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Documente Profesional
Documente Cultură
Exercise Programs in
Dysphagia Intervention
Valerie Adams
School of Humanities and Social Science
The University of Newcastle
Callaghan, Australia
Robin Callister
School of Biomedical Sciences and Pharmacy
The University of Newcastle
Callaghan, Australia
Bernice Mathisen
LaTrobe Rural Health School
LaTrobe University
Bendigo, Australia
Purpose: The purpose of this article was to review the literature with regard to use of tongue-strengthening exercise in the management of swallowing disorders (dysphagia) such as those with cerebrovascular accident
(stroke) or head and neck cancer.
Methods: A database of articles published from 1984 to June 2010 was
compiled from MEDLINE, CINAHL, and PubMed using combinations of
the following key words: exercise, exercise therapy, swallowing, dysphagia, stroke, cerebrovascular disorder, tongue strength, tongue-strength ex-
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140 ASIA PACIFIC JOURNAL OF SPEECH, LANGUAGE, AND HEARING, VOL. 14, NO. 3
ercise, lingual strength, age, intensity, head and neck cancer, and swallowing rehabilitation. References listed in identified publications as well
as abstracts were examined. Studies that satisfied the following selection
criteria were included: (1) individuals had a diagnosis of dysphagia after
stroke or head and neck cancer; (2) effects of tongue-strength exercises
were examined; and (3) the design of the studies was either randomized
control trial (RCT), prospective cohort intervention study, or case study.
Results: Analysis of candidate studies showed that tongue-strengthening exercise is applicable to dysphagia intervention in general. However,
the optimum dose, frequency, and duration of the exercise required to rehabilitate tongue function has yet to be established.
Conclusion: Tongue-strengthening exercise has the potential to be a
simple yet effective therapeutic tool to add to the options for swallowing
rehabilitation in adults.
Key Words: Tongue-strengthening, exercise, stroke, dysphagia, swallowing
Introduction
The purpose of swallowing is to
safely transport food and saliva from the
mouth to the stomach; however, myriad
diseases and conditions may affect this
basic function. Dysphagia is the term used
when the normal swallow is disrupted. Any
condition that weakens or damages the
muscles and nerves used for swallowing
may cause dysphagia, for example, stroke,
traumatic brain injury, central nervous
system infection, head and neck cancer, and
degenerative diseases in young and older
adults (Logemann, 2007; Sellars, Campbell,
Stott, Stewart, & Wilson, 1999). Difficulty
in swallowing can cause food to enter the
airway, resulting in respiratory difficulties,
inadequate nutritional intake and hydration,
weight loss, reduced quality of life, and
increased mortality and morbidity. Tonguestrengthening exercise is a relatively new
therapeutic tool for dysphagia. Evidence
suggests that exercise therapy designed
to strengthen the tongue has the potential
to improve swallowing in people with
dysphagia
(Clark, OBrien, Calleja, & Corrie, 2009; Kays, Porcaro, Gangnon, Hind, &
Robbins, 2008; Robbins et al., 2005; Robbins et al., 2007). The primary objective of
this review is to examine the effectiveness
of tongue-strengthening exercises in
the prevention of long-term swallowing
dysfunction after stroke or head and neck
cancer. Recommendations regarding the
use of strengthening exercises in dysphagia
management, and suggestions for future
research are discussed.
Swallowing
Swallowing is one of the most complex
neuromuscular processes in the body. It
involves precise co-ordination between
physiologic systems including the nervous
system, the respiratory and gastrointestinal
systems, as well as the specific muscles
involved in each system (Chi-Fishman,
2000). Eating or drinking is done without
being aware of the sequence of events
that occurs in taking food or liquid (bolus)
into the mouth, and transferring it safely to
the stomach.For individuals with normal
swallow function, the experience of food or
liquid going down the wrong way and the
142 ASIA PACIFIC JOURNAL OF SPEECH, LANGUAGE, AND HEARING, VOL. 14, NO. 3
Using Tongue-Strengthening
Exercises in Dysphagia
Intervention: The Evidence
Studies of exercise-training with
individuals following stroke support the
use of exercise to improve mobility and
functional independence and to prevent
or reduce further long-term disease and
functional impairment (Burkhead et al.,
2007). For this reason, exercises designed
specifically to strengthen the tongue may
prove to be an integral part of a dysphagic
therapy plan as an improvement in the
mobility and strength of the tongue can
result in an increased ability to improve
eating and general health status
(Chi-Fishman, Stone, & McCall, 1998). Indeed, the
weakness that occurs in limb muscles is
replicated in the head and neck musculature,
Conclusion
Although exercise principles used in
physical rehabilitation and sports training
have been gaining increasing attention in
dysphagia rehabilitation, future studies
should focus on developing new optimal
programs from these principles. A number
of research studies (Clark et al., 2009; Kays
et al., 2008; Robbins et al., 2005; Robbins
et al., 2007) have attempted to determine
the appropriate resistance required to
strengthen tongue muscle as well as the
number and frequency of repetitions, the
frequency of sessions, the duration of the
program, and the specific exercises (tongue
muscle movements) necessary.
Recent research for the management
of dysphagia in older adults has led to the
SUBJECTS
PROTOCOL
OUTCOMES
RESULTS
Robbins
et al.
(2005)
10 healthy
adults
8 weeks
Baseline, 2, 4, 6, & 8
wks.
Increased isometric
strength
(7089
yrs.)
Isometric lingual
exercise
Max. isometric
pressure
Increased
swallowing
pressures for liquid
and semisolid
boluses
10
ischaemic
stroke
patients
(6 acute, 4
chronic)
Max. swallowing
pressure
Lingual volume (MRI)
10 repetitions
(3 day, 3 days/
week)
Bolus flow
Quality of Life
(SWAL-QOL)
Dietary level
Clark,
OBrien,
Calleja,
& Corrie
(2009)
39 healthy
adults
Baseline, 9
weeks
(1867
yrs.)
Isometric lingual
exercise
sequential or
concurrent
Lingual strength
and cheek strength
assessed weekly
30 repetitions
in sets of 10, 7
days/week
elevation,
protrusion,
lateralization
Robbins
et al.
(2007)
10
ischaemic
stroke
patients
(6 acute,
4 chronic)
(5190 yrs.)
10 stroke
&8
myopathy
adults
8 weeks
Isometric lingual
exercise
Increased isometric
strength
Max. swallowing
pressure
Increased
swallowing pressures
Reduced
penetration for
liquids
10 repetitions
(3 day, 3 days/
week)
Kays,
Porcaro,
Gangnon,
Hind, &
Robbins
(2008)
Reduced
penetration for
liquids
8 weeks
Isometric lingual
exercise
anterior and
posterior tongue
Max. isometric
pressure
Max. swallowing
pressure
Lingual volume (MRI)
Pene. Asp. (VFSS)
10 repetitions
(3 day, 3 days/
week)
144
Increase in lingual
volume in two
patients
Increased lingual
strength for
anterior/posterior
for stroke &
posterior for
myopathy
Increased lingual
volume -> increased
tongue mass
References
American Stroke Association. (2010). Understanding risk. Retrieved February 7, 2010, from http://
www.strokeassociation.org/STROKEORG/
AboutStroke/UnderstandingRisk/
Understanding-Risk_UCM_308539_
SubHomePage.jsp
Burkhead, L. M., Sapienza, C. M., & Rosenbek, J.
C. (2007). Strength-training exercise in dysphagia rehabilitation: Principles, procedures,
146 ASIA PACIFIC JOURNAL OF SPEECH, LANGUAGE, AND HEARING, VOL. 14, NO. 3
from http://www.strokefoundation.com.au/
news/latest/clinical-guidelines-for-acutestroke-management-2010
Ney, D. M., Weiss, J. M., Kind, A. J., & Robbins, J.
(2009). Senescent swallowing: impact, strategies, and interventions. Nutrition and Clinical Practice, 24(3), 395413.
Nicosia, M. A., Hind, J., Roecker, E. B., Carnes,
M., Doyle, J., Dengel, G. A., & Robbins, J.
(2000). Age effects on the temporal evaluation
of isometric and swallowing pressure. Journal of Gerontology, 55A(11), M634M640.
Robbins, J., Gangnon, R. E., Theis, S. M., Kays,
S. A., Hewitt, A. L., & Hind, J. A. (2005). The
effects of lingual exercise on swallowing in
older adults. Journal of American Geriatric
Society, 53, 14831489.
Robbins, J., Kays, S. A., Gangnon, R. E., Hind, J.
A., Hewitt, A. L., Gentry, L. R., & Taylor, A.
J. (2007). The effects of lingual exercise in