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Using Tongue-Strengthening Exercise Programs in Dysphagia Intervention
Using Tongue-Strengthening Exercise Programs in Dysphagia Intervention
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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 re-
gard to use of tongue-strengthening exercise in the management of swal-
lowing 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, dyspha-
gia, stroke, cerebrovascular disorder, tongue strength, tongue-strength ex-
ercise, lingual strength, age, intensity, head and neck cancer, and swal-
lowing 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-strengthen-
ing exercise is applicable to dysphagia intervention in general. However,
the optimum dose, frequency, and duration of the exercise required to re-
habilitate 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.
optimize recovery and improve the quality Teaching targeted muscles to increase
of life of the individual. in strength over the course of an exercise
This is exemplified by studies �������
(Carna- regime requires regular adjustment of the
by, Hankey, & Pizzi, 2006; Elmståhl, Bül- resistance level. By progressively loading the
ow, Ekberg, Petersson, & Tegner, 1999) that major muscles involved in swallowing, there
concluded that early intervention should is the potential for significant improvements
be employed to provide individuals with in swallowing function (Burkhead et al.,
as much therapy for dysphagia as can be 2007). Preliminary findings have indicated
tolerated to aid recovery. In a review of the that a lingual exercise program, using
effects of augmented exercise therapy time resistance to increase strength, is a reliable
after stroke, Kwakkel et al. (2004) concluded and effective treatment for dysphagia in
that early implementation of intensive stroke persons living after stroke (Kays������������
& Rob-
rehabilitation was associated with enhanced bins, 2006; Robbins et al., 2005; Robbins
and faster improvement of function after et al., 2007). Tongue-strengthening training
stroke. Although this study evaluated the programs in dysphagia rehabilitation may be
effects of exercise therapy on activities of more effective if they are tailored to target
daily living (ADL), gait, and dexterity, in the specific activation patterns required
patients after stroke it is probable that early during various swallowing movements. For
exercise intervention would be equally example, if the goal is to improve the dynamic
successful for improving swallowing force during tongue base retraction at the
dysfunction in adults after stroke. initiation of the pharyngeal swallow, then
the strength-training task would be aimed at
Recent advances in the treatment of
targeting rapid force generation. Similarly,
dysphagia have investigated using exercise as
targeting sustained static contraction during
a means of swallowing rehabilitation (Kays &
treatment may aid the endurance of muscles
Robbins, 2006). The exercise principles used
required during consecutive swallows (Bur-�����
in other physical rehabilitation or athletic
khead et al., 2007).
training used to strengthen weak limbs
may be applied to dysphagia rehabilitation.
For example, to restore the functional use
Using Tongue-Strengthening
of a limb, a physiotherapist may start by
retraining the essential components of Exercises in Dysphagia
the task with isolated strength training Intervention: The Evidence
with manual facilitation, assistance, and
gravity elimination until the patient has Studies of exercise-training with
the strength and motor control to perform individuals following stroke support the
the task independently (Burkhead,
������������������
Sapien- use of exercise to improve mobility and
za, & Rosenbek, 2007). The same principle functional independence and to prevent
applies in swallowing rehabilitation. For or reduce further long-term disease and
example, tongue strengthening therapy may functional impairment (Burkhead et al.,
begin with isometric contractions or low 2007). For this reason, exercises designed
force movements, then progress to task- specifically to strengthen the tongue may
specific exercises while encouraging the prove to be an integral part of a dysphagic
patient to use more challenging levels of therapy plan as an improvement in the
resistance (higher intensity) throughout the mobility and strength of the tongue can
therapy program. Indeed, intensive exercise result in an increased ability to improve
programs appear to have a positive impact eating and general health status ����������
(Chi-Fish-
on long-term motor rehabilitation leading man, Stone, & McCall, 1998). Indeed, the
to a therapy-induced recovery after stroke weakness that occurs in limb muscles is
(Robbins et al., 2007). replicated in the head and neck musculature,
USING TONGUE-STRENGTHENING EXERCISE PROGRAMS IN DYSPHAGIA INTERVENTION 143
and may be reversed with exercise (Nic- ����� was that stroke patients with dysphagia
osia et al., 2000; Robbins, Levine, Wood, were able to increase tongue strength
Roecker, & Luschei, 1995). This gives food after a program of resistance exercises for
for thought that elderly individuals with the tongue and hold that improvement
age-related disease as well as sarcopenia over the 8-week period of the study. They
may improve to a greater extent than the also showed a significant improvement in
responsiveness demonstrated by healthy swallowing function and dysphagia-specific
individuals. Nonspeech oromotor exercise QOL measures, with beneficial changes to
(NSOMExs) to improve swallowing function their social lives and dietary intake.
in the dysphagic population is a widely used Further research was conducted to de-
practice by speech-language pathologists termine if resistance exercise would bene-
with the tongue being a common target fit other dysphagic populations. Kays et al.,
for exercises using resistance, for example, (2008) investigated the use of an 8-week iso-
a tongue depressor, to increase strength metric exercise program of progressive re-
(McKenzie, Muir, & Allen, 2010). sistance for the tongue with 10 stroke and
Primary studies of resistance exercise 8 myopathy patients. Findings indicated that
therapy were conducted with healthy adults significant increases in tongue-strengthen-
to determine if tongue strength could be ing were achieved by both groups, thus pro-
improved in individuals with no history viding further evidence that tongue strength
of swallow impairment (Clark et al., 2009; exercise has the ability to improve swallow
Robbins et al., 2005). One such study function in other dysphagic populations.
conducted by Robbins and her colleagues These studies provide evidence that resis-
in 2005 reported positive changes in tance exercise has the capacity to increase
tongue strength after an 8-week program tongue muscle strength in dysphagic popu-
of progressive resistance exercises in 10 lations. A summary of strength-training regi-
healthy men and women aged over 70 years. mens for the oropharyngeal musculature and
Demonstrating the capacity to improve swallowing-related outcomes for the studies
tongue strength in healthy adults provided mentioned above is provided in Table 1.
the motivation to explore the effects of
lingual exercise on people with dysphagia
secondary to stroke. Clark et. al. (2009) Conclusion
examined 39 healthy adults with mean age
of 38 years using sequential or concurrent
training conditions and exercises including Although exercise principles used in
elevation, protrusion, and lateralization physical rehabilitation and sports training
of the tongue. Results indicated that by have been gaining increasing attention in
incorporating tongue movements in several dysphagia rehabilitation, future studies
directions as well as resistance in the exercise should focus on developing new optimal
program there was potential to increase programs from these principles. A number
lingual strength as well as increase lingual of research studies (Clark et al., 2009; Kays
protrusion and lateralization strength. et al., 2008; Robbins et al., 2005; Robbins
Evidence supporting intensive tongue et al., 2007) have attempted to determine
strength exercise in dysphagia rehabilitation the appropriate resistance required to
has been shown in several research studies strengthen tongue muscle as well as the
(Kays et al., 2008; Robbins et al., 2007). To number and frequency of repetitions, the
validate this theory Robbins and her team frequency of sessions, the duration of the
(2007) investigated the effects of progressive program, and the specific exercises (tongue
resistance lingual exercises on swallowing muscle movements) necessary.
outcomes in 10 stroke patients with Recent research for the management
dysphagia. The main finding of this study of dysphagia in older adults has led to the
Table 1. Summary of Strength-Training Regimens for the Oropharyngeal Musculature and
Swallowing-Related Outcomes
144
USING TONGUE-STRENGTHENING EXERCISE PROGRAMS IN DYSPHAGIA INTERVENTION 145