, Volume 33, Issue 3, pp 380–388 | Cite as

Alterations to Swallowing Physiology as the Result of Effortful Swallowing in Healthy Seniors

  • Sonja M. Molfenter
  • Chuan-Ya Hsu
  • Ying Lu
  • Cathy L. Lazarus
Original Article


A significant proportion of healthy seniors report difficulty swallowing, thought to result from age-related decline in muscle bulk/function. Effortful Swallowing (ES) is used both as a compensatory maneuver to improve pharyngeal propulsion/clearance and has been proposed as an exercise to improve pharyngeal strength. This study sought to quantify the immediate kinematic, temporal, and functional changes during an ES maneuver to quantify its exercise potential to combat age-related changes in swallowing. Videofluoroscopy data were collected from 44 healthy seniors (21 male) over 65 years old (mean = 76.9, SD = 7.1). Each participant swallowed six 5 ml boluses of Varibar nectar-thick liquids: three with regular effort and three using ES. Individual swallows (n = 260) were measured on pharyngeal constriction, pharyngeal shortening, laryngeal closure duration, hyoid movement duration, UES opening duration, stage transition duration, pharyngeal transit time, pharyngeal response duration, Normalized Residue Ratio Scale (NRRS), and the Penetration–Aspiration Scale (PAS). Non-parametric Wilcoxon Rank Sum for repeated measures tested the effect of ES on each outcome. Exact p-values were calculated based on permutation methods, individual p values < 0.008 was deemed to be significant. The ES maneuver significantly prolonged all temporal variables. While we found no significant differences for pharyngeal constriction, significantly less (i.e., worse) pharyngeal shortening was observed in ES condition compared with regular effort swallows. Further, significantly worse pyriform sinus residue (NRRSv) was observed in the ES condition. No differences between ES and regular effort swallows were noted for pharyngeal constriction, NRRSv or PAS. We speculate that these negative manifestations of worse kinematics (less pharyngeal shortening) and function (increase in NRRSp) may be the result of forced volitional manipulation of swallowing in the ES condition in an otherwise normal elderly swallow.


Deglutition Dysphagia Aging Effortful swallow Kinematics Temporal NRRS Pharynx 



The authors would like to thank Charles Lenell, Erica Herzberg, Danielle Brates, Mehak Noorani, Emily Ottinger, Shelby Norman, Il Young Jung, Julie Bancroft, Wendy Liang, Chelsea Sandler, Marina Casale, and Katrin Gabriel for their assistance during data collection and data analysis.


This study was funded by NIH National Institute on Deafness and Other Communication Disorders 1R21DC015067.

Compliance with Ethical Standards

Conflict of interest

This work was presented as an oral presentation at the 2017 European Society for Swallowing Disorders (ESSD).

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Leonard R, Kendall KA, McKenzie S. Structural displacements affecting pharyngeal constriction in nondysphagic elderly and nonelderly adults. Dysphagia. 2004;19(2):133–41.CrossRefPubMedGoogle Scholar
  2. 2.
    Kahrilas PJ, Logemann JA, Lin S, Ergun GA. Pharyngeal clearance during swallowing: A combined manometric and videofluoroscopic study. Gastroenterology. 1992;103(1):128–36.CrossRefPubMedGoogle Scholar
  3. 3.
    Leonard R, Rees CJ, Belafsky P, Allen J. Fluoroscopic surrogate for pharyngeal strength: the pharyngeal constriction ratio (PCR). Dysphagia. 2011;26(1):13–7.CrossRefPubMedGoogle Scholar
  4. 4.
    Palmer JB, Tanaka E, Ensrud E. Motions of the posterior pharyngeal wall in human swallowing: a quantitative videofluorographic study. Arch Phys Med Rehabil. 2000;81(11):1520–6.CrossRefPubMedGoogle Scholar
  5. 5.
    Olsson R, Castell J, Johnston B, Ekberg O, Castell DO. Combined videomanometric identification of abnormalities related to pharyngeal retention. Acad Radiol. 1997;4(5):349–54.CrossRefPubMedGoogle Scholar
  6. 6.
    Ekberg O, Nylander G. Pharyngeal constrictor paresis in patients with dysphagia: a cineradiographic study. Clin Radiol. 1982;33(3):253–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Molfenter SM, Amin M, Branski RC, Brumm J, Hagiwara M, Roof S, et al. Age-related changes in pharyngeal lumen size: a retrospective MRI analysis. Dysphagia. 2015;30(3):321–7.CrossRefPubMedGoogle Scholar
  8. 8.
    Logemann JA. Evaluation and treatment of swallowing disorders. 2nd ed. Austin: Pro-Ed; 1998.Google Scholar
  9. 9.
    Pouderoux P, Kahrilas PJ. Deglutitive tongue force modulation by volition, volume, and viscosity in humans. Gastroenterology. 1995;108(5):1418–26.CrossRefPubMedGoogle Scholar
  10. 10.
    Takasaki K, Umeki H, Hara M, Kumagami H, Takahashi H. Influence of effortful swallow on pharyngeal pressure: evaluation using a high-resolution manometry. Otolaryngol Head Neck Surg. 2011;144(1):16–20.CrossRefPubMedGoogle Scholar
  11. 11.
    Hoffman MR, Mielens JD, Ciucci MR, Jones CA, Jiang JJ, McCulloch TM. High-resolution manometry of pharyngeal swallow pressure events associated with effortful swallow and the Mendelsohn maneuver. Dysphagia. 2012;27(3):418–26.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Nativ-Zeltzer N, Logemann JA, Zecker SG, Kahrilas PJ. Pressure topography metrics for high-resolution pharyngeal-esophageal manofluorography-a normative study of younger and older adults. Neurogastroenterol Motil. 2016;28(5):721–31.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Lamvik K, Macrae P, Doeltgen S, Collings A, Huckabee M. Normative data for pharyngeal pressure generation during saliva, bolus, and effortful saliva swallowing across age and gender. Speech Lang Hear. 2014;17(4):210–5.CrossRefGoogle Scholar
  14. 14.
    Lazarus C, Logemann JA, Song CW, Rademaker AW, Kahrilas PJ. Effects of voluntary maneuvers on tongue base function for swallowing. Folia Phoniatr Logop. 2002;54(4):171–6.CrossRefPubMedGoogle Scholar
  15. 15.
    Bülow M, Olsson R, Ekberg O. Videomanometric analysis of supraglottic swallow, effortful swallow, and chin tuck in healthy volunteers. Dysphagia. 1999;14(2):67–72.CrossRefPubMedGoogle Scholar
  16. 16.
    Bülow M, Olsson R, Ekberg O. Videomanometric analysis of supraglottic swallow, effortful swallow, and chin tuck in patients with pharyngeal dysfunction. Dysphagia. 2001;16(3):190–5.CrossRefPubMedGoogle Scholar
  17. 17.
    Bülow M, Olsson R, Ekberg O. Supraglottic swallow, effortful swallow, and chin tuck did not alter hypopharyngeal intrabolus pressure in patients with pharyngeal dysfunction. Dysphagia. 2002;17(3):197–201.CrossRefPubMedGoogle Scholar
  18. 18.
    Lenius K, Stierwalt J, LaPointe LL, Bourgeois M, Carnaby G, Crary M. Effects of lingual effort on swallow pressures following radiation treatment. J Speech Lang Hear Res. 2015;58(3):687–97.CrossRefPubMedGoogle Scholar
  19. 19.
    Hind JA, Nicosia MA, Roecker EB, Carnes ML, Robbins J. Comparison of effortful and noneffortful swallows in healthy middle-aged and older adults. Arch Phys Med Rehabil. 2001;82(12):1661–5.CrossRefPubMedGoogle Scholar
  20. 20.
    Yeates EM, Steele CM, Pelletier CA. Tongue pressure and submental surface electromyography measures during noneffortful and effortful saliva swallows in healthy women. Am J Speech Lang Pathol. 2010;19(3):274–81.CrossRefPubMedGoogle Scholar
  21. 21.
    Wheeler-Hegland KM, Rosenbek JC, Sapienza CM. Submental sEMG and hyoid movement during mendelsohn maneuver, effortful swallow, and expiratory muscle strength training. J Speech Lang Hear Res. 2008;51(5):1072–87.CrossRefPubMedGoogle Scholar
  22. 22.
    Hiss SG, Huckabee ML. Timing of pharyngeal and upper esophageal sphincter pressures as a function of normal and effortful swallowing in young healthy adults. Dysphagia. 2005;20(2):149–56.CrossRefPubMedGoogle Scholar
  23. 23.
    Fritz M, Cerrati E, Fang Y, Verma A, Achlatis S, Lazarus C, et al. Magnetic resonance imaging of the effortful swallow. Ann Otol Rhinol Laryngol. 2014;123(11):786–90.CrossRefPubMedGoogle Scholar
  24. 24.
    Witte U, Huckabee M, Doeltgen SH, Gumbley F, Robb M. The effect of effortful swallow on pharyngeal manometric measurements during saliva and water swallowing in healthy participants. Arch Phys Med Rehabil. 2008;89(5):822–8.CrossRefPubMedGoogle Scholar
  25. 25.
    Steele CM, Huckabee ML. The influence of orolingual pressure on the timing of pharyngeal pressure events. Dysphagia. 2007;22(1):30–6.CrossRefPubMedGoogle Scholar
  26. 26.
    Pearson WG Jr, Molfenter SM, Smith ZM, Steele CM. Image-based measurement of post-swallow residue: the normalized residue ratio scale. Dysphagia. 2013;28(2):167–77.CrossRefPubMedGoogle Scholar
  27. 27.
    Molfenter SM, Steele CM. Variation in temporal measures of swallowing: sex and volume effects. Dysphagia. 2013;28(2):226–33.CrossRefPubMedGoogle Scholar
  28. 28.
    Stokely SL, Peladeau-Pigeon M, Leigh C, Molfenter SM, Steele CM. The relationship between pharyngeal constriction and post-swallow residue. Dysphagia. 2015;30:349–56.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale. Dysphagia. 1996;11(2):93–8.CrossRefPubMedGoogle Scholar
  30. 30.
    Fleiss JL. The design and analysis of clinical experiments. New York: Wiley; 1986.Google Scholar
  31. 31.
    Kotrlik J, Williams H. The incorporation of effect size in information technology, learning, and performance research. Inform Technol Learn Perform. 2003;21(1):1–7.Google Scholar
  32. 32.
    Kim H, Park J, Nam K. Effortful swallow with resistive electrical stimulation training improves pharyngeal constriction in patients post-stroke with dysphagia. J Oral Rehabil. 2017;. Scholar
  33. 33.
    Allen JE, White CJ, Leonard RJ, Belafsky PC. Prevalence of penetration and aspiration on videofluoroscopy in normal individuals without dysphagia. Dysphagia. 2010;25(4):347–8.Google Scholar
  34. 34.
    Garcia JM, Hakel M, Lazarus C. Unexpected consequence of effortful swallowing: case study report. J Med Speech Lang Pathol. 2004;12(2):59–67.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2017

Authors and Affiliations

  1. 1.Department of Communicative Sciences & DisordersNYU SteinhardtNew YorkUSA
  2. 2.Department of Applied Statistics Social Science & HumanitiesNYU SteinhardtNew YorkUSA
  3. 3.Department of Otolaryngology Head & Neck SurgeryMount Sinai Beth IsraelNew YorkUSA

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