Adult Swallowing EBP Group Extravaganza Presentation 2010 Does weight lifting for the tongue improve the swallow?

Taking EBP back to the workplace 2009 CAT: In patients with dysphagia is there a relationship between oral hygiene and pneumonia? Oral Care Project at St Vincent’s Hospital. This CAT was a lead into our next CAT (2011) on the Free Water Protocol.

The Function of The Tongue In Normal Swallowing The tongue is made entirely of muscle 1. Major role is propulsion of the bolus 1,2. Other roles include oral clearance and secondary roles in the pharyngeal phase What happens when the tongue function is impaired?

Muscle Strength Training Good for improving limb function. If tongue strengthening exercises are good for improving tongue function then what is the impact on swallowing function particularly in dysphagia?

Clinical Question Do tongue strengthening exercises affect the impaired oropharyngeal swallow?

Critically Appraised Papers 62 identified and accessible articles identified. 6 were deemed relevant but 2 of these were in abstract form only so not suitable for “capping”.

Yates, E.M., Molfenter, S,M., & Steele, C.M (2008) 6 Level of Evidence: IV - Case studies Dysphagia of neurological origin Tongue pressure generation exercises conducted with biofeedback from the Iowa Oral Performance Instrument (IOPI).

Results: Yates et al (2008) 6 CaseFunctional outcomesPhysiological changes Acommenced oral intake for total nutrition and thin fluids, ceased PEG feeds  isometric tongue pressure Bsteady increase in oral intake, and reduction in PEG feeds  isometric tongue pressure and accuracy CFunctional swallow did not return. Total intake via PEG. Gradual  in tongue pressure measures, and transient opening of cricoesophageal sphincter.

Strengths & Limitations: Yates et al (2008) StrengthsLimitations Need for further research acknowledged. Functional outcomes included Need to measure temporal procession in tongue pressure generation acknowledged. Small sample size Varying Rx design and duration amongst subjects. Difficult to understand methodology in relation to Rx.

Clinical Bottom Line: Yates et al (2008) 6 Tongue strengthening exercises may result in positive functional outcomes for some patients with an impaired oropharyngeal swallow of neurological aetiology, depending on the severity of the swallowing impairment.

Carroll, W.R., Locher, J.L., Canon, C.L., Bohannon, I.A., McCulloch, N.L. & Magnuson, J.S. (2008) 7. Level of Evidence: III (2) – Retrospective case control design Dysphagia due to advanced SCC of the oropharynx, hypopharynx and larynx treated with combined chemo and radiotherapy (CRT). The experimental group received pre-treatment swallowing exercises. The control group received post-treatment swallowing exercises as problems arose.

Results: Carroll et al (2008) 7 The experimental group showed significantly better:  Epiglottic inversion  Posterior tongue base position during the swallow than the control group on MBS 3 months after treatment. No other statistically significant results were found on other outcome measures, including timing of PEG removal.

Strengths & Limitations: Carroll et al (2008) 7 StrengthsLimitations Objective evaluation Attempts made to match participants in experimental and control groups. Use of statistical analysis. 12 month follow-up No randomisation No baseline MBS The control group received post-treatment swallowing exercises as problems arose MBS only 3 months post CRT but patients followed up for 12 months. Small sample size No comment on oral intake prior to study or compliance with Rx. Only 1 radiologist to interpret MBS – no peer review

Clinical Bottom Line: Carroll et al (2008) 7 The limited improvements in epiglottic inversion and tongue base to posterior wall approximation are promising with regard to pre-treatment exercises in head and neck cancer. Further research, including baseline functional and instrumental swallow measures, is needed to determine the potential for functional outcomes.

Ibayashi, H., Fujino, Y., Pham, T.M., & Matsuda, S. (2008) 8 Level of evidence: II – RCT 54 healthy elderly without dysphagia The experimental group were given a 6 month exercise program for oral function.

Results: Ibayashi et al (2008) 8 All oral functions in the experimental group (overall) showed significant improvement. In the experimental group, only participants with ‘20 or more teeth remaining teeth’ showed significant improvement, while those with less than 20 teeth showed no significant improvement.

Strengths & Limitations: Ibayashi et al (2008) 8 StrengthsLimitations RCT study design Multiple measures used to assess oral function and swallowing, including Repetitive Saliva Swallow Test. Smaller sample size than anticipated. Tongue strength per se was not measured. No instrumental evaluation of swallowing or aspiration status conducted.

Clinical Bottom Line: Ibayashi et al (2008) 8 In healthy elderly people with 20 or more teeth, daily oral musculature and swallowing exercises (including tongue exercises) can result in enhanced oral movements and swallowing function. However, a direct link between tongue strengthening and an enhancement in swallow function cannot be made from this paper, nor can these results be extrapolated to the dysphagia population.

Robbins, J., Kays, S.A., Gangnan, R., Hweitt, A. & Hind, J. (2007) 9 Level of evidence: III (3) - Prospective cohort intervention study 10 participants with ischemic strokes, with dysphagia diagnosed on MBS 8 week lingual exercise program using the IOPI Variety of outcome measures (MBS, tongue MRI, QOL and dietary questionnaires)

Results: Robbins et al (2007) 9 The 8 week program of isometric tongue exercises in Stroke patients resulted in the following improvements:   oropharyngeal residue   penetration/aspiration   oral bolus transit time   lingual strength during saliva swallows   lingual volume (2/3 patients; ?significant)   duration of airway closure   variety of solid food textures   hydration   QOL

Strengths & Limitations: Robbins et al (2007) 9 StrengthsLimitations Large number of different measures including muscular, neurological, physiological and QOL. Use of MBS and MRI No control group Small number or participants. Wide age range. Not all subjects could complete all aspects of the data collection. No long term follow up

Clinical Bottom Line: Robbins et al (2007) 9 In 10 stroke patients with dysphagia confirmed on MBS, an 8 week program of isometric tongue exercises significantly improved swallow function and QOL, in the short term.

Abstract # 1: Sullivan, Hind & Robbins (2001) 10 Single case study Participant: 48 yr old male, 3-4 yrs post chemo-radiation and surgery for right neck SCC, with residual dysphagia Outcome measures (pre- and post- treatment): isometric pressures, MBS data and info on dysphagia-specific QOL Treatment: 8 week exercise protocol using IOPI Results:   tongue pressure   speed of pressure generation during swallow   diet (soft to normal diet)   QOL

Abstract # 2: Prasse et al (2009) 11 Randomised Trial Participants: 22 adults post chemo-radiation therapy for oral/oropharyngeal ca Outcome measures (pre- and post-treatment): isometric pressures (IOPI), MBS, QOL Control Group: ‘traditional’ swallowing exercises Experimental Group: tongue strengthening + ‘traditional’ exercises Results:  No significant improvement in tongue strength or swallow measures for either group  BUT significantly  QOL for Experimental Group post- treatment

Critically Appraised Topic Do tongue strengthening exercises affect the impaired oropharyngeal swallow? "There is early evidence to suggest that tongue strengthening exercises improve some aspects of swallowing physiology in adults with dysphagia of varying aetiologies. It is a potentially effective treatment for patients with neurogenic dysphagia, and possibly those with head and neck cancer, however further research that includes functional outcomes in the head and neck caseload is warranted.”

References 1) Robbins, J., Gangnon, R.E., Theis, M.S., Kays, S.A., Hewitt, A.L. & Hind, J.A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatrics Society, 53: ) Lazarus, C., Logemann, J.A., Huang, C., Rademaker, A.W. (2003). Effcets of two types of tongue strengthening exercises in young normals. Folia Phoniatrica et Logopaedica, 55: ) Logemann J.A. (1983) Evaluation and Treatment of Swallowing Disorders. San Diego, CA: College Hill.. 4) Palmer, J.B. (1998). Bolus aggregation in the oropharynx does not depend on gravity. Archives of Physical Medical Rehabilitation, 79: ) Lazarus, C. (2006). Tongue strength and exercise in healthy individuals and in head and neck cancer patients. Seminars in Speech and Language, 27: ) Yates, E.M., Molfenter, S.M., & Steele, C.M. (2008). Improvements in tongue strength and pressure – generation precision following a tongue-pressure training protocol in older individuals with dysphagia: Three case reports. Clinical Interventions in Aging, 3(4): ) Carroll, W.R., Locher, J.L. Canon, C.L., Bohannon, I.A., McCulloch, N.L. & Magnuson, J.S. (2008). Pretreatment swallowing exercises improve swallow function after chemoradiation. Laryngoscope, 118: ) Ibayashi, H., Fujino, Y., Pham, T.M., & Matsuda, S. (2008). Intervention study of exercise program for oral function in healthy elderly people. Tohoku, J. Exp. Med. 215: ) Robbins, J., Kays, S.A., Gangnan, R., Hewitt, A., & Hind, J. (2007). The effects of lingual exercise in stroke patients. Archives of Physical Medicine, 88: ) Prasse, J., Sanfilippo, N., DeLacure, M., Falciglia, D., Branski, R., Ho, M., Ganz, C., Kraus, D., Lee, N. & Lazarus, C. (2009) Tongue strength and swallowing in oral cancer patients. 11) Sullivan, P., Hind, J.A., & Robbins, J.A. (2001) Lingual exercise protocol for head and neck cancer: A case study.