The Effect of Lingual Resistance Training Interventions on Adult Swallow Function: A Systematic Review

Swallowing Safety after Remote sub-total Esophagectomy: How Important is Tongue Pressure?

The factors related to oropharyngeal dysphagia after remote esophagectomy (greater than five months) remain unclear. This study aimed to assess patient perception of dysphagia, maximum anterior isometric pressure (MAIP), maximum posterior isometric pressure (MPIP), lingual swallowing pressure (LSP) and radiographic physiological components of the oral and pharyngeal phases of swallowing in patients who are post remote sub-total esophagectomy (SE). Patient perception of dysphagia was assessed using the Eating Assessment Tool (EAT-10). MAIP, MPIP, and LSP were measured using the Iowa Oral Performance Instrument. Videofluoroscopy was used to assess the physiologic components of swallowing with the Modified Barium Swallow Impairment Profile (MBSImP) and the Penetration-Aspiration Scale (PAS). Ten patients were included in the study (53.2% male; mean age 54.5 ± 18.0). The mean postoperative time was 30 months (range, 5.0-72 months). Seven patients had elevated EAT-10 scores (> 3). All patients demonstrated impaired oropharyngeal swallowing on at least three MBSImP components (range 3-12) and two patients aspirated (PAS 8). There was a significant difference in MAIP values when comparing patients with normal versus impaired laryngeal elevation and epiglottic movement (p < 0.001). MPIP values were significantly different in patients with normal versus impaired epiglottic movement as well as normal versus elevated PAS scores (p < 0.001). Decreased lingual pressure and physiological changes in swallowing coexist after SE. Our results indicate that the decrease in tongue strength may be one of the factors related to unsafe swallow. The assessment of lingual pressure provides diagnostic value and should be incorporated as part of a comprehensive assessment in this population.

Cortical Activation during Swallowing Exercise Tasks: an fNIRS Pilot Study

This pilot study used functional near-infrared spectroscopy (fNIRS) to examine brain activity in selected regions of the left motor and sensory cortex while doing swallowing-related tasks. Specifically, differences in cortical activation during normal saliva swallows, effortful swallows, and tongue pressing were investigated. Nine healthy, right-handed adults (5 female, 4 male; Age: 22-30 years) were recruited. The tasks included were (1) normal saliva swallowing, (2) effortful saliva swallowing, and (3) lingual pressing against the palate. Each task was completed three times in a block, for a total of five blocks. Blocks were randomized and presented with set time intervals using PsychoPy. Motor activity was highest during effortful swallows, followed by normal swallows, and lingual presses. Activation in the sensory region was not significantly different across tasks; however, effortful swallows elicited the highest mean peak activation. Our findings suggest that fNIRS can be a viable imaging method used to examine differences in cortical activity in the context of swallowing. Its applicability in future dysphagia research should be explored.

Compressed Sensing-Based Cine-MRI for Location of Dysphagia and Swallowing Function assessment in Patients with Head and Neck Cancer: A Comparative Study

Cine magnetic resonance imaging (Cine-MRI) may evaluate the swallowing function and locations of patients with dysphagia, which requires very fast imaging speed. Compressed sensing is a technique that allows for faster MRI imaging by sampling fewer data points and reconstructing the image via optimization techniques, crucial for capturing the rapid movements involved in swallowing. This study aimed to analyze swallowing function and locations in patients with head and neck cancer and healthy individuals using Cine-MRI based on compressed sensing. This comparative study enrolled 36 patients with dysphagia and 10 healthy controls at the Department of Radiology, Yunnan Cancer Hospital between June 2020 and January 2021. Significant correlations were found between primary tumor location and Cine-MRI parameters, and between swallowing function and Cine-MRI parameters. The areas under the receiver operating characteristic curve for the combined Cine-MRI-related parameters in predicting mild and severe dysphagia were 0.806 (95% CI: 0.662-0.949). Cine-MRI with compressed sensing may identify swallowing function and abnormal stages of the physiologic swallowing process in patients with dysphagia after treatment.

Minimal Detectable Change of Cough and Lingual Strength Outcomes in Neurodegenerative Disease

OBJECTIVE

Minimal detectable change (MDC) represents the smallest amount of change required for an outcome to be considered real and not merely due to measurement error or task variability. This study aimed to examine MDC for cough and lingual strength outcomes among individuals with neurodegenerative disease.

METHODS

In a single session, individuals diagnosed with Parkinson's disease (PD), progressive supranuclear palsy (PSP), and cerebellar ataxia completed repeated measurements of voluntary sequential cough via spirometry (n = 143) and lingual isometric and swallowing pressure with the Iowa Oral Performance Instrument (n = 231). The MDC at the 95% confidence level was calculated with the following formula: MDC = 1.96 × √2 × SEM.

RESULTS

MDC for cough strength was 0.52 L/s (PD), 0.57 L/s (PSP), and 0.20 L/s (ataxia). On trials with the same number of coughs, MDC for cough strength was 0.18 L/s in PD and 0.24 L/s in ataxia. MDC for lingual isometric pressure was 5.44 kPa (PD), 2.35 kPa (PSP), and 3.41 kPa (ataxia), whereas swallowing pressure was 5.60 kPa (PD), 2.97 kPa (PSP), and 7.34 kPa (ataxia).

CONCLUSIONS

These findings elucidate MDC for cough and lingual strength outcomes and expand our understanding of change that can be considered "real" and not merely due to task variability. MDC facilitates valid interpretations of changes following treatment, as well as power analyses to determine the smallest effect size of interest before data collection. To illustrate the application of MDC, we situate these findings in the context of hypothetical case studies and research studies.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:5034-5040, 2024.

Changes in the Activation Level of the Floor of the Mouth Muscles during Pressing and Swallowing Tasks According to the Degree of Tongue Pressure

The suprahyoid muscles play an important role in protecting the airway by elevating both the hyoid bone and larynx superior-anteriorly during swallowing. However, providing systematic external resistance when performing exercises to improve suprahyoid muscle strength is practically difficult. This study attempted to confirm whether systematic resistance can be provided to the suprahyoid muscles using the Iowa Oral Performance Instrument (IOPI)-a representative tongue pressure measurement device. Thirty-one healthy adults participated in this study (20.6 ± 0.96 y, 19 females). The participants performed 16 exercise tasks using the IOPI three times each in random order (Anterior/posterior tongue × pressing/swallowing task × 40/60/80/100% maximum tongue pressure). Furthermore, the floor of the mouth (FOM) muscle activity during exercise was simultaneously measured using surface electromyography. During the pressing task, there were significant differences in FOM maximal muscle activity among the four exercise intensities for both the anterior and posterior oral tongue. For the swallowing task, a significant difference was found in FOM muscle activity among the four exercise intensities for the anterior tongue. For the posterior tongue, significant differences were identified among all conditions except for the comparison between 80% and 100% maximum tongue pressure. Significant correlations between the degree of tongue pressure and maximal FOM muscle activity were found in both the pressing and swallowing tasks at the anterior and posterior oral tongue. Overall, these results indicate that objective and systematic external resistance can be applied using the IOPI-a standard tongue pressure measurement device-during the program to improve suprahyoid muscle function.

Effect of home-based tongue-strengthening exercise using a portable tool on oropharyngeal muscles in older adults with sarcopenic dysphagia: A randomised controlled study

BACKGROUND

Tongue-strengthening exercises may be used at home to strengthen swallowing-related oropharyngeal muscles in community-dwelling older adults with sarcopenic dysphagia; however, evidence of their effectiveness remains unclear.

OBJECTIVE

This study aimed to investigate the effects of a home-based tongue-strengthening exercise (hTSE) using portable tool on swallowing-related oropharyngeal muscles in community-dwelling older adults with sarcopenic dysphagia.

METHODS

Forth community-dwelling older adults with sarcopenic dysphagia were enrolled in the study. The participants were randomly assigned to the experimental and control groups. 1-Repetition Maximum (1-RM) of tongue muscle was measured in the experimental group using the Iowa Oral Performance Instrument, and hTSE was performed using a portable tool with an intensity corresponding to approximately 70%-80% of the range based on the 1-RM value (90 times/day, 5 days/week, for 8 weeks). The control group did not perform any tongue exercises. The primary outcome measures were tongue strength and thickness. The secondary outcome measure was suprahyoid muscle strength (digastric and mylohyoid muscles).

RESULTS

The experimental group showed significantly greater increases in suprahyoid muscle (mylohyoid and digastric) thickness (p = .01 and .011, d = 1.0 and .55), as well as tongue strength and thickness (p < .001 and .029, d = 2.2 and .6) than the control group.

CONCLUSION

This study confirmed that hTSE using a portable tool is effective in increasing swallowing-related oropharyngeal muscle activity in older adults with sarcopenic dysphagia. Therefore, hTSE is recommended as an inexpensive, safe, and easy-to-use therapy for sarcopenic dysphagia in older adults.

Association of oral hypofunction with aspiration pneumonia, fractures, and mortality in older Japanese adults

AIM

In Japan's public health system, dentists can assess and intervene in oral hypofunction cases. However, the associations between oral hypofunction and health outcomes and costs remain unclear. This study aimed to identify these associations.

METHODS

This retrospective cohort study using a Japanese health insurance claims database included 45 916 individuals aged ≥65 years who underwent dental examinations for oral hypofunction. The primary outcomes were incidence rates of aspiration pneumonia, femoral or vertebral fractures and all-cause mortality. Secondary outcomes were annual medical and dental costs. We used competing risk regression and Cox models to estimate primary outcomes, and gamma regression models for secondary outcomes.

RESULTS

The adjusted hazard ratios were 0.84 (95% CI 0.74-0.96) for the incidence of aspiration pneumonia, 1.11 (1.02-1.21) for the incidence of femoral or vertebral fractures and 1.27 (1.07-1.50) for all-cause mortality in individuals with oral hypofunction compared with those without. The adjusted relative risk was 1.05 (1.01-1.10) for annual medical costs and 0.94 (0.81-1.09) for annual dental costs in individuals with oral hypofunction compared with those without.

CONCLUSIONS

Individuals with oral hypofunction were at increased risk of femoral or vertebral fractures and all-cause mortality, and they incurred significantly higher annual medical costs, compared with those without this condition. Notably, they showed a lower risk of aspiration pneumonia, suggesting potential benefits of dental intervention. Integrating dental care into medical strategies might be necessary to improve health outcomes and reduce healthcare costs for those with oral hypofunction. Geriatr Gerontol Int 2024; 24: 1053-1059.

Effects of oropharyngeal exercises on the swallowing mechanism of older adults: A systematic review

PURPOSE

Age-related changes to the swallowing mechanism, or presbyphagia, may put older adults at a higher risk for developing diseases and dysphagia. Maintaining swallowing functions could help prevent frailty and facilitate healthy ageing. This review summarises and appraises the effects of oropharyngeal exercises on the swallowing functions of healthy older adults without dysphagia. It is hypothesised that these exercises will strengthen and improve the structures and functions of the normal ageing swallow.

METHOD

This review was reported according to the PRISMA 2020 guidelines. Five electronic databases (Medline, Embase, Cochrane Library, Web of Science, CINAHL) and Google Scholar were searched in June 2021. A rerun was done in January 2023. Study selection, data extraction, and quality assessment were done by two independent raters.

RESULT

A total of 23 studies were reviewed. Meta-analysis was not conducted due to the heterogenous training protocols and outcomes. Majority (n = 21) had fair quality due to incomplete reporting. Exercises targeting oral structures were implemented the most (n = 15), followed by variations of the head lift (n = 4), and effortful swallow exercise (n = 1). Others implemented combined or multiapproach exercise studies (n = 3). Apart from surface electromyography findings, statistically significant improvements in oral and pharyngeal phase swallowing outcomes such as increased lingual isometric and swallowing pressures, bite force, muscle thickness, hyolaryngeal excursion, and upper oesophageal sphincter opening diameter were reported in 95% of the studies (n = 22).

CONCLUSION

Collective evidence suggests that strength training for swallowing-related structures leads to increases in structural strength, endurance, and muscle mass. The effects of exercises on overall swallowing efficiency and safety remain unclear. Results should be interpreted with caution due to methodological limitations. Further research should examine the long-term effects of these exercises in preventing frailty and reducing the burden of dysphagia in older adults.

Effects of Home-Based Daily Respiratory Muscle Training on Swallowing Outcomes in Patients with Chronic Stroke: Protocol for a Randomized Controlled Trial

(1) Background: Swallowing disorders are common following a stroke. This study aims to evaluate the effects of a home-based daily intervention focused on inspiratory and expiratory muscle training on swallowing outcomes in patients with chronic stroke. (2) Methods: This manuscript presents the protocol of a single-blind randomized clinical trial. Patients with chronic stroke will be randomly assigned to either an experimental or a control group. The experimental group will undergo daily home-based respiratory muscle training in addition to standard speech and language therapy, while the control group will receive only the standard intervention. The main outcome measures will include the aspiration risk, the strength of respiratory muscles, and peak cough flow. (3) Results: It is hypothesized that patients receiving home-based respiratory training in addition to standard therapy will achieve significant improvements in aspiration risk, respiratory muscle strength, and cough efficacy in comparison with those included in the control group. The results will be published as a manuscript. (4) Conclusions: This study aims to provide evidence on the effectiveness of home-based respiratory muscle training in enhancing swallowing function and respiratory parameters in patients with chronic stroke.

Rehabilitation to Improve Outcomes after Cervical Spine Surgery: Narrative Review

PURPOSE

The increasing elderly patient population is contributing to the rising worldwide load of cervical spinal disorders, which is expected to result in a global increase in the number of surgical procedures in the foreseeable future. Cervical rehabilitation plays a crucial role in optimal recovery after cervical spine surgeries. Nevertheless, there is no agreement in the existing research regarding the most suitable postsurgical rehabilitation program. Consequently, this review assesses the ideal rehabilitation approach for adult patients following cervical spine operations.

MATERIALS AND METHODS

This review covers activities of daily living and encompasses diverse treatment methods, including physiotherapy, specialized tools, and guidance for everyday activities. The review is organized under three headings: (1) historical perspectives, (2) patient-reported functional outcomes, and (3) general and disease-specific rehabilitation.

RESULTS

Rehabilitation programs are determined on the basis of patient-reported outcomes, performance tests, and disease prognosis. CSM requires strengthening of the neck and shoulder muscles that have been surgically invaded. In contrast, the CCI requires mobility according to the severity of the spinal cord injury and functional prognosis. The goal of rehabilitation for CCTs, as for CCIs, is to achieve ambulation, but the prognosis and impact of cancer treatment must be considered.

CONCLUSIONS

Rehabilitation of the cervical spine after surgery is essential for improving physical function and the ability to perform daily activities and enhancing overall quality of life. The rehabilitation process should encompass general as well as disease-specific exercises. While current rehabilitation protocols heavily focus on strengthening muscles, they often neglect the crucial aspect of spinal balance. Therefore, giving equal attention to muscle reinforcement and the enhancement of spinal balance following surgery on the cervical spine is vital.

Criterion (Concurrent) Validity and Clinical Utility of the Tongueometer Device

PURPOSE

Tongue manometry (i.e., tongue pressure measurement) is a commonly used assessment for patients with suspected oral-motor involvement in swallowing disorders. Availability of lingual manometry has changed in recent years, with the introduction of the Tongueometer device being a more affordable tongue manometry system. The purpose of this study was to test concurrent (criterion) validity of the Tongueometer compared to the current standard reference device, the Iowa Oral Performance Instrument (IOPI).

METHOD

Adults without dysphagia were recruited for participation in this study. Standard lingual measurements (swallowing-related pressures, maximum isometric pressure [MIP], and maximum isometric endurance) were recorded, with the bulb anteriorly placed, with both devices, in a randomized order. The Bland-Altman method was used to determine concurrent (criterion) validity of these measurements compared to the clinical standard IOPI device. A recently available suggested corrective value by Curtis et al. (2023) was also applied, with comparisons made between devices both with and without the Curtis correction.

RESULTS

The final sample included 70 adult participants aged 20-89 years (Mage = 52.3 years). Measures with the Tongueometer device were significantly lower when compared with the same measures taken using the IOPI (p < .01) for all measures including MIP, endurance, and swallow pressures. The correction suggested by Curtis and colleagues did not ameliorate these differences.

CONCLUSIONS

The Tongueometer lingual measurements were consistently lower compared to the IOPI. Clinical use of values taken with the Tongueometer device should be compared to normative data published for each specific device. Available features of each device (e.g., display, bulb texture, technology/application) should be considered when selecting which device to use with an individual patient.

Mechanism of the Immediate Effect of Balloon Dilation Therapy in Spinal Muscular Atrophy With Dysphagia: A High-Resolution Manometric Study

Balloon dilation therapy (BDT) is used to treat pharyngeal dysphagia in patients with impaired upper esophageal sphincter (UES) relaxation due to cricopharyngeal dysfunction. However, the mechanism underlying this immediate effect remains unclear. Here, we present a case in which we investigated the immediate effects of BDT on UES dysfunction using high-resolution manometry (HRM). A 67-year-old man was diagnosed with spinal muscular atrophy (SMA). He gradually developed dysphagia, and a gastrostomy was performed. Despite continuing oral intake of supplemental nutrition, the patient developed dysphagia. Videofluoroscopic (VF) examination of swallowing revealed pharyngeal residue, while HRM showed weak pharyngeal contractility and impaired UES opening. BDT was performed to address the UES dysfunction. Immediately following BDT, VF demonstrated improved pharyngeal bolus passage. As for the UES function during swallowing, HRM revealed that the UES relaxation duration was significantly longer and the UES nadir pressure was significantly decreased. The patient continued the BDT before oral intake. HRM revealed immediate and prolonged UES opening with decreased UES pressure during swallowing as an immediate effect of BDT. This suggests that these findings represent the mechanisms underlying dysphagia in this patient with SMA. BDT resulted in an immediate improvement in UES function, potentially leading to dysphagia improvement. BDT should be combined with conventional rehabilitation for impaired UES opening. However, further studies are needed to confirm the long-term effectiveness of BDT for dysphagia due to SMA.

Tongue Pressure Resistance Training for Post-Stroke Dysphagia: A Case Study

INTRODUCTION

Swallowing outcomes regarding lingual resistance training have been mixed due to variability in methods, leading to ambiguity concerning the utility of this intervention. The purpose of this study was to explore the effect of a lingual resistance training protocol on the swallowing function of an individual presenting with dysphagia and reduced tongue pressure following a supratentorial ischemic stroke.

METHODS

A study involving a lingual resistance training protocol with videofluoroscopy to measure outcomes comparing different parameters to ASPEKT normative reference values at three timepoints: baseline (videofluoroscopic swallowing study [VFSS] A), following a 4-week lead-in period to control for spontaneous recovery (VFSS B), and at the 8-week endpoint of treatment (VFSS C). The study was interrupted due to the COVID-19 pandemic after 1 participant enrollment and is presented as a single case study.

RESULTS

Isometric tongue pressures: Following the 4-week lead-in, a decline in maximum isometric anterior tongue pressure (MAIP) and regular effort saliva swallow pressures (RESS) was noted; however, there was no change in maximum posterior isometric tongue pressures (MPIP). Isometric tongue pressures improved post-treatment, with increases in MAIP, MPIP, and to a lesser degree RESS. Swallowing function: Impairments in swallowing safety continued between the baseline VFSS A (Penetration-Aspiration Scale score [PAS] = 8) and lead-in VFSS B (PAS = 5). Swallowing safety improved following the intervention, with PAS scores = 1 at the endpoint VFSS C. Pixel-based measures of swallowing efficiency revealed a reduced frequency of post-swallow total pharyngeal residue following the treatment. Improvements were found in two other swallowing parameters, laryngeal vestibule closure integrity and pharyngeal area at maximum pharyngeal constriction, at the endpoint VFSS.

CONCLUSION

These pilot data suggest improvements in some swallowing parameters as an outcome of intervention.

Quantitative evaluation of swallowing function in Parkinson's disease using tongue pressure measurement: a mini-review

Dysphagia is a common symptom of Parkinson's disease (PD) associated with aspiration pneumonia, choking, malnutrition, and a decreased quality of life, and is a leading cause of death among patients with PD. Tongue dysfunction in patients with PD affects the oral phase of swallowing, including the formation and propulsion of a bolus into the pharynx. Assessing tongue pressure, generated between the tongue and palate, is a method that quantitatively measures tongue function and is related to dysphagia in PD. Two assessment methods are used to measure tongue pressure: tongue strength and tongue pressure during swallowing. Previous studies measuring tongue pressure in PD have reported decreased tongue strength and pressure during swallowing, as well as a prolonged tongue pressure rise time, which are symptoms associated with PD severity and dysphagia. In this mini-review, we present a method for measuring tongue pressure and discuss its relationship with dysphagia in PD. We also describe limitations and future perspectives in tongue pressure measurement research.

A Comparison of Lingual Pressure Generation Measures Using Two Devices in Community-Dwelling, Typically Aging Adults: An Important Clinical Implication

DESIGN

A multisite, prospective, and randomized within-subject design study.

SETTING

Five university settings in varied geographical areas in the United States.

PURPOSE

The purpose of this study was to compare lingual pressure generation using the Tongueometer (TO) and the Iowa Oral Performance Instrument (IOPI) in typically aging, community-dwelling adults during three measurement tasks: maximum isometric pressure (MIP), regular effort saliva swallow (RESS) pressure, and effortful saliva swallow pressure (ESP).

PARTICIPANTS

Eighty-seven typically aging, community-dwelling adults (aged 55 years and over) with no self-reported history of swallowing or neurological disorders were recruited to complete this study.

RESULTS

Strong positive associations were found between the lingual pressure generation measures from the TO and IOPI in all tasks in typically aging adults, with Pearson correlations ranging from r = .780 to .874, p < .001. Agreement between the devices (Lin's concordance correlation coefficient) ranged from moderate for the MIP (ρc = .78) and ESP (ρc = .61) tasks to weak agreement for the RESS task (ρc = .47). MIP, RESS pressure, and ESP were lower when measured by the TO compared with the IOPI, p < .001.

CONCLUSIONS

The TO measures lingual pressure generation similarly to the IOPI but pressures register lower when using the TO than the IOPI in typically aging persons. This supports the need for developing normative values specific to the TO device or development of a valid and reliable conversion formula from TO to IOPI normative values. At this time, the clinical use of reference values from the TO should not be generalized to IOPI normative values.

Fahr's disease in a patient with recurrent pneumonias, parkinsonism and dementia

Fahr's disease is a rare condition characterised by the presence of idiopathic familial bilateral basal ganglia calcifications, transmitted in an autosomal-dominant fashion. Diagnosis is based on clinical features of neuropsychiatric and somatic symptoms in conjunction with radiological findings. Our patient, a man in his early 50s, presented with pneumonia. History was significant for five admissions in the last 2 years for pneumonia and falls, with gradual cognitive and motor decline since his late 30s. Hypophonia, bradykinesia and dementia were noted on examination. CT of the brain revealed bilateral thalamic calcinosis, consistent with Fahr's syndrome. Further investigations and retrospective history taking, and similar radiological findings within first-degree and second-degree relatives with early deaths, transitioned the diagnosis from Fahr's syndrome to Fahr's disease. We present this case of Fahr's disease to emphasise the value of collaboration among multidisciplinary professionals to improve quality of care for such patients.

Effects of Device-Facilitated Lingual Strengthening Therapy on Dysphagia Related Outcomes in Patients Post-Stroke: A Randomized Controlled Trial

BACKGROUND

Swallowing impairments resulting from stroke have few rehabilitative options. Prior evidence suggests lingual strengthening exercise may provide some benefit, but more randomized controlled trials are required. The purpose of this study was to examine efficacy of progressive lingual resistance training on lingual pressure generative capacity and swallowing outcomes for individuals with dysphagia after stroke.

METHODS

Participants with dysphagia within 6 months of acute stroke were randomly assigned to: (1) treatment: progressive resistance tongue exercise using pressure sensors for 12 weeks with usual care; or (2) control: usual care only. Outcomes were measured at baseline, 8 and 12 weeks to assess group differences in lingual pressure generation, swallow safety, efficiency, oral intake, and swallowing quality of life.

RESULTS

Final sample included 19 participants [treatment (N = 9) and control (N = 10)] with 16 males and 3 females (mean age = 69.33). Functional Oral Intake Scale (FOIS) scores improved significantly (p = 0.04) in the treatment group from baseline to 8 weeks compared to usual care (control). No significant differences between treatment groups were identified for other outcomes; large effect sizes were detected for group differences in lingual pressure generative capacity from baseline to 8 weeks at the anterior sensor (d = .95) and posterior sensor (d = 0.96), and vallecular residue of liquids (baseline to 8-week d = 1.2).

CONCLUSIONS

Lingual strengthening exercise resulted in significant improvements in functional oral intake for patients with post-stroke dysphagia as compared to usual care after 8 weeks. Future studies should include a larger sample size and address treatment impact on specific aspects of swallow physiology.

Flexibility for Intensity Dosing in Lingual Resistance Exercises: A Large Randomized Clinical Trial in Typically Aging Adults as Proof of Principle

OBJECTIVE

The objective of this study was to determine the effect of intensity dosing during tongue exercise on tongue pressure generation, adherence, and perceived effort.

DESIGN

This was a five-site, prospective, randomized clinical trial. Outcome measures were obtained across multiple baselines, biweekly during exercise, and 4-weeks post-intervention.

SETTING

The general community at each study site.

PARTICIPANTS

Typically aging adults between 55-82 years of age with no history of neurological or swallowing disorders. Eighty-four volunteers completed the study.

INTERVENTIONS

Participants were randomly assigned to one of four exercise groups: (a) maximum intensity/no biofeedback, (b) progressive intensity/no biofeedback, (c) maximum intensity/biofeedback, and (d) progressive intensity/biofeedback. Half of the participants completed a maintenance exercise program.

OUTCOME MEASURES

Maximum isometric pressure (MIP), regular effort saliva swallow pressure, adherence, and the Borg Rating of Perceived Exertion Scale.

RESULTS

All exercise protocols were efficacious for gains in MIP (large effect sizes; Cohen's d). Group 3 made gains in regular effort saliva swallow pressure (medium effect size). There was a significant change in perceived exertion for regular effort saliva swallow pressure at 8 weeks. Tongue pressure gains were maintained at 1 month, regardless of maintenance group status. Mean adherence across groups was high.

CONCLUSIONS

All groups improved pressure generation. Intensity dosing differences did not affect strength gains, adherence, or detraining. Regular effort saliva swallow pressure may be most responsive to maximum intensity with biofeedback. The findings suggest flexibility in approach to tongue exercise protocols. Tongue muscles may differ from limb muscles in terms of dose response and neuroplasticity principles.

Tongue Strength of Older Adults Requiring Long-Term Care Varies throughout the Day

Physical performance shows approximately 30% diurnal variation; however, diurnal variation in oral function remains unclear. This study aimed to determine the diurnal variation in oral and swallowing function in older adults requiring long-term care. The participants included 13 adults aged >60 years (3 men and 10 women, mean age: 77.2 ± 6.3 years, age range: 62-90 years) requiring long-term care. Tongue strength (TS) and oral mucosal moisture were measured as indices of oral and swallowing function, while hand grip strength was measured as an index of general muscle strength. The patients were asked to participate in a "test" after breakfast, lunch, and dinner on the same day. Multilevel linear regression analysis was used to examine diurnal differences in each item. Multilevel linear regression analysis with adjustment for age and sex revealed that TS was significantly higher at noon (p = 0.001) than in the morning. Therefore, caregivers who provide support during meals to older people requiring long-term care should consider the possibility of swallowing function differing according to the time of the day. In conclusion, it may be beneficial to establish a nutritional therapy that accounts for the diurnal variation in TS.

Effects of Age and Lingual-Palatal Pressure Levels on Submental Surface Electromyography Measures

Submental surface electromyography (sEMG) may provide information about the lingual-palatal pressure (LPP) during swallowing. However, the extent to which changes in age and LPP levels are reflected in different sEMG measures is unclear. This study aimed to understand the effects of age and different levels of submaximal LPPs on submental sEMG peak, average, and integrated values in healthy adults. Ninety community-dwelling healthy participants were categorized into three age groups (young: 20-39 years, middle age: 40-59 years, older: 60 ≥ years). sEMG and LPP measurements were collected concurrently. After placing the sEMG electrodes, the maximal isometric LPP was established using the Iowa oral performance instrument (IOPI) on the anterior tongue. sEMG recordings were conducted for three submaximal LPP levels, including 40%, 60%, and 80% of the maximum LPP. Two-way repeated measure ANOVAs were conducted to find the effects of age and varying LPP levels on mean sEMG peak, average, and integrated measures. A significant age by LPP level interaction was identified for sEMG peak [F (4, 172) = 4.116, p < 0.007, ηp2 = 0.087], sEMG average [F (4, 170) = 5.049, p < 0.001, ηp2 = 0.106], and sEMG integrated values [F (4, 170) = 4.179, p < 0.003, ηp2 = 0.090]. Post hoc testing demonstrated that, in general, sEMG values significantly increased with rising LPP levels, primarily for younger and middle-aged adults. Furthermore, at 80% of maximum LPP, older adults generated less sEMG average and integrated values than middle age (only significant for sEMG integrated value) and younger adults. Likewise, max LPP was lower in older adults compared with young and middle-aged groups. Submental sEMG has the potential to be incorporated into a skill-based lingual exercise paradigm to improve tongue function during swallowing. Moreover, submental sEMG can characterize some age-related subclinical changes in swallowing.

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.

Optimizing Function and Appearance After Head and Neck Reconstruction: Measurement and Intervention

Approximately 50% of head and neck cancer (HNC) survivors are left with dysphagia as a result of treatment sequele, and 25% of survivors experience clinically significant body image distress (BID). Both dysphagia and BID adversely affect quality of life and should be tracked using validated clinician- and patient-reported outcome measures such as the Performance Status Scale for Head and Neck Cancer, MD Anderson Dysphagia Inventory, and Inventory to Measure and Assess imaGe disturbancE-Head & Neck (IMAGE-HN). Subjective and objective evaluation measures are critical to dysphagia workup and management. Building a renewed image after head and neck cancer treatment, a brief telemedicine-based cognitive behavioral therapy, has become the first evidence-based treatment for BID among HNC survivors.

Evaluation of the maximum tongue and lip pressure in individuals with Class I, II, or III Angle malocclusions and different facial types

PURPOSE

To compare the maximum anterior and posterior tongue pressure, tongue endurance, and lip pressure in Class I, II, and III malocclusions and different facial types.

METHODS

A cross-sectional observational analytical study was carried out in 55 individuals (29 men and 26 women) aged between 18 and 55 years. The participants were divided into groups according to Angle malocclusion (Class I, II, and III) and facial type. The maximum anterior and posterior tongue pressure, tongue endurance, and maximum lip pressure were measured using the IOPI (Iowa Oral Performance Instrument). To determine the facial type, the cephalometric analysis was accomplished using Ricketts VERT analysis as a reference.

RESULTS

There was no statistically significant difference when comparing the maximum pressure of the anterior and posterior regions of the tongue, the maximum pressure of the lips, or the endurance of the tongue in the different Angle malocclusion types. Maximum posterior tongue pressure was lower in vertical individuals than in mesofacial individuals.

CONCLUSION

Tongue and lips pressure, as well as tongue endurance in adults was not associated with the type of malocclusion. However, there is an association between facial type and the posterior pressure of the tongue.

The role of oral and pharyngeal motor exercises in post-stroke recovery: A scoping review

OBJECTIVE

To analyze intervention goals, protocols, and outcome measures used for oral and pharyngeal motor exercises in post-stroke recovery.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, PsychINFO, and Cochrane databases were searched in September 2022.

METHODS

Studies were included if they (1) recruited post-stroke adult patients, (2) administered exercises for the oral and/ or pharyngeal muscles, and (3) reported results at baseline and post-exercise. The extracted data included intervention goals, protocols, and outcomes. All outcomes were classified according to the International Classification of Functioning, Disability and Health (ICF).

RESULTS

A total of 26 studies were identified. Their intervention goals aimed to rehabilitate a broad spectrum of muscle groups within the oral cavity and pharynx and to improve the functions of swallowing, speech, facial expressions, or sleep breathing. Protocol duration ranged from 1 to 13 weeks, with various exercise repetitions (times per day) and frequency (days per week). Half of the studies reported using feedback to support the training, and these studies varied in the feedback strategy and technology tool. A total of 37 unique outcome measures were identified. Most measures represented the body functions and body structure component of the ICF, and several of these measures showed large treatment effects.

CONCLUSIONS

This review demonstrated inconsistency across published studies in intervention goals and exercise protocols. It has also identified current limitations and provided recommendations for the selection of outcome measures while advancing a multidisciplinary view of oral and pharyngeal exercises in post-stroke recovery across relevant functions.

The effect of voice training interventions on patients with oropharyngeal dysphagia: a systematic review

BACKGROUND

Voice training has been proposed as an intervention to improve swallowing function in patients with dysphagia. However, little is known about the effects of voice training on swallowing physiology.

OBJECTIVES

This systematic review investigates the effect of voice training on the swallowing function of patients with oropharyngeal dysphagia and provides the theoretical basis for improving the swallowing function and life quality of patients with oropharyngeal dysphagia.

DATA SOURCES

A systematic review using a narrative synthesis approach of all published studies was sought with no date restrictions. Five electronic databases (EMBASE, PubMed, CINAHL, Web of Science, and The Cochrane Library) were searched from inception to April 2022.

STUDY SELECTION

Eight studies were included. Two researchers screened the literature according to inclusion and exclusion criteria, extracted data, and carried out quality control according to the Cochrane handbook5.1.0. Data were analyzed narratively and descriptively.

CONCLUSIONS

In general, statistically significant positive therapy effects were found. Voice training improves the oral and pharyngeal stages of swallowing in patients with neurological causes of dysphagia, such as stroke, and in patients with non-neurological causes of dysphagia, such as head and neck cancer. However, the current literature is limited and further primary research is required to provide more evidence to support voice training intervention in dysphagia.  Future studies could  further refine the content of voice training interventions, increase the number of patients enrolled, assess the long-term effects of voice training interventions and add associated assessments of the quality of life after treatment.

The relationship between sarcopenia, dysphagia, malnutrition, and frailty: making the case for proactive swallowing exercises to promote healthy aging

PURPOSE OF REVIEW

The purpose of this review is to summarize current evidence regarding the relationship between sarcopenia of the swallowing muscles, dysphagia, malnutrition, and frailty in the context of aging. Further, this review will provide preliminary support for proactive swallowing exercises to reverse and/or prevent sarcopenia of the swallowing muscles.

RECENT FINDINGS

Recent studies lend support to a cyclic relationship between sarcopenia of the swallowing muscles, dysphagia, malnutrition, and frailty. Unfortunately, all studies are limited by their study design and lack instrumental imaging of swallowing function. Research (in the limbs) supports the use of proactive exercises and protein supplementation to reverse sarcopenia, especially in prefrail individuals. This provides a foundation to design and test similar preventive exercises for the swallowing muscles.

SUMMARY

As the population is rapidly aging, it is vital to understand how the natural loss of muscle in aging impacts swallowing function and the downstream impact on nutritional and physical function. Prospective, longitudinal research with sophisticated outcome measures are required to fully understand this cycle and provide an opportunity to test methods for interrupting the cycle.

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.

Implementation of the VA Intensive Dysphagia Treatment Program: A Mixed-Methods Evaluation

The Department of Veterans Affairs (VA) Intensive Dysphagia Treatment program serves a critical role in facilitating improvements to quality of care, standardization of outcomes, and increased access to structured therapy for Veterans with dysphagia. It has been implemented at 26 sites nationally and continues expanding. An explanatory sequential mixed-methods design was utilized for program evaluation to identify barriers and facilitators to implementation as reported by speech-language pathologists (SLPs) participating in the program. All 23 IDT program SLPs were invited to participate in an online survey. SLPs were asked to describe etiologies referred for SLP evaluation, most and least clinically useful program aspects, and characteristics of patients recommended for therapy. Qualitative interviews/focus groups were then conducted with 9 SLPs at 3 facilities with varying levels of program experience. Transcripts underwent systems engineering framework informed deductive thematic analysis. Interview/focus groups revealed overall positive feedback. Barriers included data entry challenges and provider understanding of long-term program goals, while facilitators included program structure enabling increased patient follow-up, outcomes tracking, and training in new treatment modalities. Through this evaluation process, program leadership garnered actionable feedback to improve further implementation of the IDT program. Ongoing efforts will further improve data entry, site onboarding procedures, and program communication.

Profiles of Swallowing Impairment in a Cohort of Patients With Reduced Tongue Strength Within 3 Months of Cerebral Ischemic Stroke

PURPOSE

Patients with poststroke dysphagia may experience inefficient bolus clearance or inadequate airway protection. Following a stroke, impairments in lingual pressure generation capacity are thought to contribute to oropharyngeal dysphagia. The goal of our study was to determine whether similar profiles of swallowing impairment would be seen across a cohort of patients with reduced tongue strength within 3 months after cerebral ischemic stroke.

METHOD

The sample comprised six adults with reduced tongue strength (i.e., maximum anterior isometric pressure < 40 kPa). Participants underwent a videofluoroscopy according to a standard protocol. Post hoc blinded ratings were completed using the Analysis of Swallowing Physiology: Events, Kinematics and Timing Method and coded as "typical" versus "atypical" (i.e., within vs. outside the healthy interquartile range) in comparison to published reference values.

RESULTS

The videofluoroscopies suggested that having reduced tongue strength did not translate into a common profile. Of the six participants, two showed Penetration-Aspiration Scale (PAS) scores of ≥ 3 on thin liquids, associated with incomplete laryngeal vestibule closure (LVC). Another two participants displayed PAS scores of 2 (transient penetration), but these were not associated with incomplete LVC. Pharyngeal residue, above the healthy 75th percentile, was seen for three participants. Five participants presented with atypical reductions in hyoid XY peak position.

CONCLUSIONS

In this cohort of adults within 3 months of cerebral ischemic stroke, reductions in tongue strength presented alongside a variety of changes in swallowing physiology. There was no straightforward relationship linking reduced tongue strength to particular patterns of impairment on videofluoroscopy.

Comparison of Lingual Pressure Generation Capacity in Parkinson Disease, Amyotrophic Lateral Sclerosis, and Healthy Aging

PURPOSE

The tongue plays a key role in bolus propulsion during swallowing, with reduced lingual pressure generation representing a risk factor for impaired swallowing safety and efficiency. We compared lingual pressure generation capacity in people with Parkinson disease (PwPD), people with amyotrophic lateral sclerosis (PwALS), and healthy older adults. We hypothesized that both patient cohorts would demonstrate reduced maximum anterior isometric pressure (MAIP) and regular effort saliva swallow (RESS) pressures compared with healthy controls, with the greatest reductions expected in the ALS cohort.

METHOD

We enrolled 20 PwPD, 18 PwALS, and 20 healthy adults over 60 years of age. The Iowa Oral Performance Instrument was used to measure MAIP, RESS, and lingual functional reserve (LFR, i.e., MAIP - RESS). Descriptive statistics were calculated; between-groups differences were explored using univariate analyses of variance and post hoc Sidak tests with alpha set at .05.

RESULTS

Mean MAIPs for the PD, ALS, and heathy cohorts were 54.7, 33.5, and 47.4 kPa, respectively. Significantly lower MAIP was found in PwALS compared with PwPD and healthy controls. RESS values did not differ significantly across groups. LFR was significantly higher in PwPD versus PwALS and healthy controls.

CONCLUSIONS

Lingual pressure generation capacity and functional reserve were reduced in PwALS, but not in PwPD, beyond changes seen with healthy aging. Both patient cohorts displayed preserved lingual pressure during saliva swallows. Future studies exploring longitudinal changes in tongue pressure generation on isometric and saliva swallowing tasks will be needed to confirm whether tongue pressure measures serve as noninvasive clinical biomarkers of swallowing impairment.

A Comparative Assessment of the Diagnosis of Swallowing Impairment and Gastroesophageal Reflux in Canines and Humans

Swallowing impairment is a highly prevalent and clinically significant problem affecting people and dogs. There are myriad causes of swallowing impairment of which gastroesophageal reflux is the most common in both species. Similarities in anatomy and physiology between humans and canines results in analogous swallowing disorders including cricopharyngeus muscle achalasia, esophageal achalasia, hiatal herniation, and gastroesophageal reflux with secondary esophagitis and esophageal dysmotility. Accordingly, the diagnostic approach to human and canine patients with swallowing impairment is similar. Diagnostic procedures such as swallowing fluoroscopy, high-resolution manometry, pH/impedance monitoring, and endolumenal functional luminal imaging probe can be performed in both species; however, nasofacial conformation, increased esophageal length, and the difficulty of completing several of these procedures in awake dogs are inherent challenges that need to be considered. Human patients can convey their symptoms and respond to verbal cues, whereas veterinarians must rely on clinical histories narrated by pet owners followed by comprehensive physical examination and observation of the animal eating different food consistencies and drinking water. Dogs may also be unwilling to drink or eat in the hospital setting and may be resistant to physical restraint during diagnostic procedures. Despite the species differences and diagnostic challenges, dogs are a natural animal model for many oropharyngeal and esophageal disorders affecting people, which presents a tremendous opportunity for shared learnings. This manuscript reviews the comparative aspects of esophageal anatomy and physiology between humans and canines, summarizes the diagnostic assessment of swallowing impairment in both species, and discusses future considerations for collaborative medicine and translational research.

Effects of tongue strengthening exercises on tongue muscle strength: a systematic review and meta-analysis of randomized controlled trials

Tongue strengthening exercise (TSE) has been proposed as an intervention to increase tongue strength and improve swallowing. However, clinical evidence of its effectiveness is lacking. In this review, seven databases were searched from inception to September 30, 2021 for randomized controlled trials that compared tongue strengths between the TSE intervention and control groups, obtained from maximal tongue elevation peak force in kilopascals (kPa). The Cochrane risk of bias tool was used for quality assessment. In total, 12 studies with 388 participants were included. The pooled meta-analysis demonstrated that the anterior tongue strength (ATS) (MD = 5.34 kPa; 95% CI 3.28–7.40; I² = 71%) and posterior tongue strength (MD = 8.12; 95% CI 3.45–12.79; I² = 90%) were significantly higher in the TSE intervention than that in the control group. Among healthy participants, subgroup analysis showed that TSE had improvements on ATS in all age groups, with the greatest improvement in old people (≥ 65 years) (MD = 8.01; 95% CI 4.39–11.64; I² = 30%). Meta-regression analysis revealed a nonsignificant trend toward greater improvement on tongue strength with increasing TSE duration. This study provides positive evidence that TSE may be beneficial in improving tongue strength and could be applied for adults, especially healthy older adults.

Alterations in white matter microstructural properties after lingual strength exercise in patients with dysphagia

OBJECTIVES

Central nervous system effects of lingual strengthening exercise to treat dysphagia remain largely unknown. This pilot study measured changes in microstructural white matter to capture alterations in neural signal processing following lingual strengthening exercise.

METHODS

Diffusion-weighted images were acquired from seven participants with dysphagia of varying etiologies, before and after lingual strengthening exercise (20 reps, 3×/day, 3 days/week, 8 weeks), using a 10-min diffusion sequence (9 b0, 56 directions with b1000) on GE750 3T scanner. Tract-Based Spatial Statistics evaluated voxel-based group differences for fractional anisotropy, mean diffusivity, axial diffusivity, radial diffusivity and local diffusion homogeneity (LDH). Paired t-tests evaluated treatment differences on each metric (P < 0.05).

RESULTS

After lingual strengthening exercise, lingual pressure generation increased (avg increase = 46.1 hPa; nonsignificant P = 0.52) with these changes in imaging metrics: (1) decrease in fractional anisotropy, forceps minor; (2) increase in mean diffusivity, right inferior fronto-occipital fasciculus (IFOF); (3) decrease in mean diffusivity, left uncinate fasciculus; (4) decrease in axial diffusivity, both left IFOF and left uncinate fasciculus; (5) increase in LDH, right anterior thalamic radiation and (6) decrease in LDH, temporal portion of right superior longitudinal fasciculus. There was a positive correlation between diffusion tensor imaging metrics and change in lingual pressure generation in left IFOF and the temporal portion of right superior longitudinal fasciculus.

CONCLUSIONS

These findings suggest that lingual strengthening exercise can induce changes in white matter structural and functional properties in a small group of patients with dysphagia of heterogeneous etiologies. These procedures should be repeated with a larger group of patients to improve interpretation of overall lingual strengthening exercise effects on cortical structure and function.

Effects of Tongue-Strengthening Exercise on Tongue Strength and Effortful Swallowing Pressure in Young Healthy Adults: A Pilot Study

PURPOSE

The purpose of this study was to investigate the effects of tongue-strengthening exercise (TSE) on tongue strength and effortful swallowing pressure in young healthy adults.

METHOD

Thirteen young healthy volunteers (six men, seven women; M _age = 20.5 ± 0.5 years) performed 8 weeks of isometric TSE 3 days per week. A tongue pressure measurement device was used to measure maximum isometric tongue pressure (MITP) and conduct the TSE, and a tactile sensor system attached to the hard palate was used to measure effortful swallowing pressure. MITP and effortful swallowing pressure were measured at baseline, after 4 and 8 weeks of training, and at 4 and 8 weeks after the last training session to examine the detraining effects.

RESULTS

The results indicated that both MITP and effortful swallowing pressure increased significantly from baseline to 8 weeks after training. Although the improved MITP significantly decreased at 4 and 8 weeks after training cessation, no detraining effect was observed for effortful swallowing pressure.

CONCLUSIONS

TSE is an effective method for increasing tongue pressure in wide tongue-palate contact areas during effortful swallow. The effortful swallowing pressure gained with TSE appears to be maintained for at least eight nontraining weeks.

Effect of decreased tongue pressure on dysphagia and survival rate in elderly people requiring long-term care

Background/purpose

Tongue pressure plays an important role in swallowing function. The purpose of this study is to investigate whether decreased tongue pressure is associated with dysphagia and the development of pneumonia in the elderly requiring long-term care.

Materials and methods

Tongue pressure measurement and swallowing videoendoscopic (VE) examination were performed in 60 hospitalized elderly people (33 males and 27 females, with an average age of 84.3 years) to investigate the relationship with the clinical course. Factors related with dysphagia was analyzed by Fisher's exact test and one-way ANOVA, followed by multivariate logistic regression. The relationship between each variable and survival were analyzed by cox regression.

Results

Twenty-one patients had dysphagia by VE examination. Multivariate analysis showed that smaller BMI and reduced tongue pressure were significantly correlated with dysphagia. Smaller number of remaining teeth and dysphagia were significantly related to pneumonia-related death. No patients with tongue pressure of larger than 20 kpa died by pneumonia within one year, while in those with tongue pressure of smaller than 20 kpa, one-year cumulative survival rate by pneumonia was 44.3%.

Conclusion

Decreased tongue pressure was significantly associated with dysphagia and may increase the risk of pneumonia-related death in the elderly requiring long-term care.

Central activation deficits contribute to post stroke lingual weakness in a rat model

Lingual weakness frequently occurs after stroke and is associated with deficits in speaking and swallowing. Chronic weakness after stroke has been attributed to both impaired central activation of target muscles and reduced force-generating capacity within muscles. How these factors contribute to lingual weakness is not known. We hypothesized that lingual weakness due to middle cerebral artery occlusion (MCAO) would manifest as reduced muscle force capacity and reduced muscle activation. Rats were randomized into MCAO or sham surgery groups. Maximum volitional tongue forces were quantified 8 wk after surgery. Hypoglossal nerve stimulation was used to assess maximum stimulated force, muscle twitch properties, and force-frequency response. The central activation ratio was determined by maximum volitional/maximum stimulated force. Genioglossus muscle fiber type properties and neuromuscular junction innervation were assessed. Maximum volitional force and the central activation ratio were significantly reduced with MCAO. Maximum stimulated force was not significantly different. No significant differences were found for muscle twitch properties, unilateral contractile properties, muscle fiber type percentages, or fiber size. However, the twitch/tetanus ratio was significantly increased in the MCAO group relative to sham. A small but significant increase in denervated neuromuscular junctions (NMJs) and fiber-type grouping occurred in the contralesional genioglossus. Results suggest that the primary cause of chronic lingual weakness after stroke is impaired muscle activation rather than a deficit of force-generating capacity in lingual muscles. Increased fiber type grouping and denervated NMJs in the contralesional genioglossus suggest that partial reinnervation of muscle fibers may have preserved force-generating capacity, but not optimal activation patterns.NEW & NOTEWORTHY Despite significant reductions in maximum volitional forces, the intrinsic force-generating capacity of the protrusive lingual muscles was not reduced with unilateral cerebral ischemia. Small yet significant increases in denervated NMJs and fiber-type grouping of the contralesional genioglossus suggest that the muscle underwent denervation and reinnervation. Together these results suggest that spontaneous neuromuscular plasticity was sufficient to prevent atrophy, yet central activation deficits remain and contribute to chronic lingual weakness after stroke.

Examining the Relationships Between Lingual Strength, Perihyoid Strength, and Swallowing Kinematics in Dysphagic Adults: A Retrospective Cross-Sectional Analysis

Purpose The aim of this study was to examine the relationships of clinical measures of lingual and perihyoid strength with displacement swallowing kinematics and swallowing safety in a heterogenous group of dysphagic adults. Method A retrospective analysis was completed of videofluoroscopic swallow studies of consecutive dysphagic outpatient adults presenting to a tertiary swallowing center from January 1, 2015, to December 31, 2017. Videofluoroscopic swallow study records were included if containing displacement swallowing kinematics of a 20-ml single liquid swallow and clinical measures of anterior (L-MIPA) or posterior (L-MIPP) lingual maximal isometric press, saliva mean swallowing pressures (S-MSP), and/or open mouth-maximal isometric press (OM-MIP). Regression analyses were used to examine the relationships between clinical measures of lingual (L-MIPA, L-MIPP, S-MSP) and perihyoid (OM-MIP) strength and displacement swallowing kinematics, and binomial logistic regressions were used to examine the relationships between clinical measures of lingual and perihyoid strength and swallowing safety (Penetration-Aspiration Scale [PAS]). Results Multivariate regressions revealed significant relationships of L-MIPA, L-MIPP, S-MSP, and OM-MIP with group-level changes to the displacement swallowing kinematics. Univariate analyses revealed significant relationships of L-MIPA and L-MIPP with pharyngeal constriction ratio, maximal extent of upper esophageal segment opening, and PAS. Conclusions Weak relationships were identified of clinical measures of lingual and perihyoid strength with displacement swallowing kinematics. These findings suggest that clinical measures of lingual and perihyoid strength do not fully explain impairments in swallowing kinematics across a heterogenous group of dysphagic patients. Weak-to-moderate relationships were identified between clinical measures of lingual strength and PAS, suggesting that they may have value in predicting functional measures of swallowing safety. Further research is needed to examine how findings may differ between specific patient populations.

The relationship between pulmonary and swallowing functions in patients with neuromuscular diseases followed up by a tertiary referral center: a cross-sectional study

INTRODUCTION

Respiratory muscle weakness is common in patients with neuromuscular diseases (NMD). This puts them at risk for dysphagia and other pulmonary complications.

OBJECTIVES

To investigate the relationship between pulmonary function and swallowing in NMD.

MATERIALS AND METHODS

In this cross-sectional study, medical records of patients undergoing treatment at the Tertiary Referral Center for Neuromuscular Diseases of Hospital de Apoio de Brasília, Brazil, were reviewed. Respiratory function was assessed through spirometry (FVC and FEV1 measured) and swallowing assessed by the Dysphagia Risk Evaluation Protocol and the Functional Oral Intake Scale.

RESULTS

Two hundred and twenty-two patients were included. Dysphagia was present in 46.8% of patients and impairment of pulmonary function in 64.0%. The mean FVC observed was 66.9% and FEV1 was 66.0%, indicating restrictive lung disease. A correlation between the decline of pulmonary and swallowing functions was observed in patients with NMDs (FVC vs. DREP, R = 0.46; FVC vs. FOIS, R = 0.42; FEV1 vs. DREP, R = 0.42; FEV1 vs. FOIS, R = 0.40, p<.01). FVC and FEV1 values tend to be lower in patients with dysphagia in the context of NMD.

CONCLUSIONS

A positive correlation between pulmonary function and swallowing outcomes was observed in patients with NMD. Despite respiratory and swallowing impairment being widely present in the population with NMD, they require different treatments according to the disease's pathophysiology. Future studies should be conducted to explore the disease-specific relationship between pulmonary function and swallowing in patients with NMD.

Effects of Effortful Swallowing Exercise with Progressive Anterior Tongue Press Using Iowa Oral Performance Instrument (IOPI) on the Strength of Swallowing-Related Muscles in the Elderly: A Preliminary Study

The purpose of this study was to confirm the effect of effortful swallowing (ES) exercise programs applied to increase the swallowing-related muscle strength in the elderly. In this study, 20 healthy elderly people (76.65 ± 5.87 years; 10 women and 10 men) participated and exercised for 7 weeks. The experimental group performed ES exercise combined with external resistance using Iowa Oral Performance Instrument (IOPI), and the control group performed pure ES without external resistance. The exercises were performed for 20 min a day, 2 days a week for 7 weeks in both groups. ES was repeated 60 times in weeks 1 and 2, 80 times in week 3 and 4, and 120 times in weeks 5-7. In the experimental group, the isometric and swallowing tongue pressures at week 8 were significantly improved compared to baseline. At week 8, the anterior and swallowing tongue pressures and anterior tongue endurance were significantly higher than those of the control group. In the control group, no significant change in tongue pressure-related variables was observed after 7 weeks of exercise. ES exercise combined with IOPI resistance for 7 weeks tended to increase the suprahyoid muscle activation level without statistical significance. For clinical application of this exercise protocol, further studies including more elderly people and patients with dysphagia are required.

Quantitative imaging of tongue kinematics during infant feeding and adult swallowing reveals highly conserved patterns

Tongue motility is an essential physiological component of human feeding from infancy through adulthood. At present, it is a challenge to distinguish among the many pathologies of swallowing due to the absence of quantitative tools. We objectively quantified tongue kinematics from ultrasound imaging during infant and adult feeding. The functional advantage of this method is presented in several subjects with swallowing difficulties. We demonstrated for the first time the differences in tongue kinematics during breast- and bottle-feeding, showing the arrhythmic sucking pattern during bottle-feeding as compared with breastfeeding in the same infant with torticollis. The method clearly displayed the improvement of tongue motility after frenotomy in infants with either tongue-tie or restrictive labial frenulum. The analysis also revealed the absence of posterior tongue peristalsis required for safe swallowing in an infant with dysphagia. We also analyzed for the first time the tongue kinematics in an adult during water bolus swallowing demonstrating tongue peristaltic-like movements in both anterior and posterior segments. First, the anterior segment undulates to close off the oral cavity and the posterior segment held the bolus, and then, the posterior tongue propelled the bolus to the pharynx. The present methodology of quantitative imaging revealed highly conserved patterns of tongue kinematics that can differentiate between swallowing pathologies and evaluate treatment interventions. The method is novel and objective and has the potential to advance knowledge about the normal swallowing and management of feeding disorders.

Effects of Tongue-Strengthening Self-Exercises in Healthy Older Adults: A Non-Randomized Controlled Trial

Tongue-strengthening exercises (TSE) using a device have been proposed as an intervention for improving tongue strength and endurance. However, devices for TSE have been expensive and difficult to manipulate and are not commonly used in home or clinical settings. This study therefore aimed to investigate whether tongue-strengthening self-exercises (TSsE) using a tongue-strengthening self-exercise tool at home can improve tongue strength in healthy older adults. This study included 27 participants (exercise group, η = 16, 7 men, 9 women, median age 84.5 years; control group, n = 11, 2 men, 9 women, median age 79.0 years). Exercises in the exercise group consisted of pushing the anterior tongue against the hard palate 30 times, 3 times a day, 5 days a week, for 8 weeks using a tongue-strengthening self-exercise tool. This tool is available in five levels of hardness. The most suitable hardness of the tool for each participant was calculated based on 60% of maximum tongue pressure (MTP) during the first 2 weeks of the training period and 80% of MTP for the remainder of the training period, as assessed using a tongue pressure-measuring device. The exercise group showed a significant improvement of 4.1 kPa in MTP (an 11.53% increase) and 4.53 s in endurance of tongue pressure (ETP) (a 99.86% increase). Furthermore, adherence in the exercise group was 99.2%. In conclusion, performing TSsE for 8 weeks was effective for increasing MTP and ETP in healthy older adults. This indicates that TSsE may be useful in older individuals at home to prevent age-related tongue muscle weakness.

Decreased swallowing function in the sarcopenic elderly without clinical dysphagia: a cross-sectional study

Background

Sarcopenia and dysphagia are prevalent health issues as the elderly population continues to grow. However, whether sarcopenia, defined by either reduced handgrip strength or gait speed, would lead to pathological effects on swallowing function is still a matter of debate. Studies focusing on subclinical changes in the swallowing function in the sarcopenic elderly are lacking. This study evaluates the swallowing function in the sarcopenic elderly without dysphagia.

Methods: A cross-sectional study was conducted including subjects recruited from the community. Ninety-four individuals aged 65 and older without dysphagia were divided into two groups: sarcopenia and nonsarcopenia. The swallowing assessment included tongue pressure measurement, hyoid displacement (HD), hyoid velocity (HV) measurement with submental ultrasonography, 100-ml water-swallowing test, and the 10-item Eating Assessment Tool (EAT-10).

Results

The average tongue pressure was 47.0 ± 13.7 and 48.6 ± 11.5 kPa in the sarcopenia and nonsarcopenia groups, respectively (p = 0.55), whereas the average HD during swallowing was 15.3 ± 4.4 and 13.0 ± 4.2 mm in the sarcopenia and nonsarcopenia groups, respectively (p < 0.05). The median of HV during swallowing was 19.5 (6.41–45.86) and 15.9 (3.7–39.7) mm/s in the sarcopenia and nonsarcopenia group (p < 0.05). The median of time needed for consuming 100 ml water was 12.43 (3.56–49.34) and 5.66 (2.07–19.13) seconds in the sarcopenia and nonsarcopenia groups, respectively (p < 0.05). The median of the EAT-10 score was 0 (0–2) and 0 (0–1) in the sarcopenia and nonsarcopenia groups, respectively (p < 0.05).

Conclusions

In elderly individuals, swallowing function was significantly impaired with sarcopenia before clinical symptoms become clear. However, tongue muscles exhibited resistance to sarcopenia. We observed compensative strategies in patients with sarcopenia, such as reduced swallowing speed and increased hyoid bone movement.

Association between maximum tongue pressure and swallowing safety and efficacy in amyotrophic lateral sclerosis

BACKGROUND

Oropharyngeal dysphagia (OD) is common in amyotrophic lateral sclerosis (ALS), leading to a reduction of swallowing safety and efficacy. The tongue has an important role in swallowing function for oral processing and bolus propulsion through the pharynx. The study aims to analyze the association between instrumental findings of OD and tongue pressure.

METHODS

Patients with ALS referred for fiberoptic endoscopic evaluation of swallowing (FEES) were recruited. FEES was conducted to test swallowing function with liquid (5, 10, and 20 ml), semisolid (5, 10, and 20 ml), and solid. FEES recordings were assessed for swallowing safety, using the penetration-aspiration scale (PAS), and for swallowing efficacy, using the Yale Pharyngeal Residue Severity Rating Scale (YPRSRS). PAS scores >2 were suggestive of penetration, PAS scores >5 of aspiration, and YPRSRS scores >2 of residue. Maximum tongue pressure (MTP) and tongue endurance were measured using the Iowa Oral Performance Instrument. Tongue pressure measurements were compared between patients with and without penetration, aspiration, or residue.

KEY RESULTS

Fifty-five patients with ALS were included. Mean MTP was 29.7 kPa, and median tongue endurance was 10 seconds. Patients with residue in the pyriform sinus had a significantly lower MTP than patients without residue in the pyriform sinus with semisolids 10 ml (P = .011) and 20 ml (P = .032). Patients with a tongue endurance <10 seconds exhibited higher frequency of penetration with liquids 5 ml (P = .046), liquids 10 ml (P = .015), and solids (P = .22).

CONCLUSION AND INFERENCES

In patients with ALS, MTP is significantly associated with an impairment of swallowing efficacy and tongue endurance was significantly associated with an impairment of swallowing safety.