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Abstract
Purpose: This review critiques the benefit of commonly used rehabilitative exercises for dysphagia.
Method: Common goals of rehabilitation for dysphagia and principles of neuroplasticity are introduced as they apply to swal-
lowing and non-swallowing exercises. A critique of published studies is offered regarding their evidence for showing benefit
from the exercise.
Result: One of five swallow exercises had preliminary evidence for long-term benefit and two of four non-swallow exercises
have strong evidence for long-term benefit.
Conclusion: Only a minority of exercises prescribed for patients with dysphagia have sufficient evidence for long-term
improvement in swallowing.
Introduction
it is tempting to use anecdotes, clinical experience
Exercise rehabilitation has long been a treatment for and popularized methods, clinicians must remember
patients with dysphagia. A variety of exercises exist, that the best treatment is one that has not only been
ranging from direct to indirect, isolated to combined tried, but tested.
and those incorporating swallowing or non-swallowing There are several models regarding levels of evi-
exercises. Rehabilitative exercises are those meant to dence one can turn to when critiquing any particular
change and improve the swallowing physiology in study (Liddle, Williamson, & Irwig, 1996; Lohr, 2004;
force, speed or timing, with the goal being to produce Robey, 2004). The lowest level of evidence comes
a long-term effect, as compared to compensatory from a study where one group of patients is tested
interventions used for a short-term effect. Rehabili- before and after the intervention. Stronger evidence
tative exercises also involve retraining the neuromus- is achieved when two groups of subjects are compared
cular systems to bring about neuroplasticity, since in some fashion. The ultimate test of any exercise is
pushing any muscular system in an intense and per- to evaluate its efficacy in a controlled study where two
sistent way will bring about changes in neural inner- groups of subjects are studied prospectively. Efficacy
vation and patterns of movement (Burkhead, 2003; is usually studied in an ideal setting such as a con-
Sapienza, & Rosenbek, 2007; Clark, 2003; Fox, trolled environment with two similar groups of sub-
Ramig, Ciucci, Sapir, McFarland, & Farley, 2006; jects where clinician and subject bias is minimized,
Kleim & Jones, 2008; Robbins, Butler, Daniels, like a randomized controlled trial. A critical compo-
Gross, Langmore, Lazarus, et al., 2008). nent of the study design is to compare the experimen-
The purpose of this paper is to highlight where the tal treatment to another treatment or to no treatment
field stands on rehabilitative exercises for dysphagia to determine its relative benefit as measured by some
with emphasis on one question: What is the evidence? concrete variable or outcome. Such proof increases
With the field of speech pathology growing and many the likelihood that the exercise will have effectiveness
clinicians creating new treatments for their patients, or will work in a real-world setting (i.e. at home or in
it is easy to fall into the trap of using a homegrown a nursing facility with a variety of patients). Herein
or popular rehabilitative treatment. However, while lies the empirical foundation of evidence-based prac-
Correspondence: Professor Susan E. Langmore, PhD, Boston University School of Medicine, Otolaryngology, 820 Harrison Ave, FGH Bldg, 4th floor,
Boston, MA 02118, USA. E-mail: langmore@bu.edu
ISSN 1754-9507 print/ISSN 1754-9515 online © 2015 The Speech Pathology Association of Australia Limited
Published by Informa UK, Ltd.
DOI: 10.3109/17549507.2015.1024171
2 S. E. Langmore & J. Pisegna
tice. This paper aims to review and critique the cur- assigned to an experimental or control group. There
rent evidence for efficacy of exercises for dysphagia are many requirements of a clinical trial to qualify as
rehabilitation. It is not a formal systematic review but an RCT. All these precautions are aimed at reducing
a narrative review with a focus on evidence of efficacy bias or confounding factors that may influence which
of the intervention as a long-term benefit. treatment arm is proven better. Even though RCTs
remain the gold standard of research, other study
designs, including case-control cohort studies and
Why do we need well-designed studies to even single-subject designs, have potential to be well
prove a treatment works? done if they are controlled studies, designed to limit
bias, and have enough power in their sample size
Every patient is unique. Different factors play a role (Wheeler-Hegland, Frymark, Schooling, McCabe,
in each patient’s background, medical condition and Ashford, Mullen, et al., 2009).
prognosis. Age, morbidities, time post-onset, motiva-
tion and compliance are just a few of the factors that
affect a particular patient’s status. A well-designed What are the physiologic goals in
study will define the patient population, allowing cli- rehabilitation for a patient with dysphagia?
nicians to decide if their specific patient fits the Defining goals for the dysphagic patient can be chal-
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description of the study’s patients. If not, this lessens lenging because it requires the creation of a concrete
the probability that the same exercise will work on a outcome for an abstract entity. That is, how does one
patient who is very different from those described in define a “better swallow”? Is it simply a safe outcome
the published study. Of note, many studies have of no aspiration or better clearance and reduced resi-
tested the effect of an exercise on normal, healthy due? Even when a concrete outcome is selected, mea-
individuals but not in patients with dysphagia. This suring it can be challenging. For example, for an
is a severe limitation when generalizing the results to outcome of reduced aspiration, how would it be mea-
a patient population. sured? Which measurement technique or scale would
Clinical experience introduces bias (Cochrane, be used, what bolus(es) and what would the cut-off
1972; Gray, 1997; Sackett, Richardson, Gray, point be to distinguish normal from abnormal? Unfor-
For personal use only.
Haynes, & Rosenberg, 1996). As clinicians create a tunately, there is no set prescription, making goal-set-
toolbox of strategies, they begin to form biases to ting difficult and unstandardized. However, that does
certain treatments they have seen work well with not mean goals should not be set. Clinicians should
prior patients. Using clinical experience as a tool is decide if the outcomes reported in the published study
an important strategy and creates valuable knowl- are appropriate and meaningful for their patients.
edge, but must be used with caution. What works for The goals a clinician sets for a dysphagic patient
one particular clinician and patient is not going to should be based on his/her limitations and main
necessarily work for another. Well-designed studies problem(s). One goal may be to make the swallow
should control for bias by blinding both clinicians stronger. This goal could involve measuring the
and patients to treatment where possible or at least strength of the tongue with an Iowa Oral Performance
having independent persons assess outcome mea- Instrument (IOPI) using normative data (Clark,
sures without knowledge of the treatment arm to O’Brien, Calleja, & Newcomb, 2009; Robbins, Kays,
which the subjects/patient was assigned. Rather than Gangnon, Hind, Hewitt, Gentry, et al., 2007) or using
comparing two groups of patients who underwent manometry to measure the pressures generated by the
two or more different pre-determined treatments, it pharyngeal walls (Doeltgen, Macrae, Huckabee, 2011;
is preferable to randomize patients into experimental Doeltgen, Witte, Gumbley, & Huckabee, 2009;
and sham or control groups so that the outcomes are Lazarus, Logemann, Song, Rademaker, & Kahrilas,
not tied to patient-specific factors. The results of 2002). Another goal may be to improve endurance
such a design drive clinical work by proving treat- over the meal or over the day. This may involve chal-
ments to be efficacious in the absence of bias. lenging the system with tougher foods, like a dry
It is easier, but misleading, to follow the “experts” cracker or steak, to fatigue the muscles and build
instead of the evidence. Experts provide wisdom and endurance, as long as it does not pose a safety concern
experience, but their word is not gold. The advice for for airway protection. Leaders in the field have out-
them is the same as for a beginning clinician: use lined the differences between power and endurance in
external evidence to judge the appropriateness of an their comprehensive and useful tutorial articles on exer-
intervention for your particular patient. A dangerous cise (Burkhead et al., 2007; Clark, 2003). Another goal
trap is to “do what the experts do”. However, just may involve making the onset of the swallow faster or
like a poorly designed study, an expert’s opinion may better timed with bolus flow. A “controlled swallow”
have flaws as well. is an example of this technique as it teaches the patient
Thus, it is a clinician’s responsibility to look for how to reduce spillage of the bolus prior to swallow
the highest levels of evidence, such as controlled onset and to swallow the bolus in a timelier manner.
trials. The gold standard design is a randomized Other non-physiologic goals are part of the bigger
controlled trial (RCTs) where patients are randomly picture: improving the diet to include more
Exercises and efficacy 3
consistencies, improving the patient’s social life, swallowing recruits specific motor units; hence,
gaining weight and preventing aspiration pneumo- training that task will reinforce the motor units and
nia. While these goals are not direct outcomes of their involved neuronal pathways (Clark, 2003; Clark
rehabilitation exercise, they are the ultimate goal and Shelton, 2011; Robbins et al., 2008). An analogy
aiming to positively impact the patient’s life. might be found in running: to be a great runner, one
needs to practice running. However, a great runner
also should lift weights to improve strength, and this
Exercise rehabilitation is where the fourth principle, transference, fits into
swallowing exercises (Burkhead et al., 2007; Robbins
The principles of exercise rehabilitation have been
et al., 2008). Other motor units can learn to par-
widely documented and neuroplasticity is at the core
ticipate in the task (perhaps by increasing overall
of all of them. Neuroplasticity is best defined as the
strength) or even take over the task (for example
ability of the brain and nervous system to change,
after a stroke when non-damaged adjacent cortical
structurally and functionally (see Table I). These
areas or homologous areas in the non-damaged
changes can be brought about from any form of input,
hemisphere may get involved) as transference occurs
including exercise. Neuroplasticity does not accom-
(Robbins et al., 2008).
pany compensatory techniques because these are, by
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efit is that it is easier to make the exercises more trial (RCT or well controlled clinical trial) was done
“intense” because they are more easily measured on healthy subjects, it was also mentioned.
(e.g., tongue strength can be measured in kPa),
whereas the act of swallowing is more complex and
is difficult to “measure”. Increasing or decreasing the Combining exercises
“resistive load” of swallowing is an elusive challenge. One other limitation in critiquing the research in this
Thus, the principles of intensity, repetition and time area is that most exercises have been prescribed in
are most easily met with non-swallowing exercises. the context of a set of multiple exercises, such as
Further, non-swallowing exercises may be easier to Pharyngocise (Carnaby-Mann, Crary, Schmalfuss,
learn because swallowing is often understood as a & Amdur, 2012). While this makes a lot of sense in
one-dimensional task that is difficult to perform dif- the clinical world, scientifically it becomes very dif-
ferently. Finally, non-swallowing exercises can be ficult to evaluate the specific effect of the exercise of
done by patients who cannot eat orally (are tube fed) interest. In this review, only exercises that were prac-
or those post-surgery who are temporarily restricted ticed in isolation were evaluated, with one exception
from eating orally. (Carnaby-Mann & Crary, 2010).
Table I provides a checklist of the neuroplasticity
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always have an immediate or compensatory effect. It patients (for example, a matched case-control
will alter the swallow immediately because the per- design).
son is swallowing with more effort, holding it out A summary of the evidence for efficacy of exer-
longer, or holding the breath earlier. However, if the cise rehabilitation of frequently used swallowing
swallow manoeuvre is taught with the purpose of and non-swallowing exercises is shown in Tables II
making the swallow permanently stronger or faster, and III. While there are dozens of published studies
then it becomes an exercise. that have assessed these exercises, the tables are
If a swallow or non-swallow exercise is effective, limited only to those studies that have investigated
this means that, after performing the exercise for the selected exercises (1) over time, (2) using a
4–6 weeks at a given intensity, the swallow will be high-quality controlled research design and (3) on
stronger. If a swallow manoeuvre was the target exer- patients with dysphagia, with some exceptions due
cise, the swallow will be stronger even when the to the limited amount of evidence. Also listed in the
manoeuvre is no longer used, Simply put, the swallow tables is each study’s population to allow clinicians
will be stronger because it has strengthened the mus- to assess generalizability to their patients. Finally,
cles used in swallowing. The authors of this review notes regarding the study design are shown that will
have restricted their critique to studies that looked at hopefully guide clinicians in selecting well-designed
the long-term effect of exercises only (patients are studies. The last column in the tables suggests
rated at baseline and after 4–6 weeks of exercise). whether or not a clinician should use the exercise
with confidence based solely on the criteria dis-
cussed in this paper. This recommendation indi-
Use of healthy subjects cates which exercises have well-supported evidence
An important limitation in the literature is that for their use. This review is not absolutely compre-
many exercises have only been trialled in healthy hensive, as it was not a formal Systematic Review.
subjects. These studies are, indeed, important as
proof of principle, but such evidence is only vaguely
Swallowing exercises: Effortful swallow, Mendelsohn,
suggestive of what may occur if the exercise is used
super-supraglottic, Masako, McNeill dysphagia
over time in patients with dysphagia. After all,
treatment protocol
healthy persons execute a swallow with appropriate
strength and speed and may not alter their usual Effortful swallow. The authors of this review were only
swallow after an unnecessary exercise. The authors able to identify two studies that investigated the
aimed to focus on studies that enrolled patients with Effortful Swallow as an exercise over time. Clark and
dysphagia, although, if a very well-designed clinical Shelton (2014) conducted a well-designed 3-arm
Exercises and efficacy 5
RCT whereby the participants exercised for 4 weeks. Masako as an exercise over time. A small cohort
One group practiced the Effortful Swallow in isola- study (Oh, Park, Cha, Woo, & Kim, 2011) was car-
tion, whereas the other two groups performed a ried out on a single group of normal subjects who
related tongue exercise, immediately followed by the underwent 4 weeks of exercise using the manoeuvre.
Effortful Swallow. After training, subjects in all three It showed no long-term effect on swallowing. How-
groups demonstrated greater, albeit non-significant, ever, because the subjects were normal, their results
increases in lingual pressures when performing cannot be generalized to patients with dysphagia. Its
effortful swallows. Non-effortful swallows were not weak design (no control group) precluded it being
as strong. While the study design carried out in this listed in Table II.
study was excellent, two major limitations impede its
clinical utility. It was done on healthy, normal sub- McNeill dysphagia treatment protocol. This is a rela-
jects; thus, the results cannot be generalized to tively new program in which swallowing “hard” is the
patients with dysphagia. Related to this is the finding single focus. This exercise appears similar to the
that their “normal” swallows did not get significantly Effortful Swallow, but details of the program have not
stronger—likely because they were appropriately been published. Thus, this exercise was conditionally
strong already. considered. Reportedly, bolus sizes and volumes are
increased in difficulty and the patient is encouraged
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it between one’s teeth. It is intended to target the Berretin-Felix, Sia, Carnaby-Mann, & Crary, 2012)
base of tongue and pharyngeal walls at that level. where eight patients were compared to normal healthy
Only one published study has investigated the controls. This review judged the matched case-con-
Table II. Common swallowing exercises (used over time, not including immediate effects) and evidence for their use.
Effortful swallow (in Clark & Shelton Normal healthy; 4 Increased oral RCT with 3 No evidence yet with
isolation only*) (2014) weeks of exercise pressures when groups (n 40 patients with
using effortful total subjects); dysphagia
swallow only healthy
compared to subjects
non-effortful
Masako Manoeuvre No controlled studies No evidence from
met criteria controlled trials
McNeill Dysphagia Carnaby-Mann & Stroke and head-neck (MASA and Matched Not enough evidence
Treatment Protocol Crary (2010) cancer patients with FOIS) historical at this time
dysphagia; 3 weeks case-control;
of exercise vs Small cohort
historical controls (n 24 total
given traditional subjects);
therapy Exercise
duration too
short
Mendelsohn Manoeuvre McCullough Stroke patients with (in 2 out of 10 Small RCT of Yes, but cautiously
(2012) dysphagia, 6 weeks fluoroscopy cross-over with stroke patients
to 22 months measures) design (n 18 with dysphagia
post-stroke; 2 weeks total subjects)
of exercise
Super-Supraglottic No controlled studies No evidence from
Swallow met criteria controlled trials
CT, randomized controlled trial; MASA, Mann Assessment of Swallowing Ability (Mann, 2002); FOIS, Functional Oral Intake Scale
R
(Crary, Carnaby-Mann, & Groher, 2005); tx, treatment.
*Outcomes with a () indicate a finding that demonstrated statistically significant effects of the exercise by the authors at p 0.05,
whereas (−) indicates that the study found no significant outcome.
6 S. E. Langmore & J. Pisegna
trol to be of adequate quality and, thus, is included Ohmae, Logemann, Kaiser, Hanson, & Kahrilas,
in Table II. Outcomes were positive, but the evidence 1996) and, thus, it has the potential as an exercise.
is based on a relatively weak study design.
Non-swallowing exercises: Shaker head lift, tongue
Mendelsohn. The Mendelsohn is a well-known swal-
strengthening, Lee Silverman voice treatment,
low manoeuvre to target laryngeal excursion. It is
expiratory muscle strength training
often taught with some form of biofeedback to help
the patient perform it correctly. The authors of this Shaker head lift. The Shaker Head Lift, a combina-
review could find evidence for the long-term effect tion of an isometric and isokinetic exercise, has been
of the Mendelsohn manoeuvre in only one study. shown to have favourable long-term effects by
McCullough et al. (2012) led a well-designed but improving the strength of the suprahyoid muscles
small RCT (cross-over design) demonstrating lim- over time, and increasing the opening of the upper
ited beneficial effects of the Mendelsohn in improv- oesophageal sphincter in patients with dysphagia
ing the swallow in stroke patients. Two of 10 variables (Shaker et al., 1997, 2002). It improves both strength
measured in the fluoroscopy studies significantly and endurance and has evidence of long-term effects.
improved after treatment. These both measured The study designs reviewed here were good quality
hyoid movement, which is one of the primary targets
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the long-term effect of this manoeuvre, although it This was done on head and neck cancer patients
is known that this manoeuvre has immediate effects with dysphagia (Lazarus et al., 2014). The experi-
on laryngeal and hyoid excursion (Kashara, mental group practiced the same exercises as the
Hanayama, Kodama, Aono, & Masakado, 2009: control group, but with an added tongue resistance
Table III. Common non-swallowing exercises (used over time, not including immediate effects) and evidence for their use.
Shaker Head Lift Shaker et al. (1997) Healthy elderly; 6 (fluoroscopy and RCT with decent Yes, with confidence
weeks of exercise manometry) sample size (n 31 in several patient
total subjects), but types
healthy subjects
Shaker et al. (2002) Severe dysphagia; (fluoroscopy RCT (n 27 total
mixed aetiologies; measures and subjects)
all tube fed 6 return to oral
weeks of exercise feeding)
Logemann, All subjects with /− (Less aspiration; RCT but small
Rademaker, dysphagia; mixed no other differences sample size of
Pauloski, Kelly, aetiologies; 6 on fluoroscopy mixed aetiologies
Stangl-McBreen, weeks of exercise (n 14 total
& Antinoja (2009) subjects)
Tongue Lazarus et al. Head-neck cancer − (Tongue strength RCT but small Negative evidence the
strengthening (2013) patients with and fluoroscopy sample size (n 23 head-neck cancer
dysphagia. measures) total subjects) population;
1 month insufficient evidence
post-radiation; 8 in other groups
weeks of exercise
Lee Silverman No controlled studies met criteria No evidence from
Voice Treatment controlled trials
(LSVT)
Expiratory Muscle Troche et al. (2010) Parkinson’s patients (PAS and RCT with large Yes, with Parkinson’s
Strength Training with dysphagia; 4 fluoroscopy sample size patients
(EMST) weeks of exercise measures) (n 60)
exercise. After 8 weeks of exercise, the experimental investigated, but not within the context of a well-
group showed no benefit for swallowing, as designed study to determine their long-term
measured by fluoroscopic studies or tongue strength. effects.
Other studies that were considered investigated Two non-swallowing exercises, on the other hand,
tongue strengthening and reported good outcomes, were found to have high-quality evidence from
but they were judged of lesser quality due to small RCTs. Positive results were found in RCTs inves-
sample sizes, enrolment of healthy subjects or an tigating the Shaker Head Lift and Expiratory Mus-
uncontrolled study design (Lazarus, Logemann, cle Strength Training (EMST). Their efficacy,
Huang, & Rademaker, 2003; Robbins, Gangnon, therefore, could be generalized to a patients with a
Theis, Kays, Hewitt, & Hind et al., 2005; Robbins variety of aetiologies, including stroke and head/
et al., 2007). neck cancer (with the Shaker Head Lift) and to
Parkinson’s patients (for EMST). These two exer-
Lee Silverman voice treatment (LSVT). One interest- cises can be recommended with confidence, while
ing study investigated the effect of a non-swallow all the others have insufficient evidence to recom-
program designed to improve vocal intensity (Lee mend their use. Tongue strengthening has had one
Silverman Voice Treatment program; Scott, S., large RCT to test its efficacy and the result was
& Caird, F.L., 1983). One group of researchers
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