dysphagia management. Although studies report the benefit of strengthening exercises, transference of changes in muscle strength to changes in swallowing function often remains limited. Therefore, combining isolated strengthening exercises with functional training in patients with C-RAD may lead to greater functional gains.

Methods

This 3-arm multicenter randomized trial aims to compare the efficacy and possible detraining effects of mere strengthening exercises (group 1) with a combination of strengthening exercises and functional swallowing therapy (group 2) and non-invasive brain stimulation added to that combination (group 3) in 105 patients with C-RAD. Patients will be evaluated before and during therapy and 4 weeks after the last therapy session by means of swallowing-related and strength measures and quality of life questionnaires.

Discussion

Overall, this innovative RCT is expected to provide new insights into the rehabilitation of C-RAD to optimize post-treatment swallowing function.

Trial registration

International Standard Randomized Controlled Trials Number (ISRCTN) registry ID ISRCTN57028065. Registration was accepted on 15 July 2021.

Advances in the Treatment of Dysphagia in Neurological Disorders: A Review of Current Evidence and Future Considerations

Dysphagia, which refers to difficult and/or disordered swallowing, is a common problem associated with various neurological diseases such as stroke, motor neuron diseases and neurodegenerative diseases. Traditionally, dysphagia treatments are either compensatory, which includes modifications of bolus texture or feeding posture, or rehabilitative, which includes behavioral exercises and sensory stimulation. Despite being widely adopted in clinical practice, recent views have challenged the clinical efficacy of these treatments due to the low level of evidence supported by mainly non-controlled studies. As such, with advancements in technology and scientific research methods, recent times have seen a surge in the development of novel dysphagia treatments and an increasing number of robust randomized controlled clinical trials. In this review, we will review the clinical evidence of several newly introduced treatments for dysphagia in the last two decades, including rehabilitative exercises, biofeedback, pharmacological treatments, neuromodulation treatments and soft robotics. Despite the recent improvements in the quality of evidence for the efficacy of dysphagia treatments, several critical issues, including heterogeneity in treatment regimens, long-term treatment effects, underlying mechanisms of some neuromodulation treatments, and the effects of these techniques in non-stroke dysphagia, remain to be addressed in future clinical trials.

The Effects of Tongue Elevation using a Weighted Plastic Bottle on the Tongue Pressure and Activity of Suprahyoid Muscles

BACKGROUND

A rise in tongue pressure coincides with an increase in the suprahyoid muscles activity.

OBJECTIVES

The aim was to investigate the effects of holding a weighted plastic bottle on tongue pressure and the suprahyoid muscles activity.

METHODS

Eighteen participants (8 men and 10 women; mean age 42 ± 16 years) participated in this study. All participants had no history of speech, language, hearing, or swallowing disorders and no tooth loss, and they did not require dentures. Healthy participants held gauzes connected with a plastic bottle with increasing resistive loads of 0 g, 250 g, 500 g, and 750 g, between their palate and tongue. The maximum tongue pressure and average tongue pressure were measured during a 5-second hold. The average tongue pressure was defined as the mean tongue-pressure data in each task. The suprahyoid muscles activity was measured using the electromyogram (EMG). The root mean square of the EMG signals measured while lifting different loads and while performing the head lifting exercises were compared. All variables were examined using the Friedman's test and Wilcoxon signed-rank test.

RESULTS

The maximum tongue pressure (p < .05) and average tongue pressure values (p < .05) increased gradually in the anterior-median region with increasing resistive loads, and the root mean square amplitudes for 250 g, 500 g, and 750 g were not significant compared to head lifting exercises.

CONCLUSION

These results indicated that Plastic bottle holding could be a potential strength-training tool for the tongue and the suprahyoid muscles.

Chin tuck against resistance exercise with feedback to improve swallowing, eating and drinking in frail older people admitted to hospital with pneumonia: protocol for a feasibility randomised controlled study

BACKGROUND

Swallowing difficulties (dysphagia) and community-acquired pneumonia are common in frail older people and maybe addressed through targeted training of the anterior neck musculature that affects the swallow. We have developed a swallowing exercise rehabilitation intervention (CTAR-SwiFt) by adapting a previously established swallowing exercise to ensure patient safety and ease of execution in the frail elderly population. The CTAR-SwiFt intervention consists of a feedback-enabled exercise ball that can be squeezed under the chin, with real-time feedback provided via a mobile application. The aim of this study is to evaluate the feasibility of assessing the effectiveness of the CTAR-SwiFt intervention in reducing dysphagia and community-acquired pneumonia, prior to a larger-scale multi-centre randomised controlled trial.

METHODS

We will recruit 60 medically stable patients over the age of 75 years who have been admitted with a diagnosis of pneumonia to the acute frailty wards at two participating hospitals in the UK. Study participants will be randomised into one of three groups: standard care, low intensity (once daily) CTAR-SwiFt exercise or high intensity (twice daily) CTAR-SwiFt exercises. The intervention period will last for 12 weeks, the final follow-up assessment will be conducted at 24 weeks. We will assess the feasibility outcomes, including rates of participant recruitment and retention, compliance with the exercise regime and adverse incidents. Additionally, we will assess the usability and acceptability of the intervention device and the performance of different clinical outcome measures (e.g. chin tuck strength, Functional Oral Intake Scale, SWAL-QOL, EQ-5D and swallow speed). A sub-sample of study participants will complete videofluoroscopic assessments of swallowing function before and after the intervention to evaluate the physiological changes (e.g. bolus flow rates, laryngeal elevation, base-of-tongue retraction).

CONCLUSIONS

By improving the ability to swallow, using our chin tuck exercise intervention, in frail older patients admitted to hospital with pneumonia, it is anticipated that patients' oral intake will improve. It is suggested that this will further impact clinical, patient and healthcare economic outcomes, i.e. reduce the need for supplemental feeding, improve patient satisfaction with oral intake and swallowing-related quality of life, decrease the occurrence of chest infections and reduce hospital admissions and related healthcare costs.

TRIAL REGISTRATION

ISRCTN, ISRCTN12813363 . Registered on 20 January 2020.

Possible Rehabilitation Procedures to Treat Sarcopenic Dysphagia

Sarcopenic dysphagia requires the presence of both dysphagia and generalized sarcopenia. The causes of dysphagia, except for sarcopenia, are excluded. The treatment for sarcopenic dysphagia includes resistance training along with nutritional support; however, whether rehabilitation procedures are useful remains unclear. In this narrative review, we present possible rehabilitation procedures as a resistance training for managing sarcopenic dysphagia, including Shaker exercise, Mendelsohn maneuver, tongue-hold swallow exercise, jaw-opening exercise, swallow resistance exercise, lingual exercise, expiratory muscle strength training, neuromuscular electrical stimulation, and repetitive peripheral magnetic stimulation. We hope that some procedures mentioned in this article or new methods will be effective to treat sarcopenic dysphagia.

Considerations for speech and language therapy management of dysphagia in patients who are critically ill with COVID-19: a single centre case series

Background/Aims

Patients treated with intubation and tracheostomy for COVID-19 infection are at risk of increased incidence of laryngeal injury, dysphagia and dysphonia. Because of the novelty of the SARS-CoV-2 virus, little is known about the type of dysphagia patients experience as a result of infection and critical illness. The aim of this case series report was to progress understanding of COVID-19 and dysphagia following admission to an intensive care unit and to guide speech and language therapy clinical practice in the ongoing pandemic.

Methods

A retrospective case review was conducted of all patients at Imperial College Healthcare NHS Trust, London who underwent a tracheostomy because of COVID-19 and received an instrumental assessment of swallowing in the early stages of the pandemic.

Results

A total of 11 patients were identified, and descriptive statistics were used to present demographic data, with a narrative account of their dysphagia profile used to describe presentation. Causes and presentation of dysphagia were heterogenous, with each patient requiring individualised clinical management to maximise outcome. A positive trend was seen in terms of recovery trajectory and progressing to oral intake.

Conclusions

This study reports on early experience of the presentation of dysphagia in patients with COVID-19 and demonstrates the value of instrumental assessment. It indicates the need for further research to consolidate knowledge and guide clinical practice.

The effect of the Shaker head‐lift exercise on swallowing function following treatment for head and neck cancer: Results from a randomized, controlled trial with videofluoroscopic evaluation

Background

Dysphagia is common following treatment for head and neck cancer (HNC) and intervention to improve swallowing function is warranted. This study aimed to evaluate the efficacy of the Shaker head‐lift exercise (HLE) to improve dysphagia in HNC patients.

Methods

Patients treated for HNC with radiochemotherapy and with subsequent dysphagia were randomly assigned to intervention (HLE, n = 25) and control (standard dysphagia management, n = 27) groups. Videofluoroscopic evaluation of penetration‐aspiration, initiation, residue, movement of selected structures, and self‐perceived swallowing function, before and after 8 weeks of treatment, were compared.

Results

Although adherence to training was high, no statistically significant differences in objectively measured swallowing function between the groups or within‐group changes were found. Self‐perceived swallowing function improved in the intervention group.

Conclusions

In this HNC population, neither HLE nor standard dysphagia management improved objectively measured swallowing function as evaluated after 8 weeks. Future research focusing on finding effective interventions for dysphagia is warranted.

Swallowing rehabilitation following spinal injury: A case series

Context/objective: Swallowing difficulties (dysphagia) are well recognized after spinal injury. There are no published rehabilitation efficacy studies to date. This study explored viability and outcomes of swallowing rehabilitation programs for four patients with persisting dysphagia.Design: Prospective, quantitative experimental longitudinal case series.Setting: Spinal rehabilitation unit or patients' homes.Interventions: Four patients engaged in a 6-week (3×weekly) individualized progressive rehabilitation program.Outcome measures: Objective videofluoroscopic measures of timing and displacement and a validated self-reported questionnaire - the Eating Assessment Tool (EAT-10) were taken pre-therapy, immediately post-therapy and EAT-10 was repeated at 3 months. Feeling and fatigue scale scores were taken before and after each therapy session.Results: Patients (63, 67 yr, 67 yr, 76 yr; 3 male) had varying spinal diagnoses (2 traumatic, all involving the C-spine) and length of dysphagia (6 weeks, 6 weeks, 12 weeks, 10 yr). Common physiological impairments across all patients were: reduced maximum hyoid displacement, reduced pharyngeal constriction and reduced pharyngoesophageal segment maximum opening. Therapy programs were well received with 100% compliance. Participants made quantitative improvements in their videofluoroscopic measures of timing and displacement. Three out of four participants were able to have their percutaneous endoscopic gastrostomies (PEG) removed. EAT-10 scores significantly improved for all patients (P < .001). Poor upper limb function and restricted neck flexion prohibited some exercises.Conclusions: For many patients following spinal injury, dysphagia resolves during the acute phase of post-surgery recovery. For some, significant pharyngeal impairments persist. This case series demonstrates potential to regain functional swallowing following a 6-week tailored rehabilitation program. High-quality research exploring efficacy of rehabilitation programs are warranted.

The effects of neuromuscular joint facilitation treatment using neck patterns on the acoustic analysis of swallowing sounds in healthy adults

[Purpose] We aimed to investigate the changes in the swallowing sounds of healthy adults during neuromuscular joint facilitation treatment using neck patterns. [Participants and Methods] A total of 20 healthy adults (10 males and 10 females; mean age, 29.2 ± 6.3 years) swallowed 10 mL of water four times under three conditions (after the neuromuscular joint facilitation neck-flexion resistance pattern, after the Shaker-type exercise, and during relaxed sitting without prior exercise [control]), randomly ordered with an interval greater than 3 days. Swallowing sounds for each water swallow were recorded using cervical auscultation. [Results] The mean amplitude of swallowing sound intensity and the mean spectral frequency were significantly higher after the neuromuscular joint facilitation neck-flexion resistance pattern and the Shaker-type exercise, in comparison with those in the control group. [Conclusion] Neuromuscular joint facilitation training with the neck-flexion resistance pattern influenced swallowing sounds to the same degree as the Shaker-type exercise, implying that this resistance pattern may enhance suprahyoid muscle contraction.

Impact of umbilical cord arterial pH, gestational age, and birth weight on neurodevelopmental outcomes for preterm neonates

Background

The aim of this study was to determine the impact of umbilical cord arterial pH, gestational age, and birth weight on neurodevelopmental outcomes for preterm neonates.

Methods

We examined 112 neonates. Inclusion criteria were: Saturations greater than 88%, and heart rates between 100–205 beats per minute.

Measurements

We assessed several neurodevelopmental factors as part of the Brazelton Neonatal Behavioral Assessment Scale (NBAS), 4th edition, such as asymmetric tonic neck reflex (ATNR), motor maturity, response to sensory stimuli, habituation, and state regulation. Initial assessment parameters such as APGAR score and umbilical cord arterial pH were used to assess neonates.

Results

We found a strong correlation between the presence of the sucking reflex and umbilical cord arterial pH (r = 0.32; p = 0.018981). Umbilical cord arterial pH was also correlated with the presence of asymmetric tonic neck reflex (r = 0.27; p = 0.047124), cost of attention (r = 0.31; p = 0.025381) and general motor maturity (r = 0.34; p = 0.011741).

Conclusions

We found that the sucking reflex may be affected in infants with low umbilical cord arterial pH values. Practitioners and parents can use the NBAS to help determine neurodevelopmental factors and outcomes in preterm infants, possibly leading to safer and more effective feeding practices and interventions.

Review of prophylactic swallowing interventions for head and neck cancer

BACKGROUND

Head and neck cancer treatment destroys nerves and/or organs associated with swallowing. Previous studies have investigated the efficacy of exercises for muscles used in swallowing before treatment in reducing disuse atrophy and delaying the occurrence of muscle fibrosis. However, the rehabilitation effects of training and the optimal intervention strategy are unknown.

OBJECTIVES

To establish evidence for the efficacy of prophylactic swallowing interventions in reducing aspiration and restoring oral intake in patients with head and neck cancer with dysphagia.

METHODS

We searched electronic databases (PubMed, Embase, Cochrane and MEDLINE) for studies published up to June 2021 reporting outcomes following prophylactic swallowing interventions in patients with head and neck cancer with dysphagia and the related influencing factors. The methodological quality of the literature was assessed using the Joanna Briggs Institute appraisal tools.

RESULTS

The search identified 1468 articles, and 13 studies were eventually included. Four categories involving 12 different swallowing interventions were classified. Regarding the descriptive analysis of the rehabilitation effects across all studies, in terms of oropharyngeal safety, five studies showed that swallowing interventions reduced the risk of aspiration, penetration or residue. In terms of oral intake and tube feeding dependence, four studies demonstrated reduced time to return to oral intake in the intervention group compared with the control group. In terms of intervention adherence, three studies showed that speech-language pathologist- and nurse-supervised training was a potential promoter of adherence, and five studies showed that the negative factors affecting adherence included pain, fatigue, forgetting, smoking, decreased exercise motivation, side effects of radiotherapy and distance to the rehabilitation site.

CONCLUSIONS

Preventive swallowing interventions may be effective at reducing aspiration, improving swallowing function, and restoring oral intake. However, due to the lack of standardization and consistency of interventions and measurement results, which prevented the production of a best practice guide, future rigorous methodological trials will be needed to determine the most effective interventions for maximizing exercise adherence over the long term.

Using Ultrasound to Document the Effects of Expiratory Muscle Strength Training (EMST) on the Geniohyoid Muscle

Expiratory muscle strength training (EMST) is an exercise program designed to strengthen the muscles of expiration by increasing expiratory load during breathing exercises using either resistive or pressure threshold devices. Previous research has shown that EMST may increase submental suprahyoid muscle activity as measured with surface electromyography. The impact of EMST on submental muscles is of interest to those who treat dysphagia. The purpose of this study was to determine whether the cross-sectional area of the geniohyoid muscle changes as observed with ultrasound during a 5-week EMST program performed at 75% of maximum expiratory strength using the EMST150 device in healthy adults. Ten healthy adults participated in the 5-week program. Maximum expiratory pressure (MEP) and cross-sectional area of the geniohyoid muscle were measured weekly. Geniohyoid cross-sectional area was measured from ultrasound images recorded in the coronal plane. Repeated Measures ANOVA was used to determine whether there were significant changes among the dependent variables over the study period. Both MEP and geniohyoid area increased significantly in response to a 5-week program of EMST. EMST in healthy adults is effective at strengthening the geniohyoid muscle as reflected by significantly increased cross-sectional area measured with B-mode ultrasound. This is the first study to document weekly change in muscle morphology as a result of EMST. Increasing geniohyoid muscle mass and consequent strength through a program of EMST may be beneficial for persons with pharyngeal stage dysphagia resulting from reduced hyolaryngeal elevation, reduced laryngeal closure, or reduced UES opening.

Chin tuck against resistance exercise for dysphagia rehabilitation: A systematic review

BACKGROUND

Chin tuck against resistance (CTAR) exercise has been recently reported to be a new therapeutic exercise method that can help improve swallowing function in patients with dysphagia. However, due to the differences in exercise protocols, methods and the tools used across studies of CTAR exercise, an overall systematic review of these studies is necessary.

OBJECTIVE

The present study investigated the exercise protocols, methods and tools used in various studies of CTAR exercise and summarised their findings.

METHODS

We searched for studies related to CTAR exercise using electronic databases and selected nine articles for review. The articles were categorised on the basis of four criteria: study design and quality, training protocol, outcome measures and clinical effect.

RESULTS

Four articles reported that CTAR exercise not only helped activate the suprahyoid muscle in healthy adults, but also activated the sternocleidomastoid muscle less than Shaker exercise. In addition, five articles reported that CTAR exercise was effective in improving swallowing function and oral diet stage in the pharyngeal phase, including reduction of airway aspiration in patients with dysphagia after stroke.

CONCLUSIONS

CTAR exercise more selectively activates the suprahyoid muscle and is an effective therapeutic exercise for improving swallowing function in patients with dysphagia. Because it is less strenuous than Shaker exercise, it requires less physical burden and effort, allowing greater compliance.

Isolated Dysphagia in a Patient with Medial Medullary Infarction - Effects of Evidence-Based Dysphagia Therapy: A Case Report

Medial medullary infarction (MMI) is a vascular occlusion in the medulla oblongata leading to certain constellations of neurological symptoms and seriously affecting the patient. Effective evidence-based treatment of severe dysphagia as sole symptom of MMI has not yet been reported. This case study aims to report successful effects of evidence-based therapy based on findings of dysphagia symptoms and pathophysiology of swallowing by flexible endoscopic evaluation of swallowing (FEES) in severe isolated dysphagia after MMI. FEES was performed to evaluate swallowing pathophysiology and dysphagia symptoms in a 57-year-old male with severe dysphagia after MMI. On the basis of FEES findings, simple and high-frequent evidence-based exercises for improvement of swallowing were implemented: thermal stimulation of faucial arches, Jaw Opening Exercise, and Jaw Opening Against Resistance. After 7 weeks of high-frequent evidence-based therapy and regular FEES evaluation the patient was set on full oral diet with no evidence of aspiration risk. In a first case report of isolated dysphagia in MMI our case illustrates that high-frequent evidence-based dysphagia therapy in combination with FEES as the method to evaluate and monitor swallowing pathophysiology can lead to successful and quick rehabilitation of severely affected dysphagic patients.

Submandibular Push Exercise Using Visual Feedback from a Pressure Sensor in Patients with Swallowing Difficulties: A Pilot Study

Objectives: We aimed to determine the usefulness and effectiveness of a submandibular push exercise with visual feedback from a pressure sensor in patients with dysphagia through continuous exercise sessions. Methods: Twelve patients with dysphagia of various etiologies were included. A total of five exercise sessions (every 3 or 4 days) over three weeks were conducted. During the submandibular push exercise, patients were instructed to maintain a maximum force for 3 s, repeated for 1 min to measure the number of exercises, the maximum pressure, and the area of the pressure-time graph. We statistically compared the values of each exercise trial. Results: Among the 12 patients, eight completed the exercise sessions. As the number of exercise trials increased, the maximum pressure and the area in the pressure-time graph showed a significant increase compared to the previous attempt (p < 0.05). The maximum pressure and the area of the pressure-time graph improved from the first to the fourth session (p < 0.05). The values were maintained after the fourth session, and there was no significant difference between the fourth and the fifth exercise (p > 0.05). There was no significant difference between successful and non-successful groups, except for the Modified Barthel Index (p < 0.05). Conclusion: Through repetitive exercise training, the submandibular push exercise using visual feedback from a pressure sensor can be applied as an exercise method to strengthen swallowing related muscles, such as the suprahyoid and infrahyoid muscles. However, additional studies including more patients and a long-term study period are warranted to evaluate the effects of the exercise for improvement of dysphagia.

Comparison of three different types of exercises for selective contractions of supra- and infrahyoid muscles

Several exercise methods, such as the Shaker exercise, tongue press exercise, chin tuck against resistance (CTAR) exercise, and submandibular push exercise, have been introduced to strengthen the muscles involved in swallowing. In this study, we compared the effectiveness of the CTAR, submandibular push, and Shaker exercises for the induction of selective supra- and infrahyoid muscle contractions using surface electromyography (EMG). This study is a prospective non-randomized controlled study. Twenty-five healthy subjects and 20 patients experiencing swallowing difficulty were enrolled. During the three different types of exercises, the root mean square (RMS) values of the sternocleidomastoid (SCM), suprahyoid (anterior belly of the digastric and mylohyoid muscles), and infrahyoid (sternothyroid and thyrohyoid muscles) muscles were analyzed using surface EMG. Differences in the activity of swallowing muscles among the three different exercises were analyzed using one-way repeated measured analysis of variance. In terms of both the maximum and mean RMS values of the suprahyoid muscle, the submandibular push exercise showed a larger RMS value than the CTAR and Shaker exercises in healthy subjects (p < 0.05). In terms of both the maximum and mean RMS values of the suprahyoid muscle, the Shaker exercise and submandibular push exercise showed a larger RMS value than the CTAR exercise in patients with swallowing difficulty (p < 0.05). The submandibular push exercise may be effective as a swallowing muscle exercise owing to its superiority in inducing selective contractions of the supra- and infrahyoid muscles. The CTAR and Shaker exercises are also effective in this regard.

Variations in Hyoid Kinematics Across Liquid Consistencies in Healthy Swallowing

Purpose Judgments regarding hyoid movement are frequently included in evaluations of swallowing. However, the literature lacks reference values for measures of hyoid kinematics in healthy swallowing. This study explores hyoid movement across the continuum from thin to extremely thick liquids. Method Participants were 39 healthy adults under the age of 60 years (19 men) who underwent videofluoroscopy involving three sips each of 20% w/v thin barium and six sips each of slightly, mildly, moderately, and extremely thick barium. Half of the thickened stimuli were prepared using xanthan gum; and half, with a starch-based thickener. Sip volume was derived from pre- and post-sip cup weights. Hyoid position was tracked frame-by-frame relative to the anterior-inferior corner of C4. Measures of peak hyoid position (along the XY axis) were normalized to a C2-C4 scalar, and measures of time-to-peak position, speed, and time-to-peak speed were derived. As a first step, Spearman's correlations confirmed the influence of sip volume on these hyoid measures. Linear mixed-effects models then explored the effects of stimulus, sip volume, and task repetition on the dependent variables. Results The data set comprised 975 swallows with available hyoid tracking data. Sip volume was correlated with peak hyoid XY position (rs = .15, p < .01), time-to-peak position (rs = -.15, p < .05), and speed (rs = .13, p < .01). No significant differences in hyoid kinematics were found across stimuli. Conclusion Measures of hyoid movement in healthy swallowing remain stable across the range from thin to extremely thick liquids with no systematic alterations in hyoid position or kinematics.

Best Practice Recommendations for Stroke Patients with Dysphagia: A Delphi-Based Consensus Study of Experts in Turkey-Part II: Rehabilitation

Dysphagia is one of the most common and important complications of stroke. It is an independent marker of poor outcome following acute stroke and it continues to be effective for many years. This consensus-based guideline is not only a good address to clinical questions in practice for the clinical management of dysphagia including management, diagnosis, follow-up, and rehabilitation methods, but also includes detailed algorithms for these topics. The recommendation paper has been written by a multidisciplinary team and offers 117 recommendations for stroke patients with dysphagia. While focusing on management principles, diagnosis, and follow-up in the 1st part (45 items), rehabilitation details were evaluated in the 2nd part (72 items).

Clinical observation on acupoint massage plus Vitalstim electrical stimulation for deglutition disorder after stroke

Objective

Methods

Results

Conclusion

Effects of resistive jaw opening exercise in stroke patients with dysphagia: A double- blind, randomized controlled study

BACKGROUND

The resistive jaw opening exercise (RJOE) was suggested as a potential remedial treatment for patients with dysphagia. However, clinical evidence is insufficient.

OBJECTIVE

To investigate the effect of RJOE on hyoid bone movement, aspiration, and oral intake level in stroke patients with dysphagia.

METHODS

Forty stroke patients with dysphagia were randomly allocated into either the experimental group (n= 20) or placebo group (n= 20). The experimental group performed RJOE using a portable device, while the placebo group performed RJOE using a sham device with fewer loads. Intervention was conducted 5 times a week for 4 weeks. Hyoid bone movement was analyzed by two-dimensional analysis of anterior and superior motion based on a videofluoroscopic swallowing study. Aspiration was assessed using a penetration-aspiration scale (PAS), and oral intake level was assessed using the functional oral intake scale (FOIS).

RESULTS

Both groups showed statistically significant differences in hyoid movement, PAS, and FOIS scale (p< 0.05). However, after the intervention, there was no significant difference between the two groups except for the liquid type of PAS. Effect sizes (Cohen's d) were 0.9 and 0.7, 0.6 and 0.6, and 1.1 for the anterior and superior movement of the hyoid bone, semisolid and liquid type of PAS, and FOIS scale respectively.

CONCLUSIONS

This study suggests that RJOE helps in hyoid movement, aspiration reduction, and oral intake in patients with dysphagia after stroke.

Effect of Dysphagia Rehabilitation Using Kinesiology Taping on Oropharyngeal Muscle Hypertrophy in Post-Stroke Patients: A Double Blind Randomized Placebo-Controlled Trial

Background: It has recently been shown that suprahyoid muscle exercise using kinesiology taping (KT) increases the activation of the suprahyoid muscle in healthy adults, suggesting a potential therapeutic clinical exercise for dysphagia rehabilitation. This study investigated the effect of dysphagia rehabilitation using KT in stroke patients with dysphagia. Methods: Thirty subjects in South Korea were enrolled in this prospective placebo-controlled double-blind study. Participants were randomly assigned to the experimental and sham groups. In the experimental group, the tape was attached to the hyolaryngeal complex, pulled downward with approximately 70% tension, and then attached to the sternum and the clavicle bilaterally. In the sham group, the tape was applied similarly but without the tension. Both groups performed voluntary swallowing 50 times (10 times swallowing per set, times 5 sets) a day for 4 weeks with KT applied. Outcome measures were assessed using portable ultrasound equipment. The parameter measured was the change in thickness of the tongue muscle, mylohyoid muscle, and the anterior belly of the digastric muscle. Results: The experimental group showed statistically significant changes in the thickness of the tongue muscle, mylohyoid muscle, and anterior belly of the digastric muscle than the sham group (p = 0.007, 0.002, and 0.001). Conclusion: Dysphagia rehabilitation using KT is a technique that may promote oropharyngeal muscle thickness in patients with dysphagia after stroke.

Effects of Physical Rehabilitation and Nutritional Intake Management on Improvement in Tongue Strength in Sarcopenic Patients

The study aimed to investigate the impact of physical intervention and the amount of nutritional intake on the increase in tongue strength and swallowing function in older adults with sarcopenia. From November 2018 and May 2019, older patients with sarcopenia who were admitted for rehabilitation were analyzed. The intervention employed in the study was the usual physical and occupational therapy for two months. Tongue strength was measured before and after two months of treatment. Data on tongue strength, the amount of energy and protein intake, intervention time, and swallowing function were examined. A total of 95 sarcopenic older patients were included (mean age 83.4 ± 6.5 years). The mean tongue strength after the intervention was significantly increased from 25.4 ± 8.9 kPa to 30.5 ± 7.6 kPa as a result of the treatment (p < 0.001). After adjusting the confounding factors in the multivariable models, an energy intake of ≥30 kcal/kg/day and a protein intake of ≥1.2 g/kg/day based on the ideal body weight had a significant impact on the increase in tongue strength after the treatment (p = 0.011 and p = 0.020, respectively). Swallowing function assessed using the Mann Assessment of Swallowing Ability was significantly increased after the treatment (mean difference between pairs: 1.12 [0.53-1.70]; p < 0.001). Physical intervention and strict nutritional management for older inpatients with sarcopenia could be effective to improve tongue strength and swallowing function.

How Closely do Machine Ratings of Duration of UES Opening During Videofluoroscopy Approximate Clinician Ratings Using Temporal Kinematic Analyses and the MBSImP?

Clinicians evaluate swallow kinematic events by analyzing videofluoroscopy (VF) images for dysphagia management. The duration of upper esophageal sphincter opening (DUESO) is one important temporal swallow event, because reduced DUESO can result in pharyngeal residue and penetration/aspiration. VF is frequently used for evaluating swallowing but exposes patients to radiation and is not always feasible/readily available. High resolution cervical auscultation (HRCA) is a non-invasive, sensor-based dysphagia screening method that uses signal processing and machine learning to characterize swallowing. We investigated HRCA's ability to annotate DUESO and predict Modified Barium Swallow Impairment Profile (MBSImP) scores (component #14). We hypothesized that HRCA and machine learning techniques would detect DUESO with similar accuracy as human judges. Trained judges completed temporal kinematic measurements of DUESO on 719 swallows (116 patients) and 50 swallows (15 age-matched healthy adults). An MBSImP certified clinician completed MBSImP ratings on 100 swallows. A multi-layer convolutional recurrent neural network (CRNN) using HRCA signal features for input was used to detect DUESO. Generalized estimating equations models were used to determine statistically significant HRCA signal features for predicting DUESO MBSImP scores. A support vector machine (SVM) classifier and a leave-one-out procedure was used to predict DUESO MBSImP scores. The CRNN detected UES opening within a 3-frame tolerance for 82.6% of patient and 86% of healthy swallows and UES closure for 72.3% of patient and 64% of healthy swallows. The SVM classifier predicted DUESO MBSImP scores with 85.7% accuracy. This study provides evidence of HRCA's feasibility in detecting DUESO without VF images.

Comparison of 2 types of therapeutic exercise: jaw opening exercise and head lift exercise for dysphagic stroke: A pilot study

The aim of this study was to investigate the effect of the jaw opening exercise (JOE) on the thickness of the suprahyoid muscle and hyoid bone movement compared with the head lift exercise (HLE) in patients with dysphagia after strokeThis study recruited 30 patients with dysphagia after stroke. The JOE group performed a JOE using a resistance bar. The HLE group performed the traditional HLE. The total intervention duration was 6 weeks. We measured the thickness of the digastric and mylohyoid muscles using ultrasound. Two-dimensional motion analysis of the hyoid bone was performed using Image J software. The Borg rating of the perceived exertion scale was used to assess the intensity level of physical activity during the 2 exercises.Both groups showed a significant increase in the thickness of the digastric and mylohyoid muscles (P < .05). Hyoid bone motion was significantly increased in the anterior and superior movement in both groups (P < .05). After the intervention, there was no significant difference between the 2 groups. The Borg rating of perceived exertion scale for the JOE group was significantly lower than that of the HLE group (P < .05).In conclusion, this study demonstrated that the JOE and the HLE had similar effects with respect to increasing suprahyoid muscle thickness and improving hyoid bone movement. However, the JOE required less perceived exertion than the HLE.

Effect of the submandibular push exercise using visual feedback from pressure sensor: an electromyography study

We developed a new exercise method called the submandibular push exercise that can strengthen the suprahyoid muscle by inducing only the motion of the hyoid bone without neck flexion. In this study, we aimed to investigate and compare the muscle activity of the suprahyoid and infrahyoid muscles in the course of performing three different swallowing exercises. Twenty healthy participants and fifteen patients with dysphagia were recruited. Each participant consecutively performed three exercises: Shaker, CTAR, and submandibular push exercises. To investigate muscle activation, surface electromyography was performed on the suprahyoid, infrahyoid, and SCM muscles, during the exercises. Root mean square (RMS) was measured. In healthy participants, the submandibular push exercise showed a significantly higher RMS value in the suprahyoid and infrahyoid muscles than the Shaker and CTAR exercises using repeated ANOVA with Tukey's post hoc test (p < 0.05). In patients with dysphagia, the submandibular push and Shaker exercises showed significantly higher RMS value in the suprahyoid and infrahyoid muscles than the CTAR exercise. However, no significant difference was found between the submandibular push and Shaker exercises. In both healthy and patients with dysphagia, the mean RMS values of the SCM muscles during the submandibular push exercise were significantly lower than those during the Shaker exercise using repeated ANOVA with Tukey's post hoc test (p < 0.05). In conclusion, considering the relatively superior selectiveness in suprahyoid and infrahyoid muscle contraction, the submandibular push exercise using visual feedback from pressure sensor could be an efficient supplementary exercise to the conventional swallowing muscle exercises. However, further studies may be necessary to confirm the improvement in swallowing difficulty.

Motor Learning, Neuroplasticity, and Strength and Skill Training: Moving From Compensation to Retraining in Behavioral Management of Dysphagia

Purpose Learning a motor skill and regaining a motor skill after it is lost are key tenets to the field of speech-language pathology. Motor learning and relearning have many theoretical underpinnings that serve as a foundation for our clinical practice. This review article applies selective motor learning theories and principles to feeding and swallowing across the life span. Conclusion In reviewing these theoretical fundamentals, clinical exemplars surrounding the roles of strength, skill, experience, compensation, and retraining, and their influence on motor learning and plasticity in regard to swallowing/feeding skills throughout the life span are discussed.

Influence of the Craniocervical Posture on Tongue Strength and Endurance

Tongue strength has an important role in the swallowing process, and previous research has suggested that tongue position, concerning the craniomandibular region, could affect the oral function. This study aimed to evaluate the strength and endurance of three areas of the tongue in three experimentally induced craniocervical postures. A cross-sectional study with a nonprobabilistic sample of 37 participants (mean age: 3.85 ± 3.64 years; 20 men, 17 women) was performed. Tongue strength and endurance were assessed using a pressure device entitled Iowa Oral Performance Instrument (IOPI), in three different craniocervical positions: neutral head position (NHP), anterior head translation-or forward head position (FHP), and posterior head translation-or retracted head position (RHP). Measurements taken using the IOPI system showed significant differences in tongue strength for the anterior (p = 0.015) and middle areas of the tongue (p = 0.01). Significant differences were observed in analysis of variance (ANOVA) in the FHP (p = 0.02) and NHP (p = 0.009). The results of tongue endurance measurements showed statistically significant differences for FHP (p = 0.001), NHP (p = 0.00), and RHP (p = 0.007). The craniocervical position influences tongue strength, especially in the anterior and middle tongue areas, concerning the posterior, and, in the anterior and neutral head posture, regarding the retracted position. No differences were found in tongue resistance between the various craniocervical positions, but differences were found in resistance between the different tongue areas.

MRI Assessment of Swallow Muscle Activation with the Swallow Exercise Aid and with Conventional Exercises in Healthy Volunteers: An Explorative Biomechanical Study

Swallowing muscle strength exercises are effective in restoring swallowing function. In order to perform the exercises with progressive load, the swallow exercise aid (SEA) was developed. Precise knowledge on which muscles are activated with swallowing exercises, especially with the SEA, is lacking. This knowledge would aid in optimizing the training program to target the relevant swallowing muscles, if necessary. Three healthy volunteers performed the three SEA exercises (chin tuck against resistance, jaw opening against resistance and effortful swallow) and three conventional exercises [conventional effortful swallow (cES), Shaker and Masako] in supine position inside an MRI scanner. Fast muscle functional MRI scans (generating quantitative T2-maps) were made immediately before and after the exercises. Median T2 values at rest and after exercise were compared to identify activated muscles. After the three SEA exercises, the suprahyoid, infrahyoid, sternocleidomastoid, and lateral pterygoid muscles showed significant T2 value increase. After the Shaker, the lateral pterygoid muscles did not show such an increase, but the three other muscle groups did. The cES and Masako caused no significant increase in any of these muscle groups. During conventional (Shaker) exercises, the suprahyoid, infrahyoid, and sternocleidomastoid muscles are activated. During the SEA exercises, the suprahyoid, infrahyoid, sternocleidomastoid, and lateral pterygoid muscles are activated. The findings of this explorative study further support the potential of the SEA to improve swallowing rehabilitation.

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.

Repetitive Peripheral Magnetic Stimulation for Strengthening of the Suprahyoid Muscles: A Randomized Controlled Trial

OBJECTIVE

Head lift exercise is a widely known form of training in the rehabilitation of patients with dysphagia. This study aimed to compare muscular strength reinforcement training of the suprahyoid muscles using repetitive peripheral magnetic stimulation (rPMS) with head lift exercises in a randomized controlled trial.

MATERIALS AND METHODS

Twenty-four healthy adults were randomly assigned to either the magnetic stimulation group (M group) or the head lift exercise group (H group). Both groups underwent training five days a week for two weeks. The primary outcome was the cervical flexor strength, and secondary outcomes were jaw-opening force, tongue pressure, muscle fatigue of the hyoid and laryngeal muscles, displacement of the hyoid bone and opening width of the upper esophageal sphincter (UES) while swallowing 10 mL of liquid, training performance rate, and pain.

RESULTS

No dropouts were reported during the two-week intervention period. Cervical flexor strength significantly increased solely in the M group. Tongue pressure significantly improved in both groups. There were no significant differences in the jaw-opening force, median frequency rate of the anterior belly of the digastric muscle, sternohyoid muscle, sternocleidomastoid muscle, anterior and superior hyoid bone displacement, and UES opening width in both groups.

CONCLUSIONS

Two-week rPMS of the suprahyoid muscles increased the strength of these muscles compared with the head lift exercise during the same period.

Effects of the head lift exercise and neuromuscular electrical stimulation on swallowing muscles activity in healthy older adults: a randomized pilot study

PURPOSE

Swallowing physiology exhibits several changes in advanced ages. The present study aimed to investigate and compare effects of a period of the head lift exercise (HLE) and neuromuscular electrical stimulation (NMES) on swallowing muscles activity in healthy elderly.

PATIENTS AND METHODS

A total of 23 older adults were randomized to either the HLE or NMES group for ten therapy sessions. They received pre- and post-therapy surface electromyography (sEMG) during water swallowing.

RESULTS

For the HLE group, duration of suprahyoid muscles activity was significantly reduced at post-intervention compared to pre-intervention (p=0.036). Moreover after treatments, duration and latency between onset and peak amplitude of suprahyoid muscles activity was significantly shorter in the HLE group compare to the NMES group (respectively, p=0.007 and p=0.003).

CONCLUSION

Our findings suggest that the HLE, against the NMES, may be effective in reducing some aging effects on the suprahyoid muscles activity, especially in elders who demonstrate prolonged duration and latency between onset and peak of the suprahyoid muscles activity during swallowing.

Forehead against Resistance (FAR): Preliminary Findings from A Clinical Alternative to Shaker's Type of Exercise

Background

Reduced UES opening is a well-known risk factor for dysphagia. The Shaker exercise and the CTAR are the widely used intervention strategies to bring about effective UES opening. But there are well-known difficulties with the clinical use of these two exercise regimes. The present study proposes a clinical alternative to Shaker's exercise and CTAR called the forehead against resistance (FAR) and its variants without altering the central principles of these two regimes. The aim of the present study was to investigate the efficacy of FAR and its variants in bringing about UES opening.

Method

The study used a comparative cross-sectional study design, with the nonrandomized convenient sampling that included 27 healthy adults. MBS was carried out in the anterior-posterior and lateral views, while the participants performed FAR and its variants. The UES diameter was measured in the baseline and with the subjects performing FAR maneuver and its variants.

Results

The result revealed that the participants had greater UES opening on FAR and its variant than the baseline swallow. Also, mean values of UES opening were greater for FAR with chin tuck when compared to FAR alone, although there was no significant main effect with exercise.

Conclusion

FAR and its variant could be one of the options for increasing UES opening in individuals with dysphagia.