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Rehabilitation of swallowing by exercise in tube-

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Article in Gastroenterology · May 2002

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Rehabilitation of Swallowing by Exercise in Tube-Fed Patients
With Pharyngeal Dysphagia Secondary to Abnormal
UES Opening
REZA SHAKER, CARYN EASTERLING, MARK KERN, TERILYNN NITSCHKE, BENSON MASSEY,
STEPHANIE DANIELS, BARBARA GRANDE, MARTA KAZANDJIAN, and KAREN DIKEMAN
MCW Dysphagia Institute, Division of Gastroenterology and Hepatology, Digestive Disease Center, Medical College of Wisconsin and
Zablocki VA Medical Center, Milwaukee, Wisconsin
Background & Aims: We evaluated the effect of a novel
rehabilitative exercise on restoration of deglutition in a
group of patients with deglutitive failure caused by ab-
normal upper esophageal sphincter (UES) opening man-
ifested by postswallow residue and aspiration necessi-
tating percutaneous tube feeding. Methods: We studied
a total of 27 patients by videofluoroscopy and functional
assessment of swallowing scores before and after 6
weeks of a head-raising exercise program. Seven of 27
patients, assigned randomly, participated in a sham
exercise before entering the tested exercise program.
Eleven of 27 were randomized to the real exercise pro-
gram. Results: Although there was no change in swallow
function and biomechanics after the sham exercise,
following 6 weeks of real exercise, all 11 patients exhib-
ited a significant improvement in their UES opening,
anterior laryngeal excursion (P < 0.01), as well as res-
olution of postdeglutitive aspiration and were able to
resume oral feeding. Similar results were found when
the 7 patients in the sham group were crossed over to
the real exercise group. Comparison of before and after
exercise values for anteroposterior UES opening (P <
0.01) and laryngeal anterior excursion (P < 0.05), as
well as functional outcome assessment of swallowing
(P < 0.05) in the entire group of 27 patients also
showed significant improvement. Etiology and duration
of dysphagia did not affect the outcome. Conclusions:
The proposed suprahyoid muscle strengthening exercise
program is effective in restoring oral feeding in some
patients with deglutitive failure because of abnormal
UES opening.
bnormalities of swallowing are common especially
A among elderly individuals1– 8 and may involve the
preparatory, oropharyngeal, or esophageal phases of swal-
lowing. Normal deglutition requires an elaborate coor-
dination of neuromuscular activity to achieve passage of
the swallowed material from the oropharynx into the
esophagus while avoiding aspiration. Disorders of deglu-
tition are common sequelae of central nervous system
GASTROENTEROLOGY 2002;122:1314 –1321
diseases, neuromuscular disorders, and therapy for head-
and-neck cancers. Failure of normal deglutition may
cause symptoms of dysphagia, coughing, and choking,
leading to malnutrition, pneumonia, and asphyxia.
Separating the oropharynx and esophagus, the upper
esophageal sphincter (UES) serves as a critical gateway in
the coordination of breathing and swallowing. Between
swallows, the UES prevents air entry into the digestive
tract during respiration and speech. However, during
swallows the cricopharyngeus muscle, the main compo-
nent of the UES, relaxes and is pulled open forcibly by
the contraction of suprahyoid muscles such as mylohy-
oid, geniohyoid, and digastric involved in UES open-
ing.9,10 In a variety of pathologic conditions,11 including
cerebrovascular accident, brainstem lesions, central de-
generative disorders, posterior cerebellar artery thrombo-
sis, and bulbar paralysis, the UES opening is inadequate
and acts as a relative resistor to bolus flow out of the
pharynx. This, in turn, may result in postswallow residue
and aspiration.
The possibility of decreasing the resistance to bolus
flow by increasing the deglutitive UES opening through
exercise aimed at the suprahyoid UES opening muscles
was recently shown in a group of asymptomatic elderly
who were found to have a significantly smaller UES
opening compared with young individuals.12 This study
reported that after 6 weeks of an isometric-isokinetic
head-lift exercise, performed 3 times a day, there was a
significant increase in UES anteroposterior opening di-
ameter and a significant decrease in hypopharyngeal in-
trabolus pressure; a marker of resistance to flow.13,14
The present study was undertaken to evaluate the
effect of this exercise on the deglutitive biomechanical
Abbreviations used in this paper: FOAMS, functional outcome as-
sessment of swallowing; UES, upper esophageal sphincter.
© 2002 by the American Gastroenterological Association
0016-5085/02/$35.00
doi:10.1053/gast.2002.32999
May 2002 SWALLOW REHABILITATION EXERCISE 1315

events and functional outcome of swallowing in a group in a sham or real exercise protocol. The patients were random-
of patients with deglutitive failure because of abnormal ized by choosing an envelope that gave written directions for
UES opening manifested by postswallow residue and an exercise to be performed 3 times per day for the following
aspiration necessitating percutaneous tube feeding. 6 weeks. The enrolling speech-language pathologist was aware
of the randomly chosen exercise. The same speech pathologist
Materials and Methods performed the functional outcome assessment of swallowing
(FOAMS). The investigators that performed the videofluoro-
We studied a total of 27 consecutive outpatients (age scopic data analysis, however, were blinded to the assigned
range, 62– 89 years) with a median age of 72 years with exercise group. The enrolling speech pathologist observed the
pharyngeal phase dysphagia secondary to abnormal upper patients as they demonstrated the written exercise format and
esophageal sphincter opening because of a variety of causes. sequence. The speech pathologist gave them written exercise
Patients were enrolled in the study at the Veterans Adminis- instructions to follow while at home and a log on which to
tration Hospital, Froedtert Memorial Lutheran Hospital, and record completion of the exercise sequence 3 times per day for
St. Joseph’s Hospital. Studies were approved by the Human
6 weeks. The sham exercise comprised 15 repetitions of passive
Research Review Committee of the Medical College of Wis-
tongue lateralization performed 3 times a day for 6 weeks. The
consin and other respective institutions, and subjects gave
real exercise was performed as previously described.12 Briefly,
informed consent before their studies. Patients were enrolled in
the patients were instructed to lie flat on the bed or floor and
the study if they met the predetermined criteria for abnormal
perform 3 sustained head raisings for 1 minute in the supine
UES opening, namely, postswallow residue and aspiration and
position, interrupted by a 1-minute rest period. These sus-
were able to independently perform the exercise. Because of the
tained head-raisings were followed by 30 consecutive repeti-
severity of their dysphagia, 18 of 27 patients were fed by
gastrostomy and 9 by jejunostomy tubes. Tube-fed patients tions of head raisings in the same supine position. For both
resided in their homes. Patients with a history of cervical spine sustained and repetitive head raisings, participants were in-
surgery, inability to independently perform the exercise, and structed to raise their head high and forward enough to be able
patients with tracheostomy were excluded from the study. to observe their toes without raising their shoulders off the
Demographics for the patients included in the study are shown floor or bed. Both the sham and real exercises were performed
in the Table 1. Patients were randomized to either participate 3 times a day for a 6-week period. Although there was no
direct observation of patient exercise performance at home, the
patients recorded daily exercise participation on a log that was
Table 1. Patient Demographics returned to the enrolling speech pathologist when the exercise
Duration of was completed.
Patient Gender Age Etiology of dysphagia dysphagia On the day before and the day after completion of 6 weeks
JA M 69 Right CVA 42 days
of exercise, each participant’s deglutitive function was evalu-
FB M 65 Left carotid endarterectomy 42 days ated in the upright position using videofluoroscopy in lateral
WB M 76 Left CVA 30 days and anteroposterior projections during 3 dry and 3 barium
AD M 76 Right CVA 240 days swallows of 5-mL each. For calibration of videofluoroscopic
WD M 66 Pharyngeal radiation 150 days
measurements and to compensate for possible magnification
RG M 82 Myocardial revascularization 18 days
HG M 74 Brainstem stroke 10 days error, before each study a 4-mm diameter catheter with 3
DG M 78 Pharyngeal radiation 2880 days tantalum markers 3 cm apart was placed on the skin in the
FH M 79 Left carotid endarterectomy 107 days pharyngo-UES region and videotaped for subsequent spacial
EK M 67 Pharyngeal radiation 1080 days calibration of distance measurements.
RK M 76 Brainstem stroke 150 days
CL M 62 Right CVA 120 days
For videofluoroscopic recordings, the subjects were in-
GM M 89 Brainstem stroke 10 days structed to hold their head in a neutral position. Videofluoro-
MM M 83 Brainstem stroke 12 days scopic recordings were obtained at 90 keV, using a 9-inch
GM M 72 Left CVA 73 days image-intensifier mode and appropriate collimation so that an
WM M 65 Right CVA 90 days
image was obtained of the posterior mouth, pharynx, and
DM M 76 Myocardial revascularization 100 days
RM M 68 Pharyngeal radiation 9 days pharyngoesophageal region. Fluoroscopic images were re-
PK M 75 Pharyngeal radiation 61 days corded on a super-VHS videocassette recorder (AG-1960 Pro-
DP F 72 Pharyngeal radiation 540 days line; Panasonic, Tokyo, Japan), which recorded 30 frames/60
MR F 72 Suboccipital meningioma 240 days fields/s. Fluoroscopic recordings were timed using a specially
LS M 74 Brainstem stroke 210 days
GT M 64 Brainstem stroke 120 days designed timer. The output of the timer provided a video-
TT M 76 Brainstem stroke 180 days displayed time signal in hundredths of a second superimposed
LV M 71 Right carotid endarterectomy 30 days on the videofluoroscopic images. The videofluoroscopic record-
RW M 76 Right CVA 180 days ings were subsequently digitized and analyzed in a blinded
HW M 78 Right CVA 270 days
fashion with respect to group identity (real or sham) and
CVA, cerebrovascular accident. exercise status (before or after exercise). To determine the
1316 SHAKER ET AL.
interobserver reproducibility, the data were subsequently re-
analyzed by a second individual in a similar blinded fashion.
The computer analysis system used for analyzing the video-
fluoroscopic data consisted of a 486 IBM-compatible computer
operating at 33 MHz. The computer system drives an analog-
to-digital conversion board and program specifically designed
for image capture and analysis. The image-analysis and capture
software (JAVA, Jandel Scientific, San Mateo, CA) allows
capture of standard raster scan video images and morphological
analysis of digitized image data. The digitized images are
stored as computer files for any subsequent recall or analysis.
Using these techniques we measured (1) the anteroposterior
and lateral diameters of the UES opening during 5-mL liquid
barium swallows, taken from the narrowest area within the
pharyngoesophageal junction when this area became maxi-
mally opened during bolus transit across the sphincter; (2)
maximum superior and anterior excursion of hyoid bone and
maximum superior and anterior excursion of the larynx during
5-mL barium swallows; (3) height and width of pyriform sinus
residue; and (4) presence or absence of aspiration.
The clinical effect of exercise on swallowing was evaluated
using the FOAMS from the Wisconsin Speech Language Pa-
thology and Audiology Association.15 In this scoring system a
numerical score of 1 to 7 is assigned to each participant’s level
of swallowing competency, that is a score of 1 being the worst
and 7 the best score corresponding to functional swallowing
(Table 2).
Several months into the exercise enrollment period, the
enrolling speech pathologist’s clinical observation of the pa-
tient’s ability to handle and clear secretions demonstrated
significant improvement in the patients performing the real
exercise, but not in the group performing the sham exercise.
For this reason, a decision was made not to enroll additional
patients in the sham exercise group. Seven patients had been
enrolled in the sham exercise group, and 11 patients were
enrolled in the real exercise group at this point. Patients who
had completed 6 weeks of sham exercise then participated in 6
weeks of the real exercise program. Therefore, a total of 27
patients had completed 6 weeks of the real exercise, 7 of whom
had completed the sham exercise before doing the real exercise.
Statistical analyses were performed using parametric and
nonparametric testing. The effect of the exercise on the mea-
sured biomechanical parameters were tested using 2-way anal-
ysis of variance (ANOVA) with repeated measures to account
for both intrasubject variability and the exercise effect.
FOAMS Scores were compared using the Wilcoxon signed
rank test. Normality was tested using Kolmogorov–Smirnov
analysis. Significance of P ⬍ 0.05 and power of 0.8 were used
as statistical criteria for rejecting the null hypothesis and
analysis of type II error. Data in the text are presented as
means ⫾ SE unless stated otherwise.
Results
All 27 patients successfully completed the exer-
cise protocols. Invariably, the patients reported some
GASTROENTEROLOGY Vol. 122, No. 5
Table 2. FOAMS Scoring Scale
FOAMS
score Description
1 Profound
Patient is NPO
Requires enteral or paraenteral feeding to maintain
adequate nutrition and hydration
Profoundly impaired airway protection
2 Severe
Primary mode of nutrition and hydration is non-oral
Oral intake is limited to therapeutic feeding/directed
swallowing therapy supervised by speech pathologist
due to severely impaired airway protection
3 Moderately/severe
Partially dependent on non-oral enteral/paraenteral
feeding for nutrition and hydration
Fairly safe swallowing only when diet consistency and/
or liquid consistency is modified
Inconsistently utilizes compensatory swallowing
strategies even with close supervision or constant
cuing
4 Moderate
Primary mode of nutrition and hydration is oral
May require non-oral supplements
Safe swallowing function only when diet consistency
and/or liquid consistency is modified
Inconsistently utilizes compensatory swallowing
strategies even with close supervision or constant
cuing
5 Mild/moderate
Primary mode of nutrition and hydration is oral
Safe swallowing function only when diet consistency
and/or liquid consistency is modified
Requires compensatory swallowing strategies with
constant supervision
Additional time usually necessary for meals because of
use of swallowing strategies
6 Mild
Safe and efficient swallowing only when diet
consistency and/or liquid consistency is modified
May require compensatory swallowing strategies with
occasional cueing
Additional time usually necessary for meals because of
use of swallowing strategies
7 Functional
Safe and efficient swallowing of thin liquids and diet
that may be modified for dentition or digestive needs
Adequate airway protection
Requires no cueing to utilize compensatory swallowing
strategies
Additional time may be required during meals to ensure
safe intake
minor degree of anterior neck muscle discomfort during
the first few days of real exercise. However, the discom-
fort was not severe enough to result in discontinuation of
the exercise by any of the patients, and it resolved
spontaneously.
Comparison of the Sham and Real Exercise
At the time of terminating the enrollment in the
sham exercise group, as explained in the Materials and
May 2002 SWALLOW REHABILITATION EXERCISE 1317

Methods section, there were 7 patients enrolled in the

sham exercise program and 11 in the real exercise pro-
gram. Comparison of the before exercise biomechanical
parameters did not show any statistical difference be-
tween the sham and the real exercise groups.
Among the 7 patients who completed the sham exer-
cise, there were no significant changes in the measured
biomechanical parameters, such as anterior laryngeal ex-
cursion, anteroposterior diameter of the maximum UES
opening, or swallowing function when compared with
the before exercise biomechanical or functional swallow-
ing values.
Among the 11 patients who were randomized to the
real exercise group, after 6 weeks of exercise, all
patients exhibited a significant increase in the antero-
posterior diameter of the UES opening (5.1 ⫾ 0.5 mm
before exercise to 7.2 ⫾ 0.5 mm after exercise; P ⬍
0.01), maximum anterior laryngeal excursion (11.8 ⫾
2.0 mm before exercise to 16.2 ⫾ 2.1 mm after
exercise; P ⬍ 0.01), as well as FOAMS (P ⬍ 0.01).
Changes in other biomechanical parameters, such as
superior laryngeal excursion, anterior and superior
hyoid bone excursion, and lateral diameter of UES
opening did not reach statistical significance after 6
weeks of real exercise.
Between group comparison of 7 patients in the
sham and 11 patients in the real exercise groups Figure 1. (A) Comparison of FOAMS scores before and after exercise
revealed a significant difference in the functional out- for the sham exercise group (n ⫽ 7) and the real exercise group (n ⫽
11). The FOAMS scores after the sham exercise are not significantly
come assessment measurements of swallowing between different from those before exercise, whereas the FOAMS scores after
the 2 groups following their respective exercises (P ⬍ the real exercise are significantly different from those before the real
0.01; Figure 1A ). In regard to biomechanical degluti- exercise (P ⬍ 0.01). Furthermore, after real exercise FOAMS scores
are significantly different from those of after sham exercise scores
tive events, although the average anteroposterior di- (P ⬍ 0.01). Each patient in each exercise group is identified by a
ameter of the UES was larger after the real exercise geometric shape that has been kept constant before and after exer-
compared with after the sham exercise, this difference cise. (B) Although there was no significant difference between the
before exercise and after exercise values for the sham exercise
did not reach statistical significance (P ⫽ 0.4; group, after 6 weeks of real exercise the maximum deglutitive antero-
Figure 1B). posterior diameter of the UES opening increased significantly com-
pared with the before-exercise values (P ⬍ 0.01). The difference
Crossover of the Sham Exercise Group to between after real exercise and after sham exercise values, however,
did not reach statistical significance (P ⫽ 0.4).
Real Exercise
Following 6 weeks of exercise, the 7 patients in
the sham exercise group were crossed over to perform Effect of Exercise on Deglutitive
the real exercise for 6 weeks. Following 6 weeks of the Biomechanical Events and Swallow
real exercise, all 7 patients exhibited a significant Function
increase in anteroposterior diameter of the UES open- Comparison of the before exercise and after exer-
ing (P ⬍ 0.01), anterior excursion of the larynx (P ⬍ cise biomechanical measurements and swallow function
0.05), as well as the functional outcome assessment of the 27 patients who participated in the real exercise
measure of swallowing (P ⬍ 0.05) (Figure 2A and B). group showed a significant increase in the anteroposterior
Changes in other biomechanical parameters, such as diameter of the UES (P ⬍ 0.01), anterior excursion of the
superior laryngeal and hyoid bone excursion or lateral larynx during swallowing (P ⬍ 0.05; Figure 3), as well
diameter of the UES did not reach statistical signifi- as a significant increase in the functional outcome assess-
cance after real exercise. ment measure of swallowing (P ⬍ 0.001; Figure 4).
1318 SHAKER ET AL.
Figure 2. (A) Comparison of the effect of sham and real exercises on
deglutitive biomechanics. Following 6 weeks of real exercise there
was a significant increase in the anteroposterior diameter of maxi-
mum UES opening (P ⬍ 0.01) and maximum anterior excursion of the
larynx (P ⬍ 0.05) during swallowing 5-mL barium bolus, compared
with both before and after sham exercise values. The sham exercise
did not change the measured parameters significantly. (B) Compari-
son of the FOAMS between sham and real exercise regimens. Al-
though the sham exercise had no effect on swallow function, the real
exercise resulted in significant improvement in swallow function (*P ⬍
0.05).
There were no statistically significant changes in other
biomechanical parameters, such as superior laryngeal,
anterior and superior hyoid excursions, or lateral diam-
eter of UES opening.
Inspection of the demographic data (Table 1) reveals
that 3 patients were enrolled in the real exercise program
within the first 21 days after their cerebrovascular acci-
dent and because these patients may have shown spon-
taneous recovery, we reanalyzed the previously men-
tioned data after excluding these 3 patients. Comparison
of the before and after exercise biomechanical measure-
ments and swallow function of the remaining 24 patients
continued to show a significant increase in the antero-
posterior diameter of the UES (5.8 ⫾ 0.4 mm before
exercise to 7.4 ⫾ 0.4 mm after exercise; P ⬍ 0.01) and
anterior excursion of the larynx (13.0 ⫾ 1.6 mm before
exercise to 16.3 ⫾ 1.8 mm after exercise; P⬍0.01). The
functional outcome assessment measure of swallowing
GASTROENTEROLOGY Vol. 122, No. 5
Figure 3. Effect of exercise on deglutitive biomechanics in all 27
patients. Following 6 weeks of exercise, there was a significant in-
crease in the anteroposterior diameter of the UES (*P ⬍ 0.01). This
was accompanied by a significant increase in maximum anterior
excursion of the larynx (*P ⬍ 0.05). Changes in other biomechanical
parameters did not reach statistical significance.
also continued to show a significant improvement fol-
lowing the real exercise (P ⬍ 0.001). Similar to the
previous analysis, there were no statistically significant
changes in other measured biomechanical parameters.
Effect of Exercise on Postdeglutitive
Residue and Aspiration
Comparison of the before and after exercise height
and width of postswallow pyriform sinus residue showed
a significant decrease after 6 weeks of exercise in both
parameters (P ⬍ 0.01; Figure 5). In all 27 subjects,
postdeglutitive aspiration observed during the before
exercise evaluation resolved completely following com-
pletion of 6 weeks of exercise. Two of the patients had
predeglutitive aspiration in addition to postdeglutitive
aspiration. The predeglutitive aspiration remained unre-
solved. All 27 patients were able to discontinue tube
Figure 4. Effect of exercise on FOAMS. Following 6 weeks of exercise,
the FOAMS score increased significantly (*P ⬍ 0.001), and all 27
patients achieved a safe swallow. Two with a score of 5, i.e., func-
tional with modified diet, 5 achieved a score of 6, and 20 achieved a
score of 7. Tube feeding was discontinued in all patients. The 3
patients who were enrolled within 21 days of their cerebrovascular
accident are identified by the open triangle.
May 2002
feedings and resume oral feeding after 6 weeks of exer-
cise. Their oral intake included: 20 patients who were
able to eat a general diet, meaning no solid or liquid food
consistency restriction, 5 patients who were able to eat a
soft mechanical diet consisting of easily chewable foods,
and no restrictions on liquid consistency secondary to
cognitive compromise, and 2 patients who ate soft chew-
able foods with liquid consistency limited to nectar
viscosity because of predeglutitive aspiration.
Although not included in the original design of the
study, we analyzed the data post hoc in regard to the
duration of dysphagia, as well as the etiology of the
abnormal UES opening. We arbitrarily grouped the 27
patients into the following 4 groups according to the
duration of their dysphagia: group I, 0 –2 months dura-
tion; group II, 2– 4 months duration; group III, 4 – 6
months duration; and group IV, those with duration of
dysphagia for more than 6 months. All groups exhibited
significant improvement in functional assessment out-
come measure of swallowing (P ⬍ 0.001; Figure 6), as
well as in biomechanical measurements, significant de-
crease in height and width of postdeglutitive residue,
and resolution of postdeglutitive aspiration (P ⬍ 0.05).
With respect to the etiology of dysphagia, similarly,
there were significant improvements in all measured
parameters regardless of the cause of the dysphagia and
abnormal UES opening (P ⬍ 0.05). Table 3 represents
the before and after exercise FOAMS scores for various
groups.
Interobserver Reproducibility
The significant increase in the UES anteroposte-
rior opening diameter, anterior laryngeal excursion, as
well as the decrease in pyriform sinus residue and reso-
lution of aspiration compared with before exercise values
Figure 5. Effect of exercise on height and width of pyriform sinus
residue. After 6 weeks of exercise, both the height and width of the
pyriform sinus residue, after 5 mL barium bolus swallows, decreased
significantly (*P ⬍ 0.01). This was associated with elimination of
postdeglutitive aspiration.
SWALLOW REHABILITATION EXERCISE 1319
Figure 6. Effect of exercise on FOAMS among patients with different
duration of dysphagia. In all categories, the performance of 6 weeks
of exercise increased the FOAMS score significantly (P ⬍ 0.001) and
resulted in achievement of functional and safe swallow. The 3 pa-
tients who were enrolled within 21 days of their stroke are identified
by the open triangle.
documented by the first observer were confirmed inde-
pendently by measurements performed by the second
observer (P ⬍ 0.05). However, there were minimal in-
terobserver differences in the magnitude of measured
parameters, but these differences did not reach statistical
significance.
Discussion
In this study, we determined the effect of a simple
isotonic and isokinetic head-raising exercise on the UES
deglutitive opening and functional outcome of swallow-
ing in a small group of patients with dysphagia and
aspiration caused by abnormal upper esophageal sphinc-
ter opening. All patients had undergone available known
swallow treatment modalities and were deemed unre-
sponsive to those treatments. Patients had a variety of
etiologic factors leading to their deglutitive failure and
because of significant postswallow residue and aspiration
had been tube-fed to maintain their nutrition. The clin-
ical evaluation and videofluoroscopic barium swallow
studies at the time of enrollment into the protocol cor-
roborated these findings.
The findings of the present study showed a significant
improvement in some deglutitive biomechanical mea-
surements in these patients, most notably a significant
increase in anterior laryngeal movement, UES maximum
anteroposterior opening, a significant decrease in postswal-
low pyriform sinus residue, as well as resolution of postde-
glutitive aspiration. These biomechanical changes were
accompanied by a significant improvement in the func-
tional outcome measures associated with resumption of
oral feeding in all patients. These results clearly indicate
that muscle-group–specific exercises aimed at the stri-
ated muscles of deglutition can make a significant con-
1320 SHAKER ET AL.
Table 3. FOAM Scores for Each Patient Designated by Etiology
Hemispheric CVA
N⫽9
Before exercise 1 1 1 3 3 1 1 1 1 3
After exercise 7 7 7 6 7 7 6 7 7 7
NOTE. Numbers in bold type represent patients who were enrolled within 3 weeks of their cerebrovascular accident.
tribution to the rehabilitation of swallow function. This
approach can potentially result in improvement of qual-
ity of life and cost savings in managing some dysphagic
patients in the acute and chronic care settings.
Opening of the UES during swallowing is determined
by the combined effect of relaxation and distensibility of
the cricopharyngeus muscle and retraction of the cricoid
cartilage caused by contraction of the suprahyoid muscle
group involved in UES opening.9,10,16 –19 The relative
contribution of these individual factors to UES opening,
as well as the relative significance of malfunction of these
factors to disordered UES opening, has not been quan-
tified. Among the 3 previously mentioned factors, only
the suprahyoid muscle group appears to be accessible to
external noninvasive manipulation, such as an exercise.
Although the exact muscles that were trained by the
tested exercise program were not determined in this
study, significant increase in the anteroposterior diame-
ter of the UES opening, along with a significant increase
in anterior excursion of the thyroid cartilage, suggests
that the UES opening muscles, including the mylohyoid/
geniohyoid muscle group, and possibly the anterior seg-
ment of the digastric muscle, were involved in the exer-
cise performed by these dysphagic patients. This notion
is supported by the previous documentation of fatigue in
suprahyoid muscles during the isometric part of the
proposed exercise using spectral analysis of surface elec-
tromyographic recordings.20 –22
Functional rehabilitation for activities of daily living
of the arms and legs after stroke, surgery, radiation, or
accident is well documented. However, swallow rehabil-
itation has lagged behind other advances in the rehabil-
itation field. Volitional control of UES opening muscles
has been previously used in Mendelsohn’s maneuver to
prolong the superior and anterior excursion of the larynx
and thus improve swallowing efficiency. This maneuver
has been found to result in prolongation of the duration
of the UES opening during swallowing.23
Mendelsohn’s maneuver is performed by voluntarily
holding the larynx at the apogee of its deglutitive ex-
cursion after swallowing. This maneuver differs from the
exercise described in this article. The exercise described
in this study is performed without the involvement of
swallowing and includes isotonic and isokinetic contrac-
GASTROENTEROLOGY Vol. 122, No. 5
Brainstem CVA Pharyngeal radiation Other
N⫽7 N⫽5 N⫽6
1 1 1 1 1 1 1 1 1 3 4 4 1 1 1 1 3
7 5 7 7 7 6 7 6 7 7 7 7 5 6 7 7 7
tion of the anterior neck muscles involved in UES open-
ing.
The exercise used in the present study is another
example of physiological manipulation of the striated
muscle group involved in deglutition to augment yet
another aspect of UES opening, namely UES diameter
and to improve oropharyngeal swallowing.
A direct comparison of the efficacy of our proposed
exercise and the Mendelsohn maneuver is not currently
available. Based on our experience, the exercise protocol
is easier for the patient to learn and follow. Given the fact
that the Mendelsohn maneuver primarily increases the
duration of UES opening and our proposed exercise
increases the magnitude of the UES opening, it is con-
ceivable that they may be helpful for different indica-
tions. Comparative studies are currently awaited to ad-
dress these issues.
It is worth noting that although the patients partici-
pating in the present study were extensively instructed
on performing the exercise, their actual exercise during
the 6-week period was not supervised. Day-to-day vari-
ability in compliance and effort cannot be excluded and
might have influenced the outcome.
Time-related improvements in swallowing indepen-
dent of exercise-related improvements were not system-
atically evaluated in this study and represented a possible
source of error. Given the long-standing and severe dys-
phagia exhibited by most of the patients in this study,
along with the patients’ unresponsiveness to conven-
tional treatment modalities, time-related improvement
alone seems to be an unlikely explanation for the docu-
mented improvement. This notion is further supported
by the lack of improvement in the sham exercise group.
In summary, the suprahyoid muscle strengthening
exercise program was shown to be effective in restoring
oral feeding in a small group of patients with deglutitive
failure caused by abnormal UES opening. Although the
proposed exercise was successful in restoring oral intake
in this group of patients with a diverse etiology and
duration of dysphagia, a larger clinical trial with a long-
term follow-up period, is necessary to further evaluate
the clinical efficacy and indications of this exercise in
various patient groups.
 May 2002
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Received September 4, 2001. Accepted January 10, 2002.
Address requests for reprints to: Reza Shaker, M.D., Division of
Gastroenterology and Hepatology, Froedtert Memorial Lutheran Hos-
pital, 9200 West Wisconsin Avenue, Milwaukee, Wisconsin 53226.
e-mail: rshaker@mcw.edu; fax: (414) 456-6215.
Supported in part by NIH grant R01 DC00669.