Swallowing Exercises

Abstract

Before describing the swallowing exercises in this chapter, we first address the principle of such exercises. This fundamental knowledge provides a comprehensive understanding of the term “exercise” and the techniques by which to achieve effective treatment outcomes. The swallowing exercise-based treatment will be described based upon the principle of rehabilitation medicine for which its target aims to achieve functional improvement through the changes of physiological impairment.

Appendix

1.1 Tongue Range-of-Motion Exercise [6]

Purpose: Improve oral transit (bolus holding , formation, propulsion, and mastication ).

Instructions:

• 1. Extend the tongue straight out of the mouth as far as possible, and then pull the tongue back as far as possible (tongue protrusion exercise).

• 2. Elevate the back of the tongue as far as possible (tongue retraction exercise ).

• 3. Elevate the tip of the tongue behind the top teeth as high as possible (tongue tip exercise).

• 4. Move the tongue to each side as far as possible within the oral cavity (tongue lateralization exercise) (Fig. 7.28).

Fig. 7.28

Tongue range-of-motion exercise, (left) tongue protrusion-retraction exercise, (middle) tongue lateralization exercise, (right) tongue elevation exercise (Reproduced from [42] with permission)

Exercise protocol:

• 1. Perform and release each exercise 5–10 times; attempt to hold each position for few seconds (up to 6–10 s).

• 2. Perform three to five sets per day.

Note: Other oral element-based exercises , including range-of-motion exercises of the jaw , cheek muscle-strengthening exercises , and lip closure training, should be considered and concurrently practiced to improve oromotor functional control, particularly with respect to chewing (Fig. 7.29).

Fig. 7.29

Other oral element-based exercises , (a) ja w range-of-motion exercise, (b) li p protrusion-retraction exercise (Reproduced from [42] with permission)

1.2 Tongue Resistance-Strengthening Exercise

Purpose: Strengthen the tongue to improve oral functions including bolus holding , formation, propulsion, and mastication .

Instructions:

• 1. Push the tongue against the clinician’s finger, tongue depressor, surface of spoon, or Pecopanda *:

  • (a) Push the tongue upward against the clinician’s finger or Pecopanda * (tongue blade elevation exercise).

  • (b) Push the tongue firmly to the left and right sides against a vertical tongue depressor.

  • (c) Push the tongue forward firmly against the clinician’s finger or tongue depressor.

• 2. Pull the tongue back with maximum effort against the pulling force provided by the clinician (Fig. 7.30).

Fig. 7.30

Tongue-strengthening exercises , (a) pulling back against the pulling force, (b) tongue blade elevation exercise (Reproduced from [42] with permission)

Exercise protocol:

• 1. Hold the pushing or pulling position for a few seconds.

• 2. Perform each exercise 5–10 times.

• 3. Perform three to five sets per day.

Note: *The Pecopanda is a tongue-strengthening training tool available at five resistance levels.

1.3 Devices to Facilitate Tongue-Strengthening Exercise

1.3.1 Pecopanda (JMS Co., Ltd., Hiroshima, Japan)

The Pecopanda is a commercialized tool produced by JMS Co. for use with tongue resistance exercises. This tool has five levels of hardness (soft, soft-medium, medium, medium-hard, and hard) depending on the patient’s ability. The Pecopanda promotes an understanding of the exercise method and encourages the patient to perform the exercise voluntarily.

Exercise protocol: Recommended frequency is three times a day on more than 3 days per week with a subsequent gradual increase in the exercise load (Figs. 7.31 and 7.32).

Fig. 7.31

Pecopanda

Fig. 7.32

Use of Pecopanda . (Left) place the tool between the hard palate and tongue, ensuring stable positioning by fixing the tool using the teeth , and (right) push the tongue upward against the tool and hold for a few seconds

1.3.2 Tongue Pressure Measurement Device [4, 40]

A balloon-type tongue pressure measurement device is also produced by JMS Co. This tool is used to measure the tongue pressure and can also be used for incremental strengthening exercises . The device has a digital screen that shows the tongue pressure while the patient performs the exercise and provides a quantitative outcome with which to objectively measure the patient’s progression. There is potential to reinforce the patient’s exercise performance to achieve the target goal by providing knowledge of his or her performance as feedback; this encourages the patient to achieve a higher pressure and increases patient compliance. The Fujita swallowing team uses this device for isometric progressive resistance oropharyngeal therapy as described below.

1.3.3 Isometric Progressive Resistance Oropharyngeal Therapy

Purpose: Strengthen the tongue to improve oral functions including bolus holding , formation, propulsion, and mastication .

Instructions:

• 1. Sit in a chair in a relaxed position.

• 2. Place the balloon (pressure bulb) in the mouth , and hold the plastic pipe at the midpoint of the central incisors with closed lips (Fig. 7.33).

• 3. Raise the tongue, and firmly compress the balloon onto the hard palate with maximum voluntary effort while counting from 1 to 10. The maximum value is recorded. Perform this exercise six times. The mean of the six measurements is then calculated, representing the baseline maximum tongue pressure .

• 4. Perform progressive resistance exercises for 8 weeks, modified from Robbins et al. [41]:

  • First week: 60% of maximum tongue pressure training.

  • Second week: 80% of maximum tongue pressure training.

  • Reevaluate maximum tongue pressure at weeks 3, 5, and 7 to assess clinical improvement and identify progressive changes in exercise target values while practicing at 80% of maximum tongue pressure training.

Fig. 7.33

(Left) balloon-type tongue pressure device (JMS Co. Ltd., Hiroshima, Japan); (right) use of the tongue-strengthening device

Exercise protocol: Ten times per set with a 30 s testing interval; three sets per day (this exercise regimen can be modified according to the patient’s condition) (Table 7.3).

Table 7.3 Maximum tongue pressure of healthy subjects in each age group [42]

1.4 Oromotor Control Exercise [6]

Purpose: Improve lingual control for bolus manipulation , mastication , and movement.

• Anteroposterior movement of the midline of the tongue during swallow initiation

• Lateralization of the tongue during chewing

• Tongue cupping to hold the bolus

• Tongue elevation against the hard palate

Instructions:

• 1. Hold a cotton swab between the tongue and hard palate.

• 2. Move it from one side to the other, and then slide it forward and backward.

• 3. Move it in a circular fashion from the middle of the tongue to the teeth on one side, back to the middle of the tongue, and then to the opposite side of the teeth in the same manner; this constitutes one cycle (Fig. 7.34).

Fig. 7.34

Oromotor control exercise . (a) Hold the cotton swab between the tongue and hard palate; (b) forward-backward swabbing exercise and lateral swabbing exercise (Reproduced from [42] with permission)

Exercise protocol:

• 1. Move in each direction 5–10 times.

• 2. Perform three to five sets per day.

• 3. Gradually increase the speed of the movements.

1.5 Shaker Exercise [2]

Purpose: Improve hyolaryngeal superoanterior movement by physiologically strengthening the suprahyoid muscles (including the digastric, mylohyoid, geniohyoid muscles ), thus improving UES opening .

Instructions: Lie in the supine position with no pillow under the head, and then perform the following two-part exercise:

Part 1: Isometric component

• One minute sustained head raise, repeat three times with 1 min rest between repetitions.

Part 2: Isokinetic component

• Thirty consecutive repetitions of head raise (without rest) (Fig. 7.35)

Fig. 7.35

Shaker exercise . The head is raised off of the floor or bed to look at the toes without raising the shoulders

Exercise protocol: Perform three times per day, 7 days per week for 6 weeks.

Notes:

• The patient is instructed to lift the head to look at the toes or umbilicus while keeping the shoulders flat on the floor or bed and continuing to breathe while performing the exercise.

• If the patient is too weak to complete the exercise protocol, the regimen should be adjusted on an individual basis to improve endurance.

Limitations: tracheostomy tube placement, limited neck mobility, and cervical spine deficits

1.6 Jaw-Opening Exercise [5]

Purpose: Improve UES opening during the swallow.

Instructions:

• 1. Maximally open the jaw and maintain for 10 s with a 10 s rest in between each exercise.

• 2. Attempt to strongly contract the suprahyoid muscles during the exercise.

• 3. Repeat five times.

Exercise protocol: Perform two sets of five repetitions daily for 4 weeks.

Note: Caution is needed in patients with a history of mandibular arthritis , degeneration of the articular disk of the temporomandibular joint , or temporomandibular joint dislocation.

1.7 Tongue Base Retraction Exercise

Purpose: Improve tongue base retraction strength to better propel the bolus and increase pharyngeal pressure .

Instructions:

• 1. Pull the back of the tongue (tongue base ) as far back into the mouth as possible and hold it for a few seconds.

• 2. Pull the back of the tongue (tongue base ) as far back into the mouth as possible, pretend to gargle hard, and then release.

• 3. Yawn while pulling the tongue as far back as possible, and hold the mouth open as wide as possible for 1–2 s.

Exercise protocol: Perform three times per day, 7 days per week for 6 weeks.

1.8 Tongue-Holding Swallow Exercise (Masako Maneuver)

Purpose: Improve posterior pharyngeal muscle contraction.

Instructions:

• 1. Protrude the tongue from the mouth .

• 2. Hold the anterior portion of the tongue gently between the front teeth or gums .

• 3. Swallow while keeping the tongue protruded (Fig. 7.36).

Fig. 7.36

Illustration of tongue protrusion during the Masako (tongue-hold) maneuver

Exercise protocol: Perform the exercise 10 times per set and 1–2 sets per day.

Note: This maneuver must be practiced only with saliva swallowing while incrementally increasing the range of protrusion.

1.9 Expiratory Muscle-Strengthening Exercise

Purpose: Breathe out against resistance (positive pressure) to gain expiratory muscle strength with the added benefit of vibrations (oscillations) to clear secretions .

1.9.1 Device 1: Acapella^®

The Acapella^® is a handheld airway clearance device that combines the resistance of a positive expiratory pressure d evice with a vibratory mode for airway clearance.

Two devices, distinguished by color, are available:

• Green or high-flow device: for patients who are able to maintain an expiratory flow of ≥15 L/min for 3 s. The green Acapella is suitable for most patients.

• Blue or low-flow device: for patients with lo w peak expiratory flow of <15 L/min for 3 s. The blue Acapella is commonly used in children and older patients.

Exercise protocol:

• The maximum expiratory pressure (MEP ) is measured in each patient to determine the resistance level during training.

• Generally start with the resistance set at 30% of the MEP and inspiratory: expiratory ratio at 1:3–1:4.

• Perform the exercise 10–20 times per set and 1–4 sets per day (the exercise program can be adjusted depending on the patient’s condition).

• Reevaluate weekly to adjust the level of resistance until reaching 60–80% of the MEP .

1.9.2 Device 2: Threshold Positive Expiratory Pressure Device (Threshold PEP™)

The Threshold PEP™ is a flow-dependent, one-way valve threshold device that is used to maintain constant pressure regardless of the patient’s airflow. Therefore, a pressure indicator is unnecessary. This device can be used with a mouthpiece or mask for increased ease of use.

Instructions:

• The patient maintains a relaxed or comfortable sitting position.

• Hold the patient’s nose with a nose clip as necessary. Breathe through the mouth .

• The MEP is measured in each patient to determine the resistance level during training.

• Placing mouthpiece device between the lips and behind the teeth . Seal lips around mouthpiece.

• Take a full inhale and then exhale 3–4 times longer than inhale . Continue this pattern during training as recommended in an exercise protocol.

Exercise protocol:

• The therapist sets the level of resistance at 30% of the MEP at the beginning of training and sets the inspiratory/expiratory ratio at 1:3–1:4.

• The resistance measurement will be reset weekly (adjusted depending on the patient’s condition).

• The exercise is performed for 10–20 min per set (5–10 times per set), and 2–4 sets are performed per day for 4 weeks (Fig. 7.37).

Fig. 7.37

Handheld airway clearance devices, (a) Acapella^® , (b) Threshold PEP™

Notable issues:

• Focus on slow and prolonged exhalation following the inspiratory phase.

• Neither device is gravity -dependent and can be used in any position nor in conjunction with postural drainage.

1.10 Thermal-Tactile Stimulation

Purpose: Decrease the threshold of the pharyngeal swallow response and improve the triggering speed of the pharyngeal swallow.

Techniques:

• 1. Place a cold, wet cotton swab in contact with the anterior faucial arches, and maintain this position while vertically rubbing it up and down.

• 2. Complete five strokes along each arch followed by a saliva swallow.

Exercise protocol: Perform once to twice daily (Fig. 7.38).

Fig. 7.38

Placement of cold, wet cotton swab at the anterior faucial arches, where thermal-tactile stimulation is to occur

1.11 K-Spoon

The K-Spoon (Aoyoshi Co., Ltd., Niigata, Japan) was invented by Kojima for concomitant use with K-point stimulation ; it can be employed for other purposes as well. This tool is lightweight, of adequate length, thin, and easy to hold during swallowing training. In addition, it is easy to control the bolus volume (2 ml) during direct training. The K-Spoon is made of metal, and the tip on the side opposite that for holding food can be easily used for cold stimulation at the K-point (Fig. 7.39).

Fig. 7.39

(Left) K-Spoon , (right) tip of K-Spoon used for K-point stimulation

1.12 Balloon Dilatation

Purpose: Gain temporary flexibility and expand the luminal diameter of the UES, particularly used in patients with cricopharyngeal dysfunction (e.g., supratentorial lesion, brain stem stroke) and disuse syndrome .

Inclusion criteria:

• 1. Patients with a large amount of pharyngeal residue after swallowing without evidence of UES opening on VF or VE study.

• 2. No structural abnormality of the pharynx or larynx .

• 3. No mass effect originating from outside, such as that induced by a tumor.

• 4. No strong gag reflex during balloon insertion.

• 5. Failure of other compensatory strategies.

• 6. Patient is cooperative during the procedure.

Methods:

• 1. Check the condition of the balloon catheter ; a 12- to 14-Fr urethral catheter is typically used.

• 2. Mark the catheter surface at 1 cm intervals, beginning approximately 20 cm from the catheter end. These marks correspond to the mouth angle when the dilated balloon is presented at the UES during VF .

• 3. Insert barium solution through the catheter for visualization on VF .

• 4. Typically, the catheter is transorally inserted (in patients with a high level of gag reflex sensitization; however, transnasal insertion is performed instead). Stop when the catheter tip passes through the UES. The position of the balloon catheter in the esophagus is confirmed on the VF image.

• 5. Inflate the balloon with 2–3 ml of air, and then pull the catheter backward until resistance against the pulling force is felt.

• 6. Record the marker seen on the catheter at the front teeth or the mouth angle as the position of the lower margin of the UES. This marker is helpful to maintain the position of the catheter during dilatation.

• 7. Perform balloon dilatation . Four balloon-expanding techniques are used in Japan:

  • A. Intermittent dilatation method

    • After resistance is felt as mentioned in Step 5, slightly deflate the catheter and move it <1 cm proximally; thus, the balloon is positioned at the level of the UES. Slowly inflate air into the balloon and increase the volume in 0.5–1.0 ml increments based on the patient’s tolerance. Try to sustain the dilatation for several seconds (up to 10 s) at the same position until the catheter passes through the UES.

  • B. Pulling with simultaneous swallowing

    • After resistance is felt as mentioned in Step 5, pull the balloon through the UES while instructing the patient to swallow the balloon.

  • C. Pulling without simultaneous swallowing

    • After resistance is felt as mentioned in Step 5, simply pull the balloon without instructing the patient to swallow it (in techniques B and C, the balloon size can be gradually increased as tolerated by the patient to a maximum of 10 ml).

  • D. Balloon swallowing method

    • Insert the balloon catheter into the lower pharynx and inflate it to 1.0–1.5 ml. Ask the patient to swallow with effort to pass the balloon through the UES. The catheter can be pushed slightly while the patient swallows.

Balloon dilatation is performed repeatedly three times on the impaired side to evaluate the immediate effect. In patients with bilateral lesions, the execution of this therapeutic procedure is recommended to be first performed on less severely affected side. Techniques B and C are easily performed by the patient or the patient’s caregivers.

Exercise protocol: Perform 5–10 times per session on each side of the UES, 1–3 sessions per day, and 5–7 days per week for 1–3 consecutive months.

Notes:

• At FHUR, the intermittent dilatation method is used under VF guidance by confirming the location of the balloon; however, the pulling method either with or without simultaneous swallowing is used during training because of the possibility of self-performance.

• In our experience, no dilatation-related complications such as pain, bleeding, tissue injury, or vagovagal reflex-related shock have occurred.

1.13 Supraglottic and Super-Supraglottic Swallow

1.13.1 Supraglottic Swallow

Kinesiology: Increase true vocal fold closure and arytenoid medial approximation before and during swallowing.

Effect: Enhance airway protection

Instructions:

• 1. Breathe in deeply.

• 2. Hold breath.

• 3. Swallow while maintaining the breath hold.

• 4. Cough immediately, and then swallow again before breathing (Fig. 7.40).

Fig. 7.40

Effect of supraglottic swallow

1.13.2 Super-Supraglottic Swallow

Kinesiology: Mainly increase closure of all laryngeal structures before and during swallowing; also increase base of tongue retraction , pressure generation, and earlier and prolonged UES opening .

Effects: Greater airway protection and enhanced pharyngeal clearance

Instructions:

• 1. Take a deep breath and hold it very tightly while bearing down.

• 2. Swallow hard while maintaining the tight breath hold.

• 3. Cough immediately after this swallow; then immediately swallow hard again before breathing (Fig. 7.41).

Fig. 7.41

Effect of super-supraglottic swallow

Notes:

• In both the supraglottic and super-supraglottic swallowing maneuvers , VE and VF studies are used for visual performance feedback to determine whether the TVCs are properly closed and maintained while swallowing.

• For dysphagic patients with problematic TVC closure, simply holding the breath may more effectively achieve TVC closure than the combination of taking a deep breath and then holding the breath. This could be because a deep breath widens (abducts) the TVCs, and they are difficult to close afterward [21].

1.14 Mendelsohn Maneuver

Kinesiology: Increase the extensio n and duration of hyolaryngeal elevation and subsequently increase the extension and duration of UES opening .

Effects: Improve pharyngeal clearance capability and swallow coordination.

Instructions:

• 1. Swallow normally. Pay attention to and feel elevation of the larynx (Adam’s apple) during swallowing by palpating its upward movement with the index finger and thumb.

• 2. When the Adam’s apple reaches the highest point of elevation, attempt to hold it with the throat muscles for several seconds, and then complete the swallow (Fig. 7.42).

Fig. 7.42

Effect of Mendelsohn maneuver

1.15 Effortful Swallow [26, 27]

Kinesiology: Increase tongue base retraction and pressure during pharyngeal swallowing.

Effect: Improve capability of bolus clearance , particularly in the vallecula

Instructions:

• 1. Swallow really hard, squeezing your throat muscles forcefully.

• 2. Pretend like you have a big piece of steak or bagel in the mouth , and it’s tough to pass down—you need to put a lot of effort into it (Fig. 7.43).

Fig. 7.43

Effect of effortful swallow