Dose in Exercise Based Dysphagia Therapies A Scoping Review

Dysphagia
https://doi.org/10.1007/s00455-020-10104-3
REVIEW
Dose in Exercise‑Based Dysphagia Therapies: A Scoping Review

Brittany N. Krekeler1,2,3 · Linda M. Rowe1,2 · Nadine P. Connor1,2
Received: 11 October 2019 / Accepted: 25 February 2020

© Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract
Background Optimal exercise doses for exercise-based approaches to dysphagia treatment are unclear. To address this gap
in knowledge, we performed a scoping review to provide a record of doses reported in the literature. A larger goal of this
work was to promote detailed consideration of dosing parameters in dysphagia exercise treatments in intervention planning
and outcome reporting.
Methods We searched PubMed, Scopus[Embase], CINAHL, and Cochrane databases from inception to July 2019, with
search terms relating to dysphagia and exercises to treat swallowing impairments. Of the eligible 1906 peer-reviewed articles,
72 met inclusionary criteria by reporting, at minimum, both the frequency and duration of their exercise-based treatments.
Results Study interventions included tongue exercise (n = 16), Shaker/head lift (n = 13), respiratory muscle strength training
(n = 6), combination exercise programs (n = 20), mandibular movement exercises (n = 7), lip muscle training (n = 5), and
other programs that did not fit into the categories described above (n = 5). Frequency recommendations varied greatly by
exercise type. Duration recommendations ranged from 4 weeks to 1 year. In articles reporting repetitions (n = 66), the range
was 1 to 120 reps/day. In articles reporting intensity (n = 59), descriptions included values for force, movement duration,
or descriptive verbal cues, such as “as hard as possible.” Outcome measures were highly varied across and within specific
exercise types.
Conclusions We recommend inclusion of at least the frequency, duration, repetition, and intensity components of exercise
dose to improve reproducibility, interpretation, and comparison across studies. Further research is required to determine
optimal dose ranges for the wide variety of exercise-based dysphagia interventions.
Keywords Scoping review · Dysphagia treatment · Dose · Evidence-based practice
Introduction These exercise approaches target specific muscles or

groups of muscles active in deglutition including the oral
Exercise-based approaches have been used in dysphagia musculature (maximum isometric pressure of tongue, lips,
treatment for over three decades. The overall aim of these jaw), pharyngeal constrictors (effortful swallow, Masako),
treatments is to increase the strength and endurance of mus- hyolaryngeal complex (Mendelsohn, Shaker Head Lift), and
cle groups involved in deglutition and airway protection. respiratory muscle complex (inspiratory and expiratory mus-
cle strength training) [1]. It is intuitive that exercise dose is
an essential component of any exercise-based therapy, and
* Brittany N. Krekeler
brittany.krekeler@northwestern.edu understanding the relationship between dose and treatment
efficacy is critical to maximizing patient benefit. As such,
1
Department of Communication Sciences and Disorders, importance of dose in resistance exercise has been well
University of Wisconsin-Madison, Goodnight Hall, 1300 established in the limb literature [2–6]. However, definitive
University Ave, Madison, WI 53706, USA
guidelines for optimal dosing in swallowing rehabilitation
2
Department of Surgery‑Otolaryngology, Clinical Science programs have yet to be established [7, 8]. Because of critical
Center, University of Wisconsin-Madison, 600 Highland
Avenue, Madison, WI 53792‑7375, USA
differences that exist between skeletal muscles of the head
3
and neck and the limb in terms of muscle structure, biology,
Department of Communication Sciences and Disorders,
Northwestern University, Swallowing Cross-Systems
and physiology [8], it is important to develop exercise dose
Collaborative, 2240 Campus Drive, Evanston, IL 60208, recommendations specific to deglutatory musculature and
USA
13
Vol.:(0123456789)
B. N. Krekeler et al.: Dose in Exercise-Based Dysphagia Therapies: A Scoping Review
not rely on prescriptions developed for limb muscles. Rec- component of endurance (e.g., head sustained head lift exer-
ognizing this gap in knowledge, we reviewed the literature cise) [19]. Since a majority of dysphagia exercise programs
to explore the range of exercise doses reported in research include some component of strength training, we will focus
on exercise-based interventions to treat dysphagia. this introductory discussion on effects of strength training
on muscle biology.
Scoping Review Muscular hypertrophy is achieved when a muscle or
group of muscles contracts to resist against increasingly
To gain perspective on reporting of exercise dose informa- higher loads, above what is normally required of that par-
tion in the dysphagia literature, we performed a scoping ticular muscular system [20–22]. Increasing load challenges
review, which is defined as: “[a] preliminary assessment of the muscle(s), requiring higher-threshold motor units to be
the potential size and scope of available research literature. It activated [20–22] and promotes protein signaling to induce
aims to identify the nature and extent of research evidence” muscular hypertrophy [23–25]. Gains in muscular strength
(p. 101) [9]. A scoping review does not require the in-depth observed after resistance exercise are due, in part, to muscu-
critique of research quality typically performed in a system- lar protein synthesis increasing fiber size (hypertrophy) and
atic review [10] and is useful for examining a particularly number as well as other shifts in muscle fiber composition
heterogeneous literature base. In contrast to a systematic and metabolism towards a more powerful, fatigue resistant
review, a scoping review can provide a more inclusive refer- profile [26–29]. At the cellular level, among other related
ence guide of research evidence available regarding exercise processes, resistance exercise can increase fiber number by
dosing. The purpose of this scoping review was twofold: inducing quiescent satellite cells to enter the mitotic cycle
1) To provide researchers and clinicians with a record of and differentiate to promote new myofiber development [30,
currently reported exercise dosing in the adult and geriat- 31].
ric dysphagia therapy literature base; 2) To call attention to Mechanisms involved in muscular hypertrophy and con-
important components of exercise dosing that should be conditioning with exercise are known to increase in a dose-
sidered in every exercise-based study and should be reported dependent manner [6], making consideration of dose in
in dysphagia treatment methodology both in clinical practice exercise particularly important. The relationship between
and peer-reviewed manuscripts. resistance exercise dose and muscular hypertrophy have
been explored and debated in the limb literature with the
Relationship Between Exercise Dose and Muscular goal of optimizing dose prescription to maximize strength-
Conditioning related outcomes [5, 6]. Relationships between training
intensity and frequency have been well studied, and these
Both endurance exercise and resistance exercise have been findings have contributed to the American College of Sports
studied in skeletal muscle and cardiorespiratory systems Medicine (ACSM) Guidelines for Exercise Testing and
[11]. Endurance exercise (aerobic) can last from minutes Prescription (9th edition) [32]. With increasing intensity of
to hours, and makes use of high-repetition actions at low resistance exercise there is a corresponding increase in the
resistance to maximize changes in skeletal muscle oxida- synthesis of myofibrillar proteins [33]. Similarly, increasing
tive capacity [12]. Resistance exercise (anaerobic) involves resistance exercise-training frequency (number of training
high resistance training with the goal of increasing muscular sets/week) is related to increasing muscular hypertrophy in
mass and power [12]. Endurance exercise increases signaling a graded, dose-responsive manner [34].
for mitochondrial biogenesis in muscles of the limbs with Other important considerations in determining dose pre-
chronic exercise effects resulting in increased mitochondrial scription are training status and the risk of over-prescription.
content and function leading to improved muscular capacity Meta-analyses in the exercise science literature have sup-
and fatigue resistance [13–17]. The primary goal of resist- ported differences in optimal dose considerations for trained
ance exercise is to increase muscle strength by increasing vs untrained individuals (outlined below), which will impact
muscle fiber cross-sectional area (CSA), also known as how exercise is prescribed [5]. More importantly, incorrect
muscular hypertrophy. These increases in size occur both dose prescription could result in over-prescription of exer-
in young and elderly individuals with resistance exercise cise, which can have negative or “diminishing” effects [5, 6].
training [2, 18]. These are critical factors to consider when designing a train-
Depending on the goals of an exercise-based treatment ing program: improper and over-training can lead to reduc-
program, there can be a focus on resistance training, endur- tions in strength and can increase risk of injury [6]. As such,
ance training, or can involve a combination of both (concur- exercise scientists who study effects of dose–response in the
rent training). Dysphagia exercise programs have generally limb have made the following recommendations regarding
focused on increasing strength, using fewer repetitions at training doses for individuals wishing to prevent age-related
increasing resistance; however, some exercises do involve a changes in muscle and induce muscle hypertrophy [5, 6, 32]:
13
• For untrained individuals: 60% of 1 Rep-Maximum For example, exercise prescription could include perfor-
(RM); 4 sets (1 set = 8–12 repetitions); 3 days/week mance of 3 sets of 10 lingual presses per day for 3 days
• For trained individuals: 80% 1RM; 4 sets; 2 days/week per week. This translates into the patient performing 30
• For trained athletes: 85% 1RM; 8 sets; 2 days/week lingual presses per day (in each of 3 sessions) and thus
90 presses total per week. The amount of rest between
These doses have been well studied and explored in mus- individual repetitions has not been well defined, nor has
cles of the limbs and trunk, dose–response recommendations the optimal number of total sets recommended for perfor-
for muscles of the head and neck have not been definitively mance in one day. In the exercise science literature, sets
determined [1, 7]. While the work of the limb and exercise per day are used to break up the number of repetitions
science literature can provide a starting point for developing of an action performed to allow for periods of rest. The
dosing for exercise-based dysphagia therapies, structural and ACSM recommends between 2–3 min for rest between
physiological differences between the limb vs cranial mus- sets [32]. However, other than the Shaker exercise, there
culature [8] require us to explore effects of exercise dose in are no current guidelines regarding proper rest between
our muscles of interest, specifically. sets of other exercises to treat dysphagia [1]. Given the
limited research and reporting on this topic, we did not
Components of Exercise Dose in Dysphagia Therapy include rest as a dosing component in this review. How-
ever, it should be considered in future studies of dysphagia
When considering dose-related effects in exercise therapy, exercise.
there are several components of dose that must be consid- Intensity reflects the amount of effort or force exerted
ered. Depending on the type of exercise, and the muscle during a single repetition of an exercise. This can be meas-
systems targeted (limb, trunk, cranial), different terminology ured by percentage of a maximum amount of effort, if
might be used to describe similar components. The ACSM’s using a device-facilitated approach, or a more descriptive
Guidelines for Exercise Testing and Prescription ( 9th Edi- criterion, such as “press has hard as you can” or “using
tion) lists 9 components of exercise: frequency, intensity, maximum amount of effort.” For an isometric exercise,
time (duration), type, repetitions, sets, pattern (rest inter- length of hold can serve as a definition of intensity. While
vals), and progression. We combined items on this list into having a device-facilitated program will most accurately
four components of exercise dose that are relevant and nec- capture intensity, providing participants with a qualitative
essary in a dysphagia treatment prescription (represented in description of level of intensity is an acceptable way of
Fig. 1 and described below): Frequency (frequency, sets), ensuring successful execution of a specific strengthening
Repetitions, Intensity, Duration [32]. maneuver.
Repetitions are defined as the number of actions per- Duration of the exercise program is the total length of
formed in one set of a specific exercise maneuver. For exam- the exercise program, and can be defined by a number of
ple, 10 lingual presses or 40 effortful swallows constitutes sessions, weeks, months, or other similar metric. The dura-
the number of repetitions of an action. tion also represents the final endpoint at which patients
Frequency defines how many of “sets” of exercise are can be expected to see measurable, clinical improvement
performed in one day or session, and how many days in function. The exercise science literature recommends
of exercise per week are prescribed. One “set” of exer- between 8–12 weeks for progressive resistance training
cise is defined by the number of repetitions in the set. programs [2]. However, the optimal duration for exercise
treatments for dysphagia have not been determined. With-
out defining a specific program duration, clinicians and
researchers are unable to compare program outcomes or
define an end point for expected clinical improvement.
We considered these components as basic dosing
parameters during our scoping review for ensuring repro-
ducibility of exercise conditions. In this review, we aimed
to highlight study parameters of frequency, repetition,
intensity, and duration of clinically relevant exercises to
allow comparison across articles. While interpreting the
specific effects of swallowing exercises was beyond the
scale of the current study, we reported the primary out-
comes and statistical findings to summarize the existing
Fig. 1 Determinants of dose in dysphagia specific exercise-based evidence of treatment effects on swallow-related outcomes
interventions for each individual study.
13
Methods for Scoping Review stimulation, thermal or gustatory stimulation techniques)

because stimulation involves a different dosing mechanism
This scoping review was performed with the assistance of than exercise alone. However, for articles that compared the
two librarians (SJ, MC). We searched 4 databases (PubMed, effects of neuromuscular stimulation to a non-stimulated
Scopus[Embase], CINAHL, Cochrane, Fig. 2) with search exercise condition, data from the exercise-only group were
terms customized for each database, and included variations included in our final results. Articles were excluded from
of Dysphagia, Deglutition disorders, Swallowing disorder, review if they reported exercise interventions lasting less
Shaker exercise, Mendelsohn maneuver, Masako exercise, than 4 weeks, did not involve a resistance exercise com-
Tongue hold, Effortful swallow, Protective airway maneu- ponent (e.g., range of motion or passive manipulation),
ver, Tongue pressure resistance, and Iowa Oral Performance reported on single case studies only, or small case series
Instrument, among others (please see “Appendix” for full (n < 10). Optimal durations for exercise treatment programs
listing of MeSH terms). The literature search in this study have not been well defined in limb or cranial muscles [1, 32],
was limited to peer-reviewed publications in the broad area and thus we chose a 4-week minimum treatment duration
of exercise treatment of adults with dysphagia that were to allow inclusion of respiratory muscle training programs,
published on or prior 7/2019. No other study design criteria which are usually 4 weeks in length [35].
were employed for the literature search, in accordance with Data abstraction was performed for all included articles
generally accepted scoping review methodology [9]. by both the first and second author (BNK, LMR). Data
All 1906 citations were reviewed by both the first and sec- regarding dosing recommendations (frequency, intensity,
ond author (BNK, LMR). Criteria for inclusion in the review repetitions, duration), populations studied, and exercise-
were broad and focused on any exercise-based intervention based treatment effects on primary outcome(s) with reported
used to treat adult dysphagia from any primary etiology. We statistical findings (p values) were recorded and are repre-
also included articles trialing exercise therapies in healthy sented in Tables 1, 2, 3, 4, 5, 6, and 7. Throughout abstract
adults without dysphagia. To meet final inclusion criteria review and data abstraction, if there was disagreement, the
for dosing specifications, articles had to report at least the first and second author reached a consensus.
frequency and the duration of exercise. Articles that reported
detailed information on all four components of dose were
considered to be “gold standard” articles and are noted in Results
the tables (see “Results”). Full text articles not available to
us were excluded from review. Articles were not included A total of 72 articles met final inclusion criteria.
if the resistance exercise treatment was supplemented with
an additional stimulation treatment (e.g., neuromuscular
Exercise Type and Study Population
Articles were grouped into tables based on the type of exer-

cise program:
(Table 1) 20 articles reporting combination exercise pro-

grams (2 or more specific exercise approaches) [36–55]
(Table 2) 16 articles reporting tongue exercise [56–71]
(Table 3) 13 articles reporting head lift (Shaker) exercise
[72–84]
(Table 4) 6 articles reporting respiratory muscle strength
training (RMST) [85–90]
(Table 5) 7 articles reporting mandible exercises [91–97]
(Table 6) 5 articles reporting lip muscle training [98–102]
(Table 7) 5 articles reporting other programs (e.g., Phar-
yngocise) [103–107]
Components of dose reported were variable within an inter-

vention type, especially for combination exercise programs.
Of all 72 articles that met inclusion criteria, 79% met “gold
standard” criteria by including all four components of dose.
Fig. 2 Flow chart demonstrating abstract search and review The majority of articles included healthy participants (24%),
13
Table 1 Combination exercise programs
GS (*) Frequency Repetitions Intensity Duration 1st author (year) Population(s) studied Primary outcome(s) p value(s)
Citation number
7 ×/day Masako = 10 X 1.5–1 month (during Virani (2015) Head and neck cancer Percutaneous endo- p = 0.011
7 days/week Pharyngeal tx for HNC) [28] scopic gastrostomy
squeeze = 10 (PEG) tube depend-
Shaker = Xa ence was lower at
Saliva swallows = X 3 months posttreat-
ment
* 5 ×/day Tongue resist- Tongue resist- 2 weeks prior to CRT Carroll (2008) Head and neck cancer Outcomes from videofluoroscopy:
7 days/week ance = 1 × (for 4 ance = hold 5 s vs 3 months post [29] Penetration aspiration p = 0.86
positions) Tongue hold = X CRT scale score
Tongue hold = 10 Effortful swal-
Posterior tongue base p = 0.071, 0.025, 0.70
Effortful swallow = 10 low = “squeezing
at rest, during swal-
Mendelsohn = X forcibly”
low, movement
Shaker = 30 Mendelsohn = hold 5 s
Shaker = hold 1 min, Vertical hyoid position p = 0.77, 0.99, 0.77
1 min rest at rest, during swal-
low, movement
Epiglottic inversion p = 0.02
Cricopharyngeal p = 0.81
opening
PEG tube use p = 0.63
12 months after CRT
Mendelsohn = 10 X 2 weeks prior Kulbersh (2006) Head and neck cancer MD Anderson Dysphagia Inventory
Tongue hold = 10 RDT—6 weeks [30] (MDADI):
Tongue Resist- during Global assessment p = 0.0002
ance = 10
Emotional p = 0.005
Shaker = 30 (sustained
and repetitive)a Functional p = 0.114
Physical p = 0.005
X X 8 weeks Millichap (2005) Globus sensation Glasgow and Edin- p < 0.001
[31] burgh Throat Scale
(GETS)
Videofluoroscopy p = not significant
ratings
13

Table 1 (continued)
Citation number
13
* 3 ×/day 10 repetitions per Group 1 (effortful 4 weeks Clark (2014) Healthy Maximum isometric p = 0.002
7 days/week group of each swallow only): max [32] lingual-palatal pres-
assigned exercise effort elevation sure
Group 2 (effortful
swallow + tongue
elevation): max effort
elevation + swallow
as hard as possible
Group 3 (straw
sips + effortful swal-
low): high resistant
straw sips + swallow
as hard as possible
* Gargling = 10 Gargling = 10 s During treat- Duarte (2013) Head and neck cancer Diet change (step p = 0.025
Effortful swallow = 10 Chug-a-lug = 3 oz at ment + 2 months [33] up or step down in
Mendelsohn = 10 once post diet—PEG, liquid,
Chug-a-lug = 1 puree, chewable)
Tongue protru- between “compliant”
sion = 10 and “noncompliant”
Tongue press = 10 patients 1 month
Shaker = 3b post-treatment
* Range of motion = 10 Range of 1 week prior to Mortenson (2015) Head and neck cancer Swallowing perfor- p = 0.14
Tongue Hold = 10 motion = hold 1 s RT—11 months post [34] mance status scale
Gargle = 10 Tongue hold = 2 cm (SPSS) from vide-
Jaw exercise = 10 tongue out of ofluoroscopy
Larynx range of mouth + swallow
Motion = 10 Gargle = 10 s
Shaker = 30 repetitive,Jaw exercise = open as
3 sustained much as possible
Larynx range of
motion = hold breath
1 s
Shaker = hold 1 min,
rest 1 min for sus-
tained
Effortful swallow = 15 X 3 months Tang (2011) Head and neck cancer Percentage of patients p = 0.02
Mendelsohn = 15 [35] with “excellent” and
“effective” results on
the “water swallow
test”
Citation number
Targeted swallowing X 4 weeks Malandraki (2016) Neurogenic dysphagia Penetration aspiration p < 0.05
practice—personal- [36] scale score
ized
60 swallows, Sets of
20, 3 ×/day
* ROM exercises = X Range of 12 weeks Hsiang (2019) Head and neck cancer Penetration aspiration p = 0.037
Resistance exercise for motion = extend as [37] scale score
tongue = 10 far as possible and
hold 1–2 s
Tongue resist-
ance = push tongue
against a blade for
5 s
* 2 ×/day Tongue mobility = 5 Tongue mobility = as During RDT and Ahlberg (2011) Head and neck cancer Weight loss (change in p = 0.4
7 days/week Mendelsohn = 10 far out as possible 3 months post [38] weight from diagno-
Mendelsohn = 2–3 s sis to 6 months after
hold treatment)
2-year survival p = 0.49
* Tongue resistance = 10 See full text for 8 weeks Carmignani (2018) Head and Neck Cancer Physical scale of p = 0.039
Effortful swallow = 10 descriptions [39] dysphagia handicap
Masako = 10 index
Mendelsohn = 10 *3 months post CRT/

Shaker = 10 RT
* Therabite = passive See full text for During CRT and Messing (2017) Head and neck cancer Dysphagia outcome p = 0.29
range of motion descriptions 3 months post [40] severity scale
exercises performed 7 Oral phase impair- p = 0.13
repetitions, (per- ments
formed 7 times per
Pharyngeal phase p = 0.007
day, instead of 2)
impairments
Lip protrusion/retrac-
tion = 10
Lingual ROM and
strength exer-
cises = 10
Pharyngeal strengthen-
ing = 5 – 10
1 ×/day “Exercise program X 2 months Kang (2012) Stroke “New VFSS Scale” (Jung et al. 2005d)
7 days/week with oral, pharyngeal, [41] Total score (oral stage) p < 0.05
laryngeal and respira-
Total score (pharyn- p = not significant
tion exercises” (X)
geal stage)
13

Citation number
13
* 2 ×/day Super-supraglot- “Work muscles hard” 12 weeks Langmore (2015)c Head and neck cancer Penetration Aspira- p < 0.001
6 days/week tic = 10 for all [42] tion Scale scores on
Regular swallows = 10 VFSS (sham group
Mendelsohn = 10 only)
Effortful swallow = 10
2 ×/day Sustained vowel pho- X 5 weeks Argolo (2013) Parkinson disease Loss of bolus control p < 0.03
5 days/week nation = 10 [43] Piecemeal swallow p = 0.05
Ascending and
Residue on tongue p < 0.01
descending gliding
phonations = 5 Residue in valleculae p = 0.01
Rotating tongue in oral Residue in pyriform p = 0.05
vestibule = 5 sinuses
Effortful dry (saliva) X 12 weeks Wang (2018) Parkinson’s disease Piecemeal deglutition p = 0.001
swallow [44] Pre- and Post-swallow p = 0.042
Tongue protrusion respiratory phase
Tongue rollback pattern
Each exercise = 2
Swallowing respiratory p = 0.178
per set / 25 sets per
pause
session (total = 50
reps of each exercise/ Onset latency p = 0.541
session) Total excursion time p = 0.117
Second deflexion of p = 0.420
laryngeal excursion
Amplitude of submen- p = 0.165
tal sEMG
Amplitude of laryngeal p = 0.039
excursion
Citation number
* 2 ×/day Resistance tongue 10 s each 3 months Wakabayashi (2018) Community dwelling Eating assessment tool p = 0.665
3 days/week exercise = 10 reps; [45] individuals with 10 (EAT-10) scores
Head flexion exer- dysphagia Mean tongue pressure p = 0.376
cise = 10 reps
“Traditional dysphagia X 6 weeks Tarameshlu (2019) Multiple Sclerosis Mann assessment of p < 0.001
therapy” [46] swallowing ability
Exercise programs,
pharyngeal swallow-
ing maneuvers, com-
pensatory strategies,
sensory stimuli listed
in Table 1
Effortful Swal- “Squeeze as hard as 5.3 weeks Li Stroke Change in functional p = 0.004
low + Mendelsohn you can with all your (2016) oral intake scale
(X) throat muscles” [47] (FOIS)
X indicates that article did not list specific exercise types and/or intensity/instructions for execution of exercise
GS gold standard , HNC head and neck cancer, Tx therapy, RDT radiation therapy, CRT chemoradiation therapy, RT radiation therapy, sEMG surface electromyography, PEG percutaneous endo-
scopic gastrostomy, reps repetitions, ROM range of motion
*Indicates a research study that reports all 4 components of dose (“Gold Standard” or GS)
a
Specifies 3 ×/day; 7 days/week for Shaker exercise
b
Specifies 1 ×/day; 7 days/week for Shaker exercise
c
Sham Neuromuscular stimulation (NEMS) group only /swallow treatment group alone, review does not include NEMS group
d
Jung et al. [117]
13

Table 2 Tongue exercise
Citation number
13
* 5 ×/day Isometric Isometric 8 weeks Moon (2018) Subacute Stroke Iowa oral performance p < 0.05
7 days/week strength = anterior strength = not speci- [48] instrument measure-
and posterior—6 reps fied ments
per location Isometric accu- Swallowing quality p < 0.05
Isometric accuracy = 50, 70, 100% of life assessment
racy = 3 × (1 × at 50, (SWAL-QoL)
60, 100%)
Mann assessment of p < 0.05
swallowing ability
(MASA)
* 2 ×/day 5 × per session Press tongues against 4 weeks Namiki (2019) Presbyphagia Anterior hyoid move- p = 0.031
7 days/week palate for 10 s, fol- [49] ment
lowed by 10 s rest Superior hyoid move- p = 0.012
ment
Tongue pressure p = 0.002
Width of UES p = 0.001
NRRSp p = 0.022
Penetration aspiration p = 0.016
scale score
* 5 ×/day 10 × per session “Press as hard as pos- 6 weeks Lazarus (2014) Head and neck cancer Head and neck cancer A: p = 1.000
5 days/week sible” for 2 s [50] inventory (A: speech, B: p = 0.347
B: eating, C: social C: p = 0.650
disruption)
Head and neck cancer A: p = 0.128
inventory (A: speech, B: p = 0.028
B: eating, C: social C: p = 0.161
disruption)—within-
group
Oropharyngeal swal- p = 0.351
lowing efficiency
score (experimental
pre–post)
Tongue strength (pre– p = 0.571
post)
Salivary flow (within p = not significant
and between groups)
Citation number
* 5 sets of 10 repetitions, 80% 1RM Park (2015) Stroke Videofluoroscopic O: p < 0.01

minimum rest of [51] dysphagia scale (O: P: p < 0.05
30 s between sets (50 oral, P: pharyngeal, T: p < 0.01
presses anterior and T: total)
posterior) Maximum tongue pres- A: p < 0.01
sure (A: anterior, P: P: p < 0.01
posterior)
1 ×/day 30 × per session for X 4 weeks Kim (2017) Stroke Videofluoroscopic O: p = 0.029
5 days/week anterior and posterior [52] dysphagia scale (O: P: p = 0.007
oral, P: pharyngeal,
T: total)
Maximum tongue pres- A: p = 0.009
sure (A: anterior, P: P: p = 0.015
posterior)
Penetration aspiration p = 0.471
scale score
* Isometric = 3 × Isometric = 10 s hold 6 weeks Park (2019) Healthy young adults Thickness of mylohyoid p = 0.037
Isotonic = 30 × Isotonic = 2 s [53] Thickness of digastric p = 0.042
* 3 ×/day 10 × per session “Push the tongue firmly 4 weeks Park (2019) Stroke Anterior tongue p = 0.046
5 days/week onto the palate, [54] strength
while squeezing neck

muscles, swallow Posterior tongue p = 0.042
as forcefully as pos- strength
sible” Oral phase of swal- p = 0.017
lowing
* 3 ×/day 10 × per session “Push hard [against 4 weeks Park (2016) Healthy Older Adults Maximum tongue p = 0.001
3 days/week alveolar ridge] for [55] pressure
3 s” Normalized peak p = 0.474
amplitude of submen-
tal sEMG
* 30 × per session Week 1: 60% of 1RM 8 weeks Robbins (2005) Lingual peak isometric Wk4: p = 0.002
Weeks 2–7: 80% of [56] pressures (week 4, Wk6: p = 0.001
1RM week 6)
Re-measure maximum
at weeks 2, 4, 6
Swallowing pressures A: p = 0.001
(A: 3 mL effortful, B: B: p = 0.18
3 mL thin, C: 10 mL C: p = 0.04
thin, D: 3 mL semi- D: p = 0.01
solid)
13

Citation number
13
Videofluoroscopic out- p = not significant
comes (penetration–
aspiration scale score,
bolus flow duration,
residue, swallow
kinematics)
* 30 × (at anterior and Robbins (2007) Stroke Maximum isometric A: p < 0.001
posterior sensors) [57] tongue pressure (A: P: p < 0.001
anterior, P: posterior)
at 8 weeks
Swallowing pressures A: p = 0.53
3 mL thin, C: 10 mL C: p = 0.03
solid)
Oropharyngeal residue A: p = 0.02
3 mL thin, C: 10 mL C: p = 0.02
solid)
Penetration–aspiration A: p = 0.005
scale scores (A: 3 mL B: p = 0.003
at week 4, B: 10 mL
at week 8)
5. SWAL-QoL ques- F: p = 0.047
tionnaire (F: fatigue, C: p = 0.026
C: communication, M: p = 0.22
M: Mental)
* 30 × per session Rogus-Pulia (2016) Older adults with Anterior and posterior p < 0.001
[58] dysphagia (multiple lingual pressures
etiologies) Penetration–aspiration p = 0.14–1.0
scale scores
Oropharyngeal residue p = 0.16–0.99
Pneumonia diagnosis p = 0.10
Hospital admissions p = 0.009
Bed days p = 0.17
Citation number
* 30 per session Week 1: 60% of 1RM 8 weeks Yano (2019) Healthy young adults Anterior and posterior tongue pressure
Weeks 2–7: 80% of 1 [59] Completion of training p = 0.023 and p = 0.041
RM
After 1 month p = 0.041 and p = 0.023
Re-measure maximum
at weeks 2, 4, 6 After 2 months p = 0.023 and p = 0.023
After 3 months p = 0.023 and p = 0.023
1 ×/day X 60% for week 1, and 8 weeks Oh (2015) Healthy young adults Outcomes at 8 weeks:
3 days/week 80% thereafter [60] Tongue tip pressure p = 0.000
(weekly update of
80% maximum) Tongue base pressure p = 0.000
Effortful swallowing p = 0.000
pressure
Outcomes after 28 weeks detraining:
Tongue tip pressure p = 0.004
Tongue base pressure p = 0.001
pressure
* Anterior tongue press 30 s rest in between 8 weeks Van den Steen (2018) Healthy elderly adults Maximum isometric Anterior group > poste-
(group 1) each of the 5 repeti- [61] pressure—anterior rior group (p = 0.000)

Posterior tongue press tions, Hold pressure Maximum isometric Both groups increased
(group 2) for 3 s, 80% of 1 RM, pressure—posterior (p = 0.000)
5 reps per set, 24 sets *recalculated every
per 1 session (120 2 weeks
tongue tasks/day)
* 120 presses per day 3 Groups 8 weeks Van den Steen (2019) Healthy elderly adults Differences in maxi- p = not significant
(60 anterior and 60 1. 60% 1RM [62] mum isometric pres-
posterior) – divided 2. 80% 1RM sure between intensity
into 24 sets of 5, 30 s 3. 100% 1RM groups
rest after each set
13
participants with dysphagia resulting from stroke (25%), or
GS gold standard, TPPT tongue-pressure profile training, TPSAT tongue-pressure strength and accuracy training, MIP maximum isometric pressure, RM = 1 repeated maximum contraction,
sEMG surface electromyography, SWAL-QoL swallowing quality of life, MASA Mann assessment of swallowing ability, NRRSp normalized residue ratio scale pyriform sinus, UES upper esoph-
p = not significant nectar
participants with head and neck cancer (25%).
As shown in Table 1, combination exercise programs were
p = not significant
the largest group (28%), and included a wide range of tasks
p = 0.05 thin
such as tongue exercise (tongue press, tongue resistance,
p value(s)
p < 0.001
p = 0.13
tongue elevation, tongue hold, tongue mobility), head lift
exercise (Shaker), effortful swallows, supraglottic swallows,
jaw exercise, and pharyngeal exercise. Most programs defined
the exercises in their regimens (85%), while the others (15%)
Penetration–aspiration
Maximum isometric
Primary outcome(s)
Stage duration (thin
Normalized residue used more general terminology such as “swallow exercise,”

posterior tongue
ratio scale (thin, or “therapeutic intervention for swallowing,” but did not list
scale score
actual exercise procedures.

pressure
liquids)
nectar)
For specific exercise categories, respiratory muscle strength
training, mandible exercises, and lip muscle training groups
had the most consistent dose reporting, with all articles in
these categories reporting all four components of dose. Most
Population(s) studied
articles reporting tongue exercise and head lift met “gold

standard” criteria as well, with the exception of two articles in
the tongue exercise category [60, 68] and one article reporting
head lift [80]. The “other programs” category included articles
ageal sphincter, PAS Penetration Aspiration Scale, 1 RM 1 rep maximum, kPa kilopascals, sEMG surface electromyography
Stroke
that did not fit into the discrete or combination exercise cat-
egories found in Tables 1, 2, 3, 4, 5 and 6 (see Table 7), with
all but two articles [106, 107] meeting “gold standard” criteria.
1st author (year)
Citation number
Components of Exercise Dose

Steele (2016)
Exercise dose components were grouped and are discussed

[63]
here by exercise type (represented in Tables 1, 2, 3, 4, 5, 6,

7).
(24 sessions
Frequency was described by all exercise programs in

8–12 weeks
this review, per final inclusion requirements. For combina-

Duration
total)
tion exercise programs, frequency varied from as much as

7 ×/day for 7 days/week to as little as 3 ×/day for 3 days/
week. Head lift exercises and tongue exercise had the most
randomized 25–85%
consistent recommendations for frequency across all treat-

based on protocol
Pressure: 85%, or
Saliva: natural, or
ment types. For head lift, 3 ×/day for 7 days/week was used
Max Isometric
most often (54%). For tongue exercise, 3 ×/day for 3 days/

effortful
week was used most often (31%). All articles that incorpo-
Intensity
rated respiratory muscle strength training (RMST) used a

frequency of 5 ×/day for either 5 or 6 days a week (100%).
Mandible exercises were performed 2–3 ×/day for 7 days/
strength and/or accu-
saliva/bolus tasks for
(Two protocols: TPPT
tongue pressure and

and TPSAT) 45–60
week in 5/7 articles. Lip muscle training occurred 3 ×/day

racy. Each exercise
total reps across
for 7 days/week for all 5 articles (100%). “Other” category of

exercise programs varied greatly, ranging from 1 ×/day for
5–20 reps
Repetitions
1 day/week to as many as 4 ×/day for 7 days/week, depend-

ing on the program.
Repetitions were described in 85% of combination pro-
grams, 94% of tongue exercise, 92% of head lift, and all
2–3 ×/week
GS (*) Frequency
respiratory muscle strength training articles (100%). Rep-

1 ×/day
etitions were described in all mandible, lip muscle training,

and the “other” exercises category (100%). For combina-
tion exercise programs, the most commonly reported set of
repetitions was 10, but other repetition counts included 15
*
13
Table 3 Head lift exercises
Citation number
* 3 ×/day 30 repetitions for isoki- Hold 1 min 6 weeks Easterling (2005) Healthy older adults Videofluoroscopy biomechanics outcomes:
7 days/week netic set [64] (non-dysphagia)
3 repetitions for isomet- Maximum anterior hyoid p < 0.05
ric set excursion
Maximum anterior p < 0.05
laryngeal excursion
Maximum anteroposte- p < 0.05
rior UES deglutitive
opening
Superior hyoid and p > 0.05
laryngeal movements
* Shaker: 30 head lifts, or Head Lift and CTAR: 6 weeks Gao (2017) Cerebral infarction Penetration aspiration p < 0.0
3 sustained head lifts isokinetic, or 1 min hold [65] scale: pre–post shaker
CTAR: 30 reps, or 3 Tongue exercise: not (4 week, 6 week)
sustained 1 min holds defined Penetration aspiration p < 0.05
Traditional therapy: scale: pre-post CTAR
10 × per each tongue (4 week, 6 week)
exercise/direction
Penetration aspiration p < 0.05
scale: shaker vs. CTAR
(4 week, 6 week)
Self-rating depression p = 0.00

scale: CTAR vs. shaker
(within-group
Self-rating depression p < 0.05
scale: CTAR vs. shaker
and control
* 30 reps for isokinetic set Hold 1 min for isometric 6 weeks Fujiki (2019) Healthy older adults Superior hyoid excursion p ≤ 0.001
3 for isometric set set [66]
Anterior hyoid excursion p = 0.0088
Upper esophageal p = 0.1322
sphincter opening
13

Citation number
13
* Mishra (2015) Healthy young adults Swallow duration p = not significanta
[67]
sEMG peak amplitude p = 0.579, p = 0.715
(within and between
groups)
Within group lingual p = 0.03
isometric strength
Between-group lingual p = 0.892
isometric strength
Perceived exertion p < 0.001, p = 0.317
(within-group,
between-groups)
* Shaker (2002) Tube-fed patients with Anteroposterior diam- p < 0.001
[68] abnormal UES open- eter of UES opening
ing (multiple etiolo- Anterior laryngeal p < 0.05
gies) excursion
Functional outcome p < 0.001
assessment measure of p < 0.05
swallowing (assigned,
crossover subjects)
Superior laryngeal p = not significanta
excursion, anterior and
superior hyoid excur-
sions, lateral diameter
of UES opening
Pyriform sinus residue p < 0.01
* Shaker (1997) Healthy older adults Maximum anterior p < 0.05
[69] laryngeal excursion
Anteroposterior diam- p < 0.05
eter of maximum UES
opening
UES cross-sectional area p < 0.05
Max superior and ante- p = not significanta
rior Hyoid excursions,
max superior laryngeal
excursion, max lateral
UES diameter
Intrabolus pressure p < 0.05
Citation number
* Group 1: 1 ×/day Woo (2014) Healthy young adults Suprahyoid muscle acti- p < 0.01
7 days/week [70] vation (within-group)
Group 2: 3 ×/day
7 days/week Infrahyoid muscle acti- 2. p < 0.05(Grp1)
vation (per group) p < 0.01(Grp2)
* 1 ×/day Head lift: 30 reps isoki- Head lift: 4 weeks Park (2017) Stroke Hyolaryngeal kinematics:
5 days/week netic Hold 1 min [71] Hyoid movement (A: A: p = 0.005
3 reps isometric Conventional Dysphagia anterior, S: superior) S: p = 0.003
conventional dysphagia Therapy:
Laryngeal movement (A: A: p = 0.014
Therapy: not specified Not defined
anterior, S: superior) S: p = 0.039
Between-groups p = 0.044 superior hyoid;
p = not significant for
all other kinematics
PAS (L: liquid, S: solid) L: p = 0.004
within-group S: p = 0.004
PAS (L: liquid, S: solid) L: p = 0.044
between-groups S: p = 0.667
1 ×/day X X 6 weeks Don Kim (2015) Stroke ASHA NOMS p < 0.05
3 days/week [72] New VFSS scale (total p < 0.05
score)b
Between group differ- p = not significanta

ences in ASHA NOMS
and new VFSS
* 1 swallow every 10 s for Head maximally 8 weeks Oh (2016) Healthy young adults Suprahyoid muscle acti- p = not significanta
10 min blocks / 2 min extended back [73] vation during effortful
breaks, over 20 min Comfortable swallow swallowing
Suprahyoid muscle acti- p = 0.016
vation during effortful p = 0.917
swallowing (8 weeks,
follow-up)
Isometric tongue Pres- A: p = 0.022, p = 0.843
sure at 8 weeks, and B: p < 0.001, p = 0.197
follow-up (A: tip, B:
base)
* 3 ×/day Shaker: 30 for isokinetic, Shaker: 60 s isometric 6 weeks Mepani (2009) Head and neck cancer, Maximum thyrohyoid p = 0.034
2 days/week 3 for isometric hold [74] and cerebrovascular muscle shortening
Traditional swallow Traditional swallow accident (between-groups)
exercise: 5 times for all exercises: 1 s each Maximum thyrohyoid p = 0.066 Shaker p = 0.48
exercises muscle shortening other
(within-groups)
13

Citation number
13
* 1 ×/day 60 repetitions (extend- 10 min swallowing every 8 weeks Oh (2018) Healthy elderly indi- Suprahyoid muscle acti- p = 0.002
2 days/week ing head back + saliva 20 s, 2 min break, then [75] viduals vation during effortful
swallow) repeat (22 total min- swallowing
utes); head extended
back maximally look- Tongue tip pressure p = 0.014
ing at ceiling Tongue base pressure p = 0.004
Normal swallowing p = 0.046
pressure
pressure
Tongue tip endurance p = 0.004
Thickness of digastric p = 0.00
muscle
Thickness of genioglos- p = 0.004
sus muscle
* Same as above, only 8 weeks Oh (2019) Healthy young individu- Tongue pressure-related p = not significant pre vs.
with head extended [76] als parameters and post training
back at 30 degrees suprahyoid activation
instead of maximally*
GS gold standard, Terms isokinetic = consecutive head lifts at a constant velocity, performed without holding or rest periods, isometric sustained hold, CTARchin tuck against resistance, SDQ-J
swallowing disturbance questionnaire—Japanese version, ALSFRS-R amyotrophic lateral sclerosis rating scale—revised, SWAL-QOL swallowing quality of life, QMG quantitative myasthenia
gravis, PAS penetration aspiration score, PNF proprioceptive neuromuscular facilitation, VFSS videofluoroscopic swallow study, ASHA NOMS American speech–language–hearing association
national outcomes measurement system, UES upper esophageal sphincter, sEMG surface electromyography
a
Value not reported
b
Jung et al. [117]
Table 4 Respiratory muscle strength training

GS (*) Frequency Repetitions Intensity Duration 1st author (year) Population(s) Primary p value(s)
Citation number studied outcome(s)
* 5 ×/day 5 sets of 60% of maximal 5 weeks Hegland (2016) Stroke Outcomes from Videofluor-
5 days/week × 5 repetitions/ expiratory [77] (ischemic) oscopy:
day pressure
(updated once Total MBSImP p < .001
per week to pharyngeal
advance) components
scorea
Rosenbek pen- p = 0.057
etration aspira-
tion score
Individual p = 0.709
MBSImP com-
ponent scores
* 75% of maximal 4 weeks Pitts Parkinson Rosenbek pen- p = 0.01
expiratory (2009) disease etration aspira-
pressure (level [78] tion score
set once, at
baseline)
* 75% of maximal 4 weeks Troche (2010) Parkinson Rosenbek pen- p = 0.001
expiratory [79] disease etration aspira-
pressure (level tion score
set once, at SWAL-QoL p = 0.007
baseline)
Onset of bolus p = 0.058
transport
UES opening p = 0.009
UES – widest p = 0.006
area
UES closure p = 0.007
Laryngeal p = 0.082
closure
Maximum laryn- p = 0.091
geal closure
Laryngeal open- p = 0.068
ing
* 75% of maximal 8 weeks Hutcheson Head and neck DIGEST p = 0.03
expiratory (2018) cancer
pressure (level [80] Penetration aspi- p = 0.59
set once, at ration scale
baseline) (PAS)
MDADI p = 0.13
MBSImP p > 0.05
* 5 breaths per set, 70% maximal 4 weeks Park (2017) Healthy elderly Buccinator p < 0.05
5 sets / day expiratory [81] individuals muscle
pressure, Orbicularis oris 2. p < 0.05*
1 min break in muscles (interven-
between sets tion and
sham)
13
GS (*) Frequency Repetitions Intensity Duration 1st author (year) Population(s) Primary p value(s)
* 5 ×/day 5 sets of × 5 30% of maximal 4 months Reyes (2015) Huntington’s SWAL-QoL d = 0.54
6 days/week repetitions/day inspiratory/ [82] disease
(inspiratory expiratory Outcomes from 50 mL water
and expiratory) pressure swallowing testb
(respectively) Time Per d = 0.58
at baseline, Swallow(s)
progressively
increased by Swallowing d = 0.50
15% resistance Capacity
every month (mL/s)
for a target of Swallowing d = 0.38
75% (thresh- Flow (mL)
olds were re-
assessed every
2 weeks)
GS gold standard, SWAL-QoL swallowing quality of life questionnaire, UES upper esophageal sphincter, MDADI MD Anderson dysphagia
index, DIGEST dynamic grade of swallowing toxicity, HNC head and neck cancer, Tx therapy, PAS penetration aspiration scale
a
MBSImP (Modified Barium Swallow Impairment Profile) pharyngeal components: initiation of pharyngeal swallow, soft palate elevation,
laryngeal elevation, anteriohyoid excursion, epiglottic movement, laryngeal vestibule closure, pharyngeal stripping wave, pharyngoesophageal
segment opening, tongue base retraction, pharyngeal residue
b
No prior studies regarding respiratory muscle strength training in Huntington’s disease; unable to control for the size of type II error. Outcomes
are reported as standardized effect sizes (Hedges’ g)
and 5. For head lift exercise, 30 lifts were recommended therapy. Head lift exercise duration ranged from 4–8 weeks.
for isokinetic exercise (lift and lower) and 3 sustained lifts Tongue exercise duration ranged from 4–12 weeks. RMST
were recommended for isometric exercise (hold); when head duration was between 4–8 weeks. Mandible exercise dura-
lift exercises were incorporated into a combination exercise tion was between 4 weeks up to 1-year post chemoradiation
program, these dosing specifications for repetitions were therapy. Lip exercise duration was between 4 weeks and
consistently used. Tongue exercise repetitions ranged from 6 months. “Other” exercise programs reported durations
5 times to as many at 120 reps in a single session, but most that ranged from 4 weeks to 6 months.
consistently included 30 repetitions per day (38%). RMST
consistently recommended 5 repetitions (100%). For iso- Outcomes
tonic/isokinetic mandible exercises, over half studied effects
of 30 repetitions (57%) with more varied for isometric (hold) Primary outcomes of each study were expressed as treatment
exercises. Lip muscle training described 3 repetitions per effects with statistical comparisons of either a control group,
session most frequently (80%). The “Other” exercise pro- another treatment group, or change in outcome from pre- to
gram category had highly variable repetition numbers, with post-exercise within one group. Of all the articles in this
all 5 articles reporting different numbers. review, 41 used comparison to control/sham or other exer-
Intensity was described in over half (55%) of the com- cise group, 29 used a pre-post analysis of the exercise group,
bination exercise programs, all but one tongue exercise and 2 articles used a unique statistical analysis [41, 72].
and head lift (94% for both), all RMST (100%), all mandi- Primary outcomes measured in the articles contained in
ble (100%), all lip (100%), and more than half of “Other” this scoping review were highly variable. Methods used for
programs (60%). When a device was not used to provide deriving outcomes were also broad (please refer to Tables 1,
objective information on resistance (e.g., IOPI, RMST, or 2, 3, 4, 5, 6, “Primary Outcome(s)” column to see a com-
other device), intensity was described as the duration of a plete list).
sustained hold (e.g., for tongue press or Mendelsohn maneu-
ver). Other articles used more qualitative descriptors, such Combination Exercise Articles
as “as hard as possible” or “maximum effort”.
Duration was included in all exercise programs in this The most commonly reported outcomes in the combination
review per inclusion requirements and had the widest spread exercise articles included grade of oral intake [36, 37, 41,
across any category. For combination exercise programs, 55], and measurements of change on videofluoroscopy using
the longest duration was 11 months post chemoradiation either the penetration aspiration scale [37, 44, 45, 108] or
13
Table 5 Exercises involving the mandible
GS (*) Name of program Frequency Repetitions Intensity Duration 1st author (year) Population(s) Primary p value(s)
* Chin tuck against 1 ×/day Isometric = 3 × Isometric = 60 s 4 weeks Park (2018) Stroke Oral, laryngeal p < 0.05
resistance 5 days/week Isotonic = 30 × hold [83] elevation/epi-
(CTAR) + Isotonic = consec- glottic closure,
“30 min/day utive repetitions residue
conventional
dysphagia treat-
ment”
* TheraBite 3 ×/day 7 days/ See publication for See publication for During CRT Molen (2014) Head and neck Weight gain, other p = 0.002 Weight
week detail detail up to 1 year [84] cancer outcomes Gain
after
* CTAR + JOAR Isokinetic: CTAR + JOAR: 6 weeks Kraaijenga (2015) Healthy senior Chin tuck strength p = 0.005
30 × consecu- bar pressed to [85] subjects Jaw opening p = 0.005
tively, 1 s per chin strength
contraction Effortful swallow:
Anterior and p = 0.016 and 0.08
Isometric: main- bar pressed to
posterior tongue
tained for 60 s, chin 50%
strength
rest for 60 s, × 3 Start intensity indi-
sets vidualized based Muscle volume p = 0.008
Effortful Swallow: on dynamometry Videofluoroscopy p = not significant
(after 60 s rest) and 30 s max. parameters
10 × Subsequent
increase by self-
perceived effort
* Swallow exercise Chin tuck against Chin tuck against 8 weeks Kraaijenga (2017) Head and Neck PAS score for d = 0.3
aid resistance and resistance and [86] Cancer thickened liquid
jaw opening jaw opening
against resistance against resistance
1. isoki- 1. Isokinetic = 1 s/
netic = 30 × contraction
2. isometric = 3 × 2. Isometric = 60 s
effortful swal- hold + 60 s rest
low = 10× *See publication
for description of
intensity
Effortful swal-
low = w/chin
bar compressed
down 50%
13

13
* Jaw opening 2 ×/day 3 sets, 20 repeti- Rapid, maximum 4 weeks Matsubara (2018) Mixed diagnoses Upward hyoid p = 0.02
exercise 7 days/week tions jaw opening, 10 s [87] w/dysphagia movement
between sets symptoms
Forward hyoid p = 0.17
movement
Pharyngeal transi- 3. p = 0.01
tion time
* Jaw opening 5 jaw extensions/ Open jaw to maxi- 4 weeks Wada (2012) Reduced opening Hyoid elevation p < 0.05
exercise set mum extent and [88] of upper esopha- UES opening p < 0.05
maintain position geal sphincter
Pharynx passage p < 0.05
for 10 s, followed (UES)
time
by 10 s rest
Pharyngeal residue p = not significant
* Modified chin tuck 1 ×/day Isometric chin Isometric = hold 6 weeks Kim (2019) Stroke PAS and FOIS p < 0.001
Against resist- 5 days/week tuck = 3 × down for 10 s [89]
ance Isotonic chin
tuck = 30 ×
+ “30 min tradi-
tional dysphagia
treatment”
GS gold standard, CTAR chin tuck against resistance, JOAR jaw opening against resistance, UES upper esophageal sphincter, PAS penetration aspiration scale, CRT chemoradiation therapy,
FOIS functional oral intake scale
Table 6 Lip muscle training
GS (*) Name of program Frequency Repetitions Intensity Duration 1st author (year) Population(s) studied Primary outcome(s) p value(s)
Citation number
* Lip muscle training 3 ×/day 3 ×/session (sessions Pulling for 5–10 s 5–8 weeks Hagg (2008) Stroke Lip force p < 0.001
7 days/week before meals) using [90] Swallowing capacity p < 0.001
the lip force meter, (ability to swallow
LF 100 150 ml of water
in “one sweep” as
quickly as possible)
* IQoro® 3 ×/session (sessions Palatal plate group— 3 months Hagg (2015) Stroke Effect on “four- p < 0.001
Lip muscle training before meals) intensity not listed [91] quadrant facial dys-
Oral Iqoro screen – function” via Facial
pulling 5–10 s Activity Testing
Swallowing capacity p < 0.001
(amount of water
swallowed / time,
mL/sec)
* IQoro® 3 ×/session (sessions Pulling for 5–10 s 3 months Hagg (2016) Stroke Oropharyngeal motor p < 0.05
Lip muscle training before meals) [92] function
* IQoro® neuromuscu- 3 repetitions Pull forward for 6 months Franzen (2018) Patients with Hiatal “Cough and misdi- Reduced in
lar training 5–10 s while resist- [93] Hernia and Gastroe- rected swallowing” obese patients
ing with sealed lips; sophageal Reflux p < 0.01
3 s rest in between Disease
each pull
* Lip closure training 1 repetition, 3 times Hold lips closed for 4 weeks Takamoto (2018) Healthy elderly adults “Eating Behavior” p < 0.05
a day 3 min [94] – time to eat per
mouthful
GS gold standard
13

Table 7 Other exercise programs
13
* Vocal exercise 4 ×/day 10 (counting up from Increased glot- 6 months Fujimaki (2017) Patients with Hospitalizations for See paper
method (glottal 7 days/week 1 to 10) tal closure by [95] “glottal closure pneumonia
closure) increasing vocal insufficiency”
intensity
* Swallow Resistance 3 ×/day 30 saliva swallows, 0–2 weeks: 20 mm 6 weeks Agrawal (2018) Healthy senior Maximum upper p < 0.01
Exercise Device 7 days/week 15 s intervals Hg resistance [96] subjects esophageal
2–4 weeks: sphincter opening
20–30 mm Hg Superior and
resistance anterior laryngeal
4–6 weeks: 40 mm excursion
Hg resistance
Posterior pharyn-
geal wall thick-
ness
Increase in degluti-
tive pharyngeal
contractile
integral
* Mendelsohn In clinic: 1 ×/week 1 repetition every 30 s Sustained laryngeal In clinic: average 7 Bogaardt (2009) Stroke Functional oral p < 0.01
(20 min sessions) for 20 min hold for 8–10 s sessions [97] intake scale
until improve- (40–60 reps/day) At home: average
ment, then bi- 76.1 days
weekly
At Home: 2–3 ×/
day, 7 days/week
“Pharyngocise” 2 ×/day 10 repetitions of 4 X 6 weeks (max dur- Carnaby–Mann Head and neck Muscle size and composition
7 days/week swallowing exer- ing CRT) (2012) cancer determined by T 2-weighted
cises [98] MRI
over 4 cycles Genioglossus p < 0.01
Mylohyoid p < 0.017
Hyoglossus p < 0.037
Cognitive behav- 1 ×/day (40– “Individualized X Up to 10 sessions Patterson (2018) Head and neck See paper See paper
ioral ther- 60 min) swallowing exer- (1 session weekly [99] cancer
apy + swallowing 1 day/week (or cises” + 45–60 min or bi-monthly)
exercises every other week) of cognitive behav-
ioral therapy
GS gold standard, MRI magnetic resonance imaging
another rating method [39, 42, 48, 49, 51, 52]. Other out- suprahyoid muscular activation [78, 81, 84], and UES open-
comes included percutaneous endoscopic gastrostomy ing [72, 74, 76, 77]. For changes in hyoid excursion, three
(PEG) tube dependence [36, 37], lingual pressure measure- out of five found significantly increased hyoid movement
ments [40, 53], or rating scales (i.e., MD Anderson Dys- (anteriorly) [72, 74, 79], but two articles did not [76, 77].
phagia Inventory) [38, 39, 42, 47, 48, 53, 54]. All but three Most of these articles used the same or a similar protocol for
articles [42, 46, 53] reported at least 1 significant finding in head lift exercise [72, 74, 76, 77]. Suprahyoid activation was
the outcome(s) measured following the combination exercise significantly increased after exercise in two out of three arti-
program. However, as shown in Table 1, it was not apparent cles, with no significant treatment effects in the study with
that improvements in various outcome measures following the least frequently prescribed exercise frequency (1 ×/day;
combination exercise programs were attributable to use of 2 days/week) [84]. Anterior–posterior opening of the UES
particular treatment doses. was significantly greater in 3 out of 4 articles [72, 76, 77].
Tongue Exercises Respiratory Muscle Strength Training
The primary goal of tongue exercise is to increase peak In dysphagia treatment, the goals of RMST are to improve
lingual pressure generation [109]. However, the effects of swallow function by increasing respiratory muscle strength,
tongue exercise on tongue pressure during swallowing, pen- because respiration and swallowing actions are highly coor-
etration, aspiration of material into the airway, and amount dinated [35]. Swallowing outcomes in the RMST articles
of residue in the oropharynx were also studied [109]. All included in this review were particularly broad. The most
16 tongue exercise articles reported on changes in lingual common measure was the penetration aspiration scale (PAS)
pressure generation anteriorly, posteriorly, or both. All arti- [108], reported in over half of the articles [85–88], with only
cles except one [58] found significantly increased tongue three of the four reporting a significant improvement in PAS
pressure after tongue exercise (p ≤ 0.05), regardless of dif- score [85–87]. Other outcomes were Modified Barium Swal-
ferences in exercise repetitions, frequencies, and treatment low Impairment Profile [111] (MBSImP) components [85,
durations. One study compared various tongue exercise 88], UES opening and closure [87], and the SWAL-QoL [87,
intensities, but did not find a difference among training lev- 90] with mixed findings across articles. As shown in Table 4,
els at 60%, 80% or 100% of a 1 repetition maximum (1RM) all articles that reported an exercise frequency of 5 ×/day
over 8 weeks [70]. Airway invasion, as measured using the for 5 days/week found that at least 1 or more swallowing
penetration aspiration scale [108] on videofluoroscopy, was outcome improved with treatment. However, an increase in
an outcome in 5 articles [57, 64–66, 71]. Only one study [57] frequency did not yield greater improvements in swallowing
found any significant improvement in airway invasion after outcomes, as indicated by the lack of significant changes
4 weeks of tongue exercise. This study used 5 tongue presses reported in a study using a 5 ×/day for 6 days/week [90] regi-
per session and was not facilitated by a device. Further, this men. This result could be due to the unique study population
study used fewer presses per session than many of other (Huntington’s Disease), or aspects of its methodology [90].
tongue exercise articles, which typically reported at least 30 This was the only study that included both inspiratory and
presses per session (see Table 2). The other 4 articles did not expiratory training, and intensity was set to 30% of maxi-
find any significant impact on airway invasion after tongue mum at baseline, with increases of 15% every month [90].
exercise at any dose. Five articles examined residue, using Intensities in all other articles ranged from 60%—75% of
a variety of techniques to quantify location and amount [57, maximum expiratory capacity.
64–66, 71]. Of these, 2 articles [57, 65] found significant
decreases in residue after a course of tongue exercise. Nei- Mandible Exercises
ther of these articles included a control or sham condition.
Accordingly, it is unclear whether these findings resulted These exercises included jaw opening, jaw closing, and chin
from tongue exercise alone or another factor. tuck against resistance (CTAR). Four out of 7 of articles that
examined mandibular exercises were published within the
Head Lift Exercises last four years. One study [93] measured chin tuck strength,
jaw opening strength, tongue strength, muscle volume, and
The purpose of the head lift exercise (Table 3) is to improve changes in videofluoroscopy and found significant changes
opening of the upper esophageal sphincter by increasing in all but the videofluoroscopy parameters. Another article
movement of the hyolaryngeal complex upward and for- reported significant weight gain after 1 year of CTAR and
ward [110]. Given the goals of this exercise, the three most TheraBite therapy 3 ×/day at 7 days/week [92]. Two arti-
common outcome measures used in 13 articles targeted cles [95, 96] examined effects of jaw opening exercise on
were changes in hyoid bone movement [72, 74, 76, 77, 79], hyoid movement and reported significant increases in hyoid
13
elevation (p < 0.05). Other articles in this category looked was not a systematic review because article inclusion was
at penetration aspiration scale (PAS) [108] ratings [94, 97], not limited by aspects of research design, such as evidence
laryngeal elevation and epiglottic closure [91]. Articles in level achieved, number of participants included, and other
this category had a wide range of methodologies in treat- considerations operationally defined in a rigorous systematic
ment administration and outcome measurement, making it review [10]. Given the wide variability in treatment meth-
difficult to make comparisons regarding exercise dosing and ods reported across articles, and the variety of outcomes
statistical findings. reported, it was not possible to determine the “best” or “most
effective dose” of resistance exercise for the treatment of
Lip Muscle Training dysphagia.
To achieve the first aim of this review, we provided an
Lip muscle training is used in rehabilitating oral function overview of the articles that reported at least the frequency
after stroke, and has also been used to facilitate improve- and duration of exercise in their methods to create a record
ments in swallowing outcomes [99]. The principles behind of exercise doses found in the research literature. We found
IQoro® lip muscle training are based on neuroplasticity, that there are a wide range of doses and outcome meas-
which is different from many of the muscle strength based ures reported in the dysphagia exercise literature. Within
approaches in these other dysphagia treatments [99–101]. individual treatment categories, some components are more
The two articles using the IQoro® training method with homogenous than others. For example, in the tongue exer-
stroke patients focused on outcomes related to facial activ- cise category, most articles reported 3 ×/day for 7 days/
ity testing and swallowing function [99, 100], both showing week for exercise frequency with 30 repetitions. For res-
significant improvements in “swallowing capacity” (amount piratory muscle strength training, articles often reported
of water swallowed, mL/s) and “oropharyngeal motor func- doses of 5 ×/day for 5 days/week, 5 sets of 5 repetitions,
tion” (not specified), respectively. Dose methods in these and 60–75% maximal expiratory capacity. However, across
articles were very similar, with the largest variation being categories, duration and intensity were varied overall. This
in duration of treatment, ranging from 4 weeks to 6 months. record clearly demonstrates the lack of agreement in dose
Articles reporting shorter treatment durations of 4–8 weeks prescription across interventions in our field.
[98, 102] found significant changes in lip force and “eating In relation to our second aim, findings suggest that a
behavior,” which may indicate that changes from this treat- broad discussion of methodological considerations in dys-
ment may occur within shorter periods of time. phagia treatment research is necessary to allow for discov-
ery of the most effective exercise doses for different treat-
Other Exercise Articles ments and patient groups, as well as adequate comparison
of study outcomes. Controlled studies that test and clearly
Outcomes for the “other” category included tracking hos- report exercise doses are needed to allow development
pitalizations for pneumonia [103], anatomical landmark of guidelines that improve reproducibility in dysphagia
changes with swallowing (i.e., UES opening, laryngeal research. This is an important consideration in delivery and
excursion) [104], functional oral intake scale (FOIS) [112] reimbursement of speech-language pathology services. For
scores [105], and measurement of muscle size and composi- example, through Medicaid, speech-language pathology
tion using MRI techniques [106]. All five articles reported treatments must be “reasonable [and have the] appropriate
positive and significant changes in these individual swallow- amount, frequency, and duration of treatment in accordance
ing outcomes following their interventions. Because of the with standards of practice” [113]. The findings of this review
different exercises and outcomes reported in these articles, demonstrate a clear need to better define these characteristics
comparisons related to dosing and outcomes are not possible of exercise dosing to allow demonstration of treatments that
across treatments. are medically necessary and that will provide patients with
adequate benefits to ensure best practice.
Findings from this review demonstrated a large breadth
Discussion in reported dosing methodology in dysphagia research as
a whole. While some interventions, such as the head lift
The purpose of this scoping review was to: (1) examine the maneuver, had more consistently reported dosing com-
dysphagia literature to provide the range of resistance-based ponents, the majority of treatments had a wide range of
dysphagia exercise doses reported in peer-reviewed publica- reported frequencies, repetitions, intensities, and dura-
tions, and (2) demonstrate the importance of dose considerations. For combination studies, the range of exercises and
tion in our exercise-based dysphagia treatments. Our broad doses was very widespread. With so many combinations of
search resulted in inclusion of 72 articles. While this review exercises and various doses reported, it is likely difficult
involved a complete literature search of four databases, it for the dysphagia clinician to identify an optimal dose for
13
use with a particular patient. Although we did not perform a minimum, basic information such as details of participant
a formal quality appraisal as a part of this scoping review, selection, interventions used, outcomes assessments and a
we did require at least exercise frequency and duration to rationale for their selection, sample size and statistical meth-
be reported, at a minimum, for inclusion. While many of ods, and if appropriate, blinding and randomization [114].
the included articles reported all four components of dose These guidelines have been clearly articulated in the Con-
(79%), there is concern regarding the reproducibility of the solidated Standards of Reporting Trials (CONSORT), which
remaining articles, either for research or clinical use. Omis- can be adapted to any number of research designs [114]. We
sion of even one parameter integral to reproducing the exer- encourage researchers in our field to use these guidelines not
cise condition, or a lack of detail in description of exercise only during manuscript preparation to guide methods report-
methodology and outcomes measured could prevent study ing, but early in study development to ensure scientific rigor.
replication. Without this information explicitly reported, it
is difficult to compare and interpret the relative effective-
ness of treatment regimens between articles. Therefore, we Conclusion
must ensure that we sustain a high level of scientific rigor in
reporting of study methodology by providing detailed infor- Exercise approaches available to the dysphagia clinician
mation about all four components of dose, and specifics on might include resistance exercise, neuromotor exercise, or
how an exercise intervention was carried out. These descrip- flexibility exercise (stretching). The ACSM recommends
tions should also include measures of patient performance or dose prescription for these exercise categories that are out-
adherence, which are critical factors to ensuring reproduc- lined in Table 8. While the ACSM guidelines provide a start-
ibility and validity of comparisons across future articles. ing point toward development of dosing criteria in dyspha-
Another area that emerged as a concern in quality and gia treatment, these recommendations may not be entirely
reproducibility was outcome selection. As we reported in applicable to dysphagia treatment, given anatomical and
the results, there are a wide range of outcome measures functional differences between spinal motor systems and the
selected and reported for various articles within the same upper aerodigestive tract [115]. More systematic, high qual-
treatment type (See “Primary Outcomes” in Tables 1, 2, 3, ity studies of varying exercises doses across exercise-based
4, 5, 6, 7). This lack of uniformity in outcome selection dysphagia treatments are required to improve our evidence
prevents us from performing any meta-analyses or true com- base regarding dose recommendations. A consensus among
parisons between different dose prescriptions. Even in the dysphagia clinicians and researchers can then be reached
case where PAS scores are reported across multiple arti- to standardize dosage parameters for exercise treatments
cles, there are various methods that can be used to evaluate across care settings. In general, it is unlikely that there is
videofluoroscopic swallow studies to obtain these ratings. a singular optimal exercise dose for each specific exercise
This makes direct comparison of findings even among these protocol. It is more probable that optimal dosing for a spe-
articles using PAS ratings more difficult, especially if vide- cific exercise will differ depending on the patient’s age, sex,
ofluoroscopic protocols are not well described (i.e., bolus comorbidities, primary etiology, physical fitness, and other
type, order, administration, size) or the method of generating factors [116]. The continued exploration of how different
ratings differs between articles (e.g., average of PAS score components of dysphagia exercise dose can be altered to
across swallows, vs “worst” PAS score across swallows). maximize benefit for different individuals with dysphagia is
Some articles developed their own outcome measurements required to improve clinical protocols for the wide range of
(i.e., swallowing capacity or “Water Swallowing Test”) that people who are treated for dysphagia. The development of
are not used broadly in dysphagia literature. The problem exercise-training programs that can be readily modified or
of outcome/assessment selection was apparent in this study, tailored to target specific population(s) will be required to
and should be considered when interpreting these dose- maximize outcomes [116].
related findings for clinical practice or future research. In future work on dysphagia exercise dose, we encourage
researchers to consider these components of exercise dose
(frequency, repetitions, intensity, duration) when designing
Limitations in the Literature and reporting on exercise-based treatment methods. For cli-
nicians seeking to engage in evidence-based practice for dys-
In evaluating the research literature examining exercise- phagia therapy, the tables provided that summarize the cur-
based dysphagia interventions, we noted that many articles rent evidence can serve as a reference point when developing
did not provide a detailed account of the exercise method- patient-specific treatment plans. Regardless of the challenges
ology used in their studies. When designing and reporting that exist related to differentiating dose recommendations in
human subjects research studies, researchers should provide these resistance-based exercise programs, continued work
sufficient detail to allow replication and thus must report, at in this area is critical for continued refinement of current
13

13
Table 8 Exercise recommendations. Adapted from the American College of Sports Medicine and other sources
Type of exercise Definition Frequency Repetitions Intensity Duration
Resistance exercise Exercises that involve 2–4 ×/day; 8–12 for most adults, 10–15 for middle-aged Novice to intermediate: 60–70% of 1-RM Specific duration of
concentric and 2–3 × days/week and older adults, 15–20 for improvement of Experienced: ≥ 80% of 1-RM for experienced training has not been
eccentric muscular muscular endurance (which may be of par- Older individuals: 40–50% 1-RM definitively deter-
contraction with ticular interest to the dysphagia clinician) To improve muscular endurance: < 50% mined according
the goal of improve 1-RM to these guidelines.
muscular strength Older individuals to improve power: 20–50% However, a sys-
and power 1-RM tematic reviewa of
resistance exercise in
older adults showed
that most programs
are between 8 and
12 weeks
Neuromotor exercise Exercises that involve 20–30 min/day, Repetitions, intensity, duration are not well defined for this type of treatment according to ACSM guidelines. However,
motor skills such 2–3 days/week there is a systematic r eviewb that lists repetitions, intensity, and duration for studies included in their review that may
as coordination and be useful to reference. The overall conclusions of this study were not definitive due to varied findings and quality of
agility, which may evidence found during review of resistance-based neuromotor exercise. It is likely that consensus on this is difficult
be impaired in dys- due to the wide range of neurological conditions that exist and the heterogeneity of individuals in the various disease
phagia from neural categories, making this difficult to study
insult
Flexibility exercise Joint range of motion 2–4 ×/each exercise, 10–30 s static stretch Stretch to the point of slight discomfort (feel- Not specified
(stretching) or flexibility ≥ 2–3 days/week time is recom- ing muscle tightness)
with daily being mended for most
most effective adults, 30–60 s for
older adults,
Table adapted from the American College of Sports Medicine’s (ACSM) [118]
1-RM 1 rep maximum
a
Latham et al. [2]
b
Cup et al. [119]
practices to provide our patients with the highest level of dysphagia OR "swallowing disorder*" OR "swallowing dif-
evidence-based care. ficult*")) in Title, Abstract, Keywords in Trials’.
Acknowledgements This work was supported by NIH Grants

1F31AG059351-01, T32-DC009401, R01DC018071, R01DC008149,
R01DC014358, R37CA225608. This manuscript was submitted in par-
tial fulfillment of the requirements for the doctoral dissertation of the References
first author, BNK. She would like to thank and recognize her disserta-
tion committee members for their valuable contributions to her training 1. Burkhead LM, Sapienza CM, Rosenbek JC. Strength-training
and feedback on this manuscript: Drs. Nicole Rogus-Pulia, Michelle R exercise in dysphagia rehabilitation: principles, procedures, and
Ciucci, Gary Diffee, Catriona Steele, and Timothy McCulloch. directions for future research. Dysphagia. 2007;22(3):251–65.
2. Latham NK, et al. Systematic review of progressive resist-
ance strength training in older adults. J Gerontol A.
Compliance with Ethical Standards 2004;59(1):M48–M61.
3. Ohkawara K, et al. A dose–response relation between aerobic
Conflict of interest The authors have no conflicts of interest to declare.
exercise and visceral fat reduction: systematic review of clinical
trials. Int J Obes. 2007;31(12):1786.
4. Radaelli R, et al. Dose-response of 1, 3, and 5 sets of resistance
Appendix exercise on strength, local muscular endurance, and hypertrophy.
J Strength Cond Res. 2015;29(5):1349–58.
5. Peterson MD, Rhea MR, Alvar BA. Applications of the dose-
PubMed response for muscular strength development: a review of meta-
analytic efficacy and reliability for designing training prescrip-
((((((((((tongue[tw] AND (pressure*[tw] OR resistance[tw] tion. J Strength Cond Res. 2005;19(4):950–8.
6. Rhea MR, et al. A meta-analysis to determine the dose
OR hold*[tw] OR lift*[tw] OR strength*[tw]))))) OR response for strength development. Med Sci Sports Exerc.
(effortful swallow*[tw] OR shaker exercise*[tw] OR men- 2003;35(3):456–64.
delsohn maneuver*[tw] OR supraglottic swallow*[tw] OR 7. Langmore SE, Pisegna JM. Efficacy of exercises to rehabilitate
exercise*[tw]))) AND (((deglutition disorders[mh] NOT dysphagia: a critique of the literature. Int J Speech Lang Pathol.
2015;17(3):222–9.
gastroesophageal reflux[mh]) OR (deglutition disorder*[tw] 8. Sciote JJ, et al. Specialized cranial muscles: how different are
OR dysphagia[tw] OR swallowing disorder*[tw] OR swal- they from limb and abdominal muscles? Cells Tissues Organs.
lowing difficult*[tw]))))))). 2003;174(1–2):73–86.
9. Arksey H, O’Malley L. Scoping studies: towards a methodologi-
cal framework. Int J Soc Res Methodol. 2005;8(1):19–32.
Scopus[Embase] 10. Wright RW, et al. How to write a systematic review. Clin Orthop
Relat Res. 2007;455:23–9.
( ( ( TITLE-ABS-KEY ( tongue) AND TITLE-ABS-KEY ( 11. Hollmann W, et al. Physical activity and the elderly. Eur J Car-
pressure* OR resistance OR hold* OR lift* OR strength*)) diovasc Prevent Rehabil. 2007;14(6):730–9.
12. Cartee GD, et al. Exercise promotes healthy aging of skeletal
OR ( TITLE-ABS-KEY ( "effortful swallow*" OR "shaker muscle. Cell Metab. 2016;23(6):1034–47.
exercise*" OR "mendelsohn man*" OR “supraglottic swal- 13. Kang C, et al. Exercise training attenuates aging-associated mito-
low*” OR exercise*))) AND ( TITLE-ABS-KEY ( "degluti- chondrial dysfunction in rat skeletal muscle: role of PGC-1α.
tion disorder*" OR dysphagia OR "swallowing disorder*" Exp Gerontol. 2013;48(11):1343–50.
14. Baar K, et al. Adaptations of skeletal muscle to exercise: rapid
OR "swallowing difficult*"))) AND ( INDEX ( embase)). increase in the transcriptional coactivator PGC-1. FASEB J.
2002;16(14):1879–86.
CINAHL 15. Yan Z, Lira VA, Greene NP. Exercise training-induced regulation
of mitochondrial quality. Exerc Sport Sci Rev. 2012;40(3):159.
16. Adhihetty PJ, et al. Plasticity of skeletal muscle mitochondria in
( ( tongue AND (pressure* OR resistance OR hold* OR response to contractile activity. Exp Physiol. 2003;88(1):99–107.
lift* OR strength*)) OR ( ("effortful swallow*" OR "shaker 17. Irrcher I, et al. Regulation of mitochondrial biogenesis in muscle
exercise*" OR "mendelsohn man*" OR “supraglottic swal- by endurance exercise. Sports Med. 2003;33(11):783–93.
low*” OR exercise*))) AND ( ("deglutition disorder*" OR 18. Kirkendall DT, Garrett WE. The effects of aging and training on
skeletal muscle. Am J Sports Med. 1998;26(4):598–602.
dysphagia OR "swallowing disorder*” OR "swallowing 19. Burkhead LM. Applications of exercise science in dyspha-
difficult*")). gia rehabilitation. Perspect Swallowing Swallowing Disord.
2009;18(2):43–8.
Cochrane CENTRAL 20. Kraemer WJ, Ratamess NA. Fundamentals of resistance training:
progression and exercise prescription. Med Sci Sports Exerc.
2004;36(4):674–88.
( ( tongue AND (pressure* OR resistance OR hold* OR 21. Spiering BA, et al. Resistance exercise biology. Sports Med.
lift* OR strength*)) OR ( ("effortful swallow*" OR "shaker 2008;38(7):527–40.
exercise*" OR "mendelsohn man*" OR “supraglottic swal- 22. Häkkinen K, Alen M, Komi P. Changes in isometric force-
and relaxation-time, electromyographic and muscle fibre
low*” OR exercise*))) AND ( ("deglutition disorder*" OR
13
characteristics of human skeletal muscle during strength train- 45. Hsiang CC, et al. Early postoperative oral exercise improves swal-
ing and detraining. Acta Physiol Scand. 1985;125(4):573–85. lowing function among patients with oral cavity cancer: a rand-
23. Kubica N, et al. Resistance exercise increases muscle protein omized controlled trial. Ear Nose Throat J. 2019;98(6):E73–E80.
synthesis and translation of eukaryotic initiation factor 2Bϵ 46. Ahlberg A, et al. Early self-care rehabilitation of head and neck
mRNA in a mammalian target of rapamycin-dependent manner. cancer patients. Acta Otolaryngol. 2011;131(5):552–61.
J Biol Chem. 2005;280(9):7570–80. 47. Carmignani I, et al. Analysis of dysphagia in advanced-stage
24. Glass DJ. Skeletal muscle hypertrophy and atrophy signaling head-and-neck cancer patients: impact on quality of life and
pathways. Int J Biochem Cell Biol. 2005;37(10):1974–84. development of a preventive swallowing treatment. Eur Arch
25. Devol DL, et al. Activation of insulin-like growth factor gene Otorhinolaryngol. 2018;275(8):2159–67.
expression during work-induced skeletal muscle growth. Am 48. Messing BP, et al. Prophylactic swallow therapy for patients with
J Physiol Endocrinol Metab. 1990;259(1):E89–E95. head and neck cancer undergoing chemoradiotherapy: a rand-
26. Tesch P, Komi P, Häkkinen K. Enzymatic adaptations con- omized trial. Dysphagia. 2017;32:487–500.
sequent to long-term strength training. Int J Sports Med. 49. Kang J-H, et al. The effect of bedside exercise program on stroke
1987;8(S1):S66–S69. patients with dysphagia. Ann Rehab Med. 2012;36(4):512.
27. Salvadego D, et al. Skeletal muscle oxidative function in vivo 50. Langmore S, et al. Efficacy of electrical stimulation and exercise
and ex vivo in athletes with marked hypertrophy from resist- for dysphagia in patients with head and neck cancer: a rand-
ance training. J Appl Physiol. 2013;114(11):1527–35. omized clinical trial. Head Neck. 2015. https://doi.org/10.1002/
28. Porter C, et al. Resistance exercise training alters mitochon- hed.24197.
drial function in human skeletal muscle. Med Sci Sports Exerc. 51. Argolo N, et al. Do swallowing exercises improve swallowing
2015;47(9):1922. dynamic and quality of life in Parkinson’s disease? NeuroReha-
29. Fry AC. The role of resistance exercise intensity on muscle bilitation. 2013;32:949–55.
fibre adaptations. Sports Med. 2004;34(10):663–79. 52. Wang CM, et al. Home-based orolingual exercise improves the
30. Hunter GR, McCarthy JP, Bamman MM. Effects of resistance coordination of swallowing and respiration in early parkinson
training on older adults. Sports Med. 2004;34(5):329–48. disease: a quasi-experimental before-and-after exercise program
31. Adams GR. Role of insulin-like growth factor-I in the regula- study. Front Neurol. 2018;9:624.
tion of skeletal muscle adaptation to increased loading. Exerc 53. Wakabayashi H, et al. The effects of resistance training of swal-
Sport Sci Rev. 1998;26:31–60. lowing muscles on dysphagia in older people: a cluster, rand-
32. Ferguson B. ACSM’s guidelines for exercise testing and pre- omized, controlled trial. Nutrition. 2018;48:111–6.
scription 9th Ed. J Can Chiropr Assoc. 2014;58(3):328. 54. Tarameshlu M, et al. The effect of traditional dysphagia therapy
33. Kumar V, et al. Age-related differences in the dose–response on the swallowing function in patients with Multiple Sclerosis: a
relationship of muscle protein synthesis to resistance exercise pilot double-blinded randomized controlled trial. J Bodyw Mov
in young and old men. J Physiol. 2009;587(1):211–7. Ther. 2019;23(1):171–6.
34. Schoenfeld BJ, Ogborn D, Krieger JW. Dose-response relation- 55. Li CM, et al. Swallowing training combined with game-based
ship between weekly resistance training volume and increases biofeedback in poststroke dysphagia. PM&R. 2016;8(8):773–9.
in muscle mass: a systematic review and meta-analysis. J 56. Moon JH, et al. The effects of tongue pressure strength and
Sports Sci. 2017;35(11):1073–82. accuracy training on tongue pressure strength, swallowing func-
35. Sapienza C, et al. Respiratory strength training: concept and tion, and quality of life in subacute stroke patients with dyspha-
intervention outcomes. Seminars in speech and language. New gia: a preliminary randomized clinical trial. Int J Rehabil Res.
York: Thieme Medical Publishers; 2011. 2018;41(3):204–10.
36. Virani A, et al. Effects of 2 different swallowing exercise 57. Namiki C, et al. Tongue-pressure resistance training improves
regimens during organ-preservation therapies for head tongue and suprahyoid muscle functions simultaneously. Clin
and neck cancers on swallowing function. Head Neck. Interv Aging. 2019;14:601–8.
2015;37(2):162–70. 58. Lazarus C, et al. Effects of exercise on swallowing and tongue
37. Carroll WR, et al. Pretreatment swallowing exercises improve strength in patients with oral and oropharyngeal cancer treated
swallow function after chemoradiation. Laryngoscope. with primary radiotherapy with or without chemotherapy. Int J
2008;118(1):39–433. Oral Maxillofac Surg. 2014;43:523–30. https: //doi.org/10.1016/j.
38. Kulbersh BD, et al. Pretreatment, preoperative swallowing exer- ijom.2013.10.023.
cises may improve dysphagia quality of life. Laryngoscope. 59. Park J-S, Kim H-J, Oh D-H. Effect of tongue strength training
2006;116(6):883–6. using the Iowa Oral Performance Instrument in stroke patients
39. Millichap F, Lee M, Pring T. A lump in the throat: Should speech with dysphagia. J Phys Therapy Sci. 2015;27(12):3631–4.
and language therapists treat globus pharyngeus? Disabil Reha- 60. Kim HD, et al. Tongue-to-palate resistance training improves
bil. 2005;27(3):124–30. tongue strength and oropharyngeal swallowing function in
40. Clark H, Shelton N. Training effects of the effortful swallow subacute stroke survivors with dysphagia. J Oral Rehabil.
under three exercise conditions. Dysphagia. 2014;29:553–63. 2017;44(1):59–64.
https://doi.org/10.1007/s00455-014-9544-7. 61. Park JS, et al. Effects of lingual strength training on oro-
41. Duarte VM, et al. Swallow preservation exercises during chemo- pharyngeal muscles in South Korean adults. J Oral Rehabil.
radiation therapy maintains swallow function. Otolaryngol Head 2019;46(11):1036–41.
Neck Surg. 2013;149(6):878–84. 62. Park HS, et al. Effect of effortful swallowing training on tongue
42. Mortensen HR, et al. Prophylactic swallowing exercises in head strength and oropharyngeal swallowing function in stroke
and neck cancer radiotherapy. Dysphagia. 2015;30(3):304–14. patients with dysphagia: a double-blind, randomized controlled
43. Tang Y, et al. A randomized prospective study of rehabilitation trial. Int J Lang Commun Disord. 2019;54(3):479–84.
therapy in the treatment of radiation-induced dysphagia and tris- 63. Park T, Kim Y. Effects of tongue pressing effortful swal-
mus. Strahlenther Onkol. 2011;187(1):39–44. low in older healthy individuals. Arch Gerontol Geriatr.
44. Malandraki GA, et al. The intensive dysphagia rehabilitation 2016;66:127–33.
approach applied to patients with neurogenic dysphagia: a case 64. Robbins J, et al. The effects of lingual exercise on swallowing in
series design study. Arch Phys Med Rehabil. 2016;97(4):567–74. older adults. J Am Geriatr Soc. 2005;53(9):1483–9.
13
65. Robbins J, et al. The effects of lingual exercise in stroke patients 88. Hutcheson KA, et al. Expiratory muscle strength training for
with dysphagia. Arch Phys Med Rehabil. 2007;88(2):150–8. radiation-associated aspiration after head and neck cancer: a case
66. Rogus-Pulia N, et al. Effects of device-facilitated isometric pro- series. Laryngoscope. 2018;128(5):1044–51.
gressive resistance oropharyngeal therapy on swallowing and 89. Park JS, Oh DH, Chang MY. Effect of expiratory muscle strength
health-related outcomes in older adults with dysphagia. J Am training on swallowing-related muscle strength in community-
Geriatr Soc. 2016;64(2):417–24. dwelling elderly individuals: a randomized controlled trial. Gero-
67. Yano J, et al. Effects of anterior tongue strengthening exercises dontology. 2017;34(1):121–8.
on posterior tongue strength in healthy young adults. Arch Oral 90. Reyes A, et al. Respiratory muscle training on pulmonary and
Biol. 2019;98:238–42. swallowing function in patients with Huntington’s disease: a pilot
68. Oh JC. Effects of tongue strength training and detrain- randomised controlled trial. Clin Rehabil. 2015;29(10):961–73.
ing on tongue pressures in healthy adults. Dysphagia. 91. Park J-S, et al. Effect of chin tuck against resistance exercise
2015;30(3):315–20. on patients with dysphagia following stroke: a randomized pilot
69. Van den Steen L, et al. Tongue-strengthening exercises in healthy study. NeuroRehabilitation. 2018;42(2):191–7.
older adults: specificity of bulb position and detraining effects. 92. Molen L, et al. Two-year results of a prospective preventive swal-
Dysphagia. 2018;33(3):337–44. lowing rehabilitation trial in patients treated with chemoradiation
70. Van den Steen L, et al. Tongue-strengthening exercises in healthy for advanced head and neck cancer. Eur Arch Otorhinolaryngol.
older adults: does exercise load matter? A randomized controlled 2014;271:1257–70. https://doi.org/10.1007/s00405-013-2640-8.
trial. Dysphagia. 2019;34(3):315–24. 93. Kraaijenga SA, et al. Effects of strengthening exercises on swal-
71. Steele CM, et al. A randomized trial comparing two tongue- lowing musculature and function in senior healthy subjects:
pressure resistance training protocols for post-stroke dysphagia. a prospective effectiveness and feasibility study. Dysphagia.
Dysphagia. 2016;31(3):452–61. 2015;30(4):392–403.
72. Easterling C, et al. Attaining and maintaining isometric and isoki- 94. Kraaijenga SAC, et al. Efficacy of a novel swallowing exercise
netic goals of the Shaker exercise. Dysphagia. 2005;20(2):133–8. program for chronic dysphagia in long-term head and neck can-
73. Gao J, Zhang HJ. Effects of chin tuck against resistance exercise cer survivors. Head Neck. 2017;39:1943–61.
versus Shaker exercise on dysphagia and psychological state after 95. Matsubara M, et al. High-speed jaw-opening exercise in train-
cerebral infarction. Eur J Phys Rehabil Med. 2017;53(3):426–32. ing suprahyoid fast-twitch muscle fibers. Clin Interv Aging.
74. Fujiki RB, et al. The recline and head lift exercises: a randomized 2018;13:125–31.
clinical trial comparing biomechanical swallowing outcomes and 96. Wada S, et al. Jaw-opening exercise for insufficient open-
perceived effort in healthy older adults. J Speech Lang Hearing ing of upper esophageal sphincter. Arch Phys Med Rehabil.
Res. 2019;62(3):631–43. 2012;93(11):1995–9.
75. Mishra A, et al. The recline exercise: comparisons with the head 97. Kim HH, Park JS. Efficacy of modified chin tuck against
lift exercise in healthy adults. Dysphagia. 2015;30(6):730–7. resistance exercise using hand-free device for dysphagia in
76. Shaker R, et al. Rehabilitation of swallowing by exercise in tube- stroke survivors: a randomised controlled trial. J Oral Rehabil.
fed patients with pharyngeal dysphagia secondary to abnormal 2019;46:1042–6.
UES opening. Gastroenterology. 2002;122(5):1314–21. 98. Hagg M, Anniko M. Lip muscle training in stroke patients with
77. Shaker R, et al. Augmentation of deglutitive upper esophageal dysphagia. Acta Otolaryngol. 2008;128(9):1027–33.
sphincter opening in the elderly by exercise. Am J Physiol. 99. Hagg M, Tibbling L. Effect of oral IQoro R and palatal
1997;272(6 Pt 1):G1518–G15221522. plate training in post-stroke, four-quadrant facial dysfunc-
78. Woo HS, Won SY, Chang KY. Comparison of muscle activity tion and dysphagia: a comparison study. Acta Otolaryngol.
between two adult groups according to the number of Shaker 2015;135(9):962–8.
exercise. J Oral Rehabil. 2014;41(6):409–15. 100. Hägg M, Tibbling L. Effect of IQoro® training on impaired pos-
79. Park JS, et al. Effect of head lift exercise on kinematic motion tural control and oropharyngeal motor function in patients with
of the hyolaryngeal complex and aspiration in patients with dys- dysphagia after stroke. Acta Otolaryngol. 2016;136(7):742–8.
phagic stroke. J Oral Rehabil. 2017;44(5):385–91. 101. Franzen T, Tibbling LI, Hägg MK. Oral neuromuscular train-
80. Don Kim K, et al. Effects of neck exercises on swallowing func- ing relieves hernia-related dysphagia and GERD symptoms as
tion of patients with stroke. J Phys Ther Sci. 2015;27(4):1005–8. effectively in obese as in non-obese patients. Acta Otolaryngol.
81. Oh JC. A pilot study of the head extension swallowing exercise: 2018;138(11):1004–8.
new method for strengthening swallowing-related muscle activ- 102. Takamoto K, et al. Lip closure training improves eating
ity. Dysphagia. 2016;31(5):680–6. behaviors and prefrontal cortical hemodynamic activity and
82. Mepani R, et al. Augmentation of deglutitive thyrohyoid muscle decreases daytime sleep in elderly persons. J Bodyw Mov Ther.
shortening by the Shaker exercise. Dysphagia. 2009;24(1):26–31. 2018;22(3):810–6.
83. Oh JC. Effect of the head extension swallowing exercise on 103. Fujimaki Y, et al. Independent exercise for glottal incompetence
suprahyoid muscle activity in elderly individuals. Exp Gerontol. to improve vocal problems and prevent aspiration pneumonia
2018;110:133–8. in the elderly: a randomized controlled trial. Clin Rehabil.
84. Oh JC. Effect of partial head extension swallowing exercise on 2017;31(8):1049–56.
the strength of the suprahyoid and tongue muscles in healthy 104. Agrawal D, et al. Swallow strength training exercise for
subjects: a feasibility study. J Oral Rehabil. 2019;46(3):242–8. elderly: a health maintenance need. Neurogastroenterol Motil.
85. Hegland KW, et al. Rehabilitation of swallowing and cough func- 2018;30(10):e13382.
tions following stroke: an expiratory muscle strength training 105. Bogaardt HC, Grolman W, Fokkens WJ. The use of biofeedback
trial. Arch Phys Med Rehabil. 2016;97(8):1345–51. in the treatment of chronic dysphagia in stroke patients. Folia
86. Pitts T, et al. Impact of expiratory muscle strength training on Phoniatr Logop. 2009;61(4):200–5.
voluntary cough and swallow function in Parkinson disease. 106. Carnaby-Mann G, et al. “Pharyngocise”: randomized controlled
Chest. 2009;135(5):1301–8. trial of preventative exercises to maintain muscle structure and
87. Troche M, et al. Aspiration and swallowing in Parkinson disease swallowing function during head-and-neck chemoradiotherapy.
and rehabilitation with EMST: a randomized trial. Neurology. Int J Radiat Oncol Biol Phys. 2012;83(1):210–9.
2010;75(21):1912–9.
13
107. Patterson JM, et al. Feasibility and acceptability of combin- 116. Blair SN, LaMonte MJ, Nichaman MZ. The evolution of physical
ing cognitive behavioural therapy techniques with swallow- activity recommendations: how much is enough? Am J Clin Nutr.
ing therapy in head and neck cancer dysphagia. BMC Cancer. 2004;79(5):913S–20S.
2018;18(1):1. 117. Jung SH, Lee KJ, Hong JB. Han TR (2005) Validation of clinical
108. Rosenbek JC, et al. A penetration-aspiration scale. Dysphagia. dysphagia scale: based on videofluoroscopic swallowing study. J
1996;11(2):93–8. Korean Acad Rehab Med. 2005;29:343–50.
109. McKenna VS, et al. A systematic review of isometric lingual 118. American College of Sports Medicine’s (ACSM). Guidelines
strength-training programs in adults with and without dysphagia. for exercise testing and prescription: medicine ACoS: ACSM’s
Am J Speech Lang Pathol. 2017;26(2):524–39. guidelines for exercise testing and prescription. Philadelphia:
110. Antunes EB, Lunet N. Effects of the head lift exercise on Lippincott Williams & Wilkins; 2013.
the swallow function: a systematic review. Gerodontology. 119. Cup EH, Pieterse AJ, Jessica M, Munneke M, van Engelen BG,
2012;29(4):247–57. Hendricks HT, van der Wilt GJ, Oostendorp RA. Exercise ther-
111. Martin-Harris B, et al. MBS measurement tool for swallow apy and other types of physical therapy for patients with neuro-
impairment—MBSImp: establishing a standard. Dysphagia. muscular diseases: a systematic review. Arch Phys Med Rehabil.
2008;23(4):392–405. 2007;88:1452–64.
112. Crary MA, Mann GDC, Groher ME. Initial psychometric assess-
ment of a functional oral intake scale for dysphagia in stroke Publisher’s Note Springer Nature remains neutral with regard to
patients. Arch Phys Med Rehabil. 2005;86(8):1516–20. jurisdictional claims in published maps and institutional affiliations.
113. Medicaid Toolkid—Medical Necessity. https://www.asha.org/
Practice/reimbursement/medicaid/Medicaid-Toolkit-Medical-
Necessity/. Accessed June 2019.
114. Schulz KF, et al. CONSORT 2010 statement: updated guide-
lines for reporting parallel group randomised trials. BMC Med. Brittany N. Krekeler PhD
2010;8(1):18.
115. McLoon LK, Andrade F. Craniofacial muscles: a new framework Linda M. Rowe MS
for understanding the effector side of craniofacial muscle control.
Berlin: Springer; 2012. Nadine P. Connor PhD
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Dose in Exercise Based Dysphagia Therapies A Scoping Review

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Dose in Exercise Based Dysphagia Therapies A Scoping Review

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Dysphagia

Dose in Exercise‑Based Dysphagia Therapies: A Scoping Review

Received: 11 October 2019 / Accepted: 25 February 2020

Keywords Scoping review · Dysphagia treatment · Dose · Evidence-based practice

Introduction These exercise approaches target specific muscles or

Methods for Scoping Review stimulation, thermal or gustatory stimulation techniques)

Articles were grouped into tables based on the type of exer-

(Table 1) 20 articles reporting combination exercise pro-

Components of dose reported were variable within an inter-

Mendelsohn = 10 *3 months post CRT/

* 5 sets of 10 repetitions, 80% 1RM Park (2015) Stroke Videofluoroscopic O: p < 0.01

while squeezing neck

(group 1) each of the 5 repeti- [61] pressure—anterior rior group (p = 0.000)

participants with dysphagia resulting from stroke (25%), or

Stage duration (thin

Normalized residue used more general terminology such as “swallow exercise,”

actual exercise procedures.

articles reporting tongue exercise and head lift met “gold

Components of Exercise Dose

Exercise dose components were grouped and are discussed

here by exercise type (represented in Tables 1, 2, 3, 4, 5, 6,

Frequency was described by all exercise programs in

this review, per final inclusion requirements. For combina-

tion exercise programs, frequency varied from as much as

consistent recommendations for frequency across all treat-

most often (54%). For tongue exercise, 3 ×/day for 3 days/

rated respiratory muscle strength training (RMST) used a

tongue pressure and

week in 5/7 articles. Lip muscle training occurred 3 ×/day

for 7 days/week for all 5 articles (100%). “Other” category of

1 day/week to as many as 4 ×/day for 7 days/week, depend-

respiratory muscle strength training articles (100%). Rep-

etitions were described in all mandible, lip muscle training,

Self-rating depression p = 0.00

Between group differ- p = not ­significanta

Table 4 Respiratory muscle strength training

Table 7 Other exercise programs

Tongue Exercises Respiratory Muscle Strength Training

Acknowledgements This work was supported by NIH Grants

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Between group differ- p = not significanta

Table 4 Respiratory muscle strength training

Table 7 Other exercise programs