Adult Swallowing EBP Group Extravaganza Presentation 2010

1. Adult Swallowing EBP GroupExtravaganza Presentation 2010 Does weight lifting for the tongue improve the swallow? The adult swallowing EBP Group comprises of both metropolitan and rural members. We teleconference with rural sites at every meeting. There are approximately 41 active and inactive members of the group. The adult swallowing EBP Group comprises of both metropolitan and rural members. We teleconference with rural sites at every meeting. There are approximately 41 active and inactive members of the group.

2. Taking EBP back to the workplace 2009 CAT: In patients with dysphagia is there a relationship between oral hygiene and pneumonia? Oral Care Project at St Vincent�s Hospital. This CAT was a lead into our next CAT (2011) on the Free Water Protocol. The 2009 CAT looking at a possible relationship between oral hygiene and pneumonia found that Oral hygiene and dysphagia are risk factors that can be attributed to the development of pneumonia and that if we can manage or minimise these risk factors the risk of developing pneumonia can be reduced. As a result of the findings of the CAT, St. Vincent�s hospital are developing and implementing an oral care project (CHRISTINE TO ADD FURTHER DETAILS) The outcomes of the 2009 CAT have also lead the group to develop our next CAT for 2011 which is investigating the Free Water Protocol and relationship with increased aspiration pneumonia. The 2009 CAT looking at a possible relationship between oral hygiene and pneumonia found that Oral hygiene and dysphagia are risk factors that can be attributed to the development of pneumonia and that if we can manage or minimise these risk factors the risk of developing pneumonia can be reduced. As a result of the findings of the CAT, St. Vincent�s hospital are developing and implementing an oral care project (CHRISTINE TO ADD FURTHER DETAILS) The outcomes of the 2009 CAT have also lead the group to develop our next CAT for 2011 which is investigating the Free Water Protocol and relationship with increased aspiration pneumonia.

3. The Function of The Tongue In Normal Swallowing The tongue is made entirely of muscle1. Major role is propulsion of the bolus1,2. Other roles include oral clearance and secondary roles in the pharyngeal phase What happens when the tongue function is impaired? We are all aware of the important role that the tongue plays in the swallow function and our academic link, Dr. Bernice Mathisen, suggested to the group that there has been an increase in research focusing on tongue strengthening in improving the swallow function and it may be a suitable time to investigate the latest research. So before investigating this topic, as a group we reviewed the function of the tongue in normal swallowing. The tongue is made entirely of muscle. It�s major role is to propel the bolus through the oral cavity, into the pharynx and esophagus. It has a major role in propelling the bolus through the oral cavity, into the pharynx and the oesophagus during swallowing1,2. Tongue strength in particular is important: - In the oral phase of the swallow for both oral transit and oral clearance of the bolus3-5 and - In the pharyngeal phase of the swallow where it has an impact on pharyngeal transit time, bolus clearance and residue6 We can expect that impairments in tongue strength to result in an abnormal swallow. We are all aware of the important role that the tongue plays in the swallow function and our academic link, Dr. Bernice Mathisen, suggested to the group that there has been an increase in research focusing on tongue strengthening in improving the swallow function and it may be a suitable time to investigate the latest research. So before investigating this topic, as a group we reviewed the function of the tongue in normal swallowing. The tongue is made entirely of muscle. It�s major role is to propel the bolus through the oral cavity, into the pharynx and esophagus. It has a major role in propelling the bolus through the oral cavity, into the pharynx and the oesophagus during swallowing1,2. Tongue strength in particular is important: - In the oral phase of the swallow for both oral transit and oral clearance of the bolus3-5 and - In the pharyngeal phase of the swallow where it has an impact on pharyngeal transit time, bolus clearance and residue6 We can expect that impairments in tongue strength to result in an abnormal swallow.

4. Muscle Strength Training Good for improving limb function. If tongue strengthening exercises are good for improving tongue function then what is the impact on swallowing function particularly in dysphagia? We know that strengthening is good for improving limb function from physio studies, so what does the research say for the tongue and what impact does this have on the swallow function and what effects does this have on dysphagia?We know that strengthening is good for improving limb function from physio studies, so what does the research say for the tongue and what impact does this have on the swallow function and what effects does this have on dysphagia?

5. Clinical Question Do tongue strengthening exercises affect the impaired oropharyngeal swallow? Knowing the significant role of the strength of the tongue in the normal swallow, we assume that reduced tongue strength will result in an impaired swallow function. So what can we do to improve tongue function and improve the swallow function? This has lead us to our clinical question for this year �do tongue strengthening exercises affect the impaired oropharyngeal swallow? We Knowing the significant role of the strength of the tongue in the normal swallow, we assume that reduced tongue strength will result in an impaired swallow function. So what can we do to improve tongue function and improve the swallow function? This has lead us to our clinical question for this year �do tongue strengthening exercises affect the impaired oropharyngeal swallow? We

6. Critically Appraised Papers 62 identified and accessible articles identified. 6 were deemed relevant but 2 of these were in abstract form only so not suitable for �capping�. As a group we have conducted a fairly complete search for evidence and found 62 potential papers, which has resulted in a total of 6 relevant studies, however only 4 were full articles. As a group we have conducted a fairly complete search for evidence and found 62 potential papers, which has resulted in a total of 6 relevant studies, however only 4 were full articles.

7. Yates, E.M., Molfenter, S,M., & Steele, C.M (2008)6 Level of Evidence: IV - Case studies Dysphagia of neurological origin Tongue pressure generation exercises conducted with biofeedback from the Iowa Oral Performance Instrument (IOPI). The study by Yates, E.M., Molfenter, S.M., & Steele, C.M. (2008). Improvements in tongue strength and pressure � generation precision following a tongue-pressure training protocol in older individuals with dysphagia: Three case reports. Clinical Interventions in Aging, 3(4): 735-747. The 3 participants had a dysphagia of neurological origin and we prescribed tongue pressure generation exercises using the IOPI. (DESCRIBE IOPI). I think we can take out the below information, it�s very lengthy and the results of the CAP is more important than the details of the study Case A 72 year old male 7 months post medullary CVA. Fed via PEG, with soft textures and thickened fluids. Case B: 63 year old male, 42 months post 4th ventricular tumour resection, resulting in damage CN XII and VC paresis. Fed via PEG, supplemented via soft texture oral snacks, H2O via teaspoon and thickened fluids. Case C: 50 year old male, 34 months post MVA resulting in brainstem stroke. Fed via PEG only (NBM). Case A: 24 Rx sessions � 2-3 sessions per week Case B: 24 sessions � 3 sessions per week Case C: 8 intensive daily face � to � face sessions, followed by home practise 3 times weekly for 90 sessions in total. Physiological changes were measured at the pre, mid way and post therapy intervals using VFSS.The study by Yates, E.M., Molfenter, S.M., & Steele, C.M. (2008). Improvements in tongue strength and pressure � generation precision following a tongue-pressure training protocol in older individuals with dysphagia: Three case reports. Clinical Interventions in Aging, 3(4): 735-747. The 3 participants had a dysphagia of neurological origin and we prescribed tongue pressure generation exercises using the IOPI. (DESCRIBE IOPI). I think we can take out the below information, it�s very lengthy and the results of the CAP is more important than the details of the study Case A 72 year old male 7 months post medullary CVA. Fed via PEG, with soft textures and thickened fluids. Case B: 63 year old male, 42 months post 4th ventricular tumour resection, resulting in damage CN XII and VC paresis. Fed via PEG, supplemented via soft texture oral snacks, H2O via teaspoon and thickened fluids. Case C: 50 year old male, 34 months post MVA resulting in brainstem stroke. Fed via PEG only (NBM). Case A: 24 Rx sessions � 2-3 sessions per week Case B: 24 sessions � 3 sessions per week Case C: 8 intensive daily face � to � face sessions, followed by home practise 3 times weekly for 90 sessions in total. Physiological changes were measured at the pre, mid way and post therapy intervals using VFSS.

8. Results: Yates et al (2008)6

9. Strengths & Limitations: Yates et al (2008) Case C appeared to have the most severe dysphagia at baseline (PEG feeds only) and received limited supervision, so perhaps this helps to explain their limited improvement? Case C appeared to have the most severe dysphagia at baseline (PEG feeds only) and received limited supervision, so perhaps this helps to explain their limited improvement?

10. Clinical Bottom Line: Yates et al (2008)6 Tongue strengthening exercises may result in positive functional outcomes for some patients with an impaired oropharyngeal swallow of neurological aetiology, depending on the severity of the swallowing impairment.

11. Carroll, W.R., Locher, J.L., Canon, C.L., Bohannon, I.A., McCulloch, N.L. & Magnuson, J.S. (2008)7. Level of Evidence: III (2) � Retrospective case control design Dysphagia due to advanced SCC of the oropharynx, hypopharynx and larynx treated with combined chemo and radiotherapy (CRT). The experimental group received pre-treatment swallowing exercises. The control group received post-treatment swallowing exercises as problems arose. The study by Carroll, W.R., Locher, J.L. Canon, C.L., Bohannon, I.A., McCulloch, N.L. & Magnuson, J.S. (2008). Pretreatment swallowing exercises improve swallow function after chemoradiation. Laryngoscope, 118: 39-43. was a retrospectice case control design study with patients with dsyphagia secondary to head and neck cancer. The experimental group were prescribed pre-treatment exercises that included: These included Masako (10 swallows), isometric tongue resistance (4 directions holding each position for 5 seconds), effortful swallow (10 swallows 5 times daily), Mendelsohn manoever and Shaker (sustained � holding for one minute times 3 sets, and repetitive � 30 repetitions). Regime was 10 repetitions, 5 times daily. Participants were encouraged to incorporate the swallow exercises into daily activities. The control group participants only received post-treatment exercises as problems arose.The study by Carroll, W.R., Locher, J.L. Canon, C.L., Bohannon, I.A., McCulloch, N.L. & Magnuson, J.S. (2008). Pretreatment swallowing exercises improve swallow function after chemoradiation. Laryngoscope, 118: 39-43. was a retrospectice case control design study with patients with dsyphagia secondary to head and neck cancer. The experimental group were prescribed pre-treatment exercises that included: These included Masako (10 swallows), isometric tongue resistance (4 directions holding each position for 5 seconds), effortful swallow (10 swallows 5 times daily), Mendelsohn manoever and Shaker (sustained � holding for one minute times 3 sets, and repetitive � 30 repetitions). Regime was 10 repetitions, 5 times daily. Participants were encouraged to incorporate the swallow exercises into daily activities. The control group participants only received post-treatment exercises as problems arose.

12. Results: Carroll et al (2008)7 The experimental group showed significantly better: Epiglottic inversion Posterior tongue base position during the swallow than the control group on MBS 3 months after treatment. No other statistically significant results were found on other outcome measures, including timing of PEG removal. Measures of epiglottic inversion, with the experimental group maintaining more normal epiglottic inversion during swallowing Measures of posterior tongue base position during swallow, with the tongue base positioned more closely to the posterior pharyngeal wall in the experimental group Measures of epiglottic inversion, with the experimental group maintaining more normal epiglottic inversion during swallowing Measures of posterior tongue base position during swallow, with the tongue base positioned more closely to the posterior pharyngeal wall in the experimental group

13. Strengths & Limitations: Carroll et al (2008)7

14. Clinical Bottom Line: Carroll et al (2008)7 The limited improvements in epiglottic inversion and tongue base to posterior wall approximation are promising with regard to pre-treatment exercises in head and neck cancer. Further research, including baseline functional and instrumental swallow measures, is needed to determine the potential for functional outcomes.

15. Ibayashi, H., Fujino, Y., Pham, T.M., & Matsuda, S. (2008)8 Level of evidence: II � RCT 54 healthy elderly without dysphagia The experimental group were given a 6 month exercise program for oral function. * Experimental group were given exercises for facial expression muscles, tongue, salivary glands (to improve saliva production) and swallowing (hold breath and take 3 saliva swallows; nil other swallowing exercises per se) which they completed once a week.* Experimental group were given exercises for facial expression muscles, tongue, salivary glands (to improve saliva production) and swallowing (hold breath and take 3 saliva swallows; nil other swallowing exercises per se) which they completed once a week.

16. Results: Ibayashi et al (2008)8 All oral functions in the experimental group (overall) showed significant improvement. In the experimental group, only participants with �20 or more teeth remaining teeth� showed significant improvement, while those with less than 20 teeth showed no significant improvement.

17. Strengths & Limitations: Ibayashi et al (2008)8 RSST = number of dry swallows in 30secondsRSST = number of dry swallows in 30seconds

18. Clinical Bottom Line: Ibayashi et al (2008)8 In healthy elderly people with 20 or more teeth, daily oral musculature and swallowing exercises (including tongue exercises) can result in enhanced oral movements and swallowing function. However, a direct link between tongue strengthening and an enhancement in swallow function cannot be made from this paper, nor can these results be extrapolated to the dysphagia population.

19. Robbins, J., Kays, S.A., Gangnan, R., Hweitt, A. & Hind, J. (2007)9 Level of evidence: III (3) - Prospective cohort intervention study 10 participants with ischemic strokes, with dysphagia diagnosed on MBS 8 week lingual exercise program using the IOPI Variety of outcome measures (MBS, tongue MRI, QOL and dietary questionnaires) The study: ) Robbins, J., Kays, S.A., Gangnan, R., Hewitt, A., & Hind, J. (2007). The effects of lingual exercise in stroke patients. Archives of Physical Medicine, 88: 150-158. There were 10 participants whom were eligible if they were 45 years or older (aged 51-90), had a hx of stroke, reduced lingual pressure with anterior or posterior tongue, referred by MO for MBS that confirmed aspiration or penetration of pharyngeal residue. There was no control group. Exercise program: anterior and posterior sections of the tongue were exercised; 10 reps, 3 times a day, 3 days a week. Data was collected pre-intervention and week 4 and week 8 post intervention The outcome measures included: Maximum isometric pressure; swallowing pressure during MBS, oropharyngeal residue, penetration and aspiration during MBS; MRI to measure lingual volume; QOL and dietary questionnaires.The study: ) Robbins, J., Kays, S.A., Gangnan, R., Hewitt, A., & Hind, J. (2007). The effects of lingual exercise in stroke patients. Archives of Physical Medicine, 88: 150-158. There were 10 participants whom were eligible if they were 45 years or older (aged 51-90), had a hx of stroke, reduced lingual pressure with anterior or posterior tongue, referred by MO for MBS that confirmed aspiration or penetration of pharyngeal residue. There was no control group. Exercise program: anterior and posterior sections of the tongue were exercised; 10 reps, 3 times a day, 3 days a week. Data was collected pre-intervention and week 4 and week 8 post intervention The outcome measures included: Maximum isometric pressure; swallowing pressure during MBS, oropharyngeal residue, penetration and aspiration during MBS; MRI to measure lingual volume; QOL and dietary questionnaires.

20. Results: Robbins et al (2007)9 The 8 week program of isometric tongue exercises in Stroke patients resulted in the following improvements: ? oropharyngeal residue ? penetration/aspiration ? oral bolus transit time ? lingual strength during saliva swallows ? lingual volume (2/3 patients; ?significant) ? duration of airway closure ? variety of solid food textures ? hydration ? QOL

21. Strengths & Limitations: Robbins et al (2007)9

22. Clinical Bottom Line: Robbins et al (2007)9 In 10 stroke patients with dysphagia confirmed on MBS, an 8 week program of isometric tongue exercises significantly improved swallow function and QOL, in the short term.

23. Abstract # 1:  Sullivan, Hind & Robbins (2001)10 Single case study Participant: 48 yr old male, 3-4 yrs post chemo-radiation and surgery for right neck SCC, with residual dysphagia Outcome measures (pre- and post- treatment): isometric pressures, MBS data and info on dysphagia-specific QOL Treatment: 8 week exercise protocol using IOPI Results: ? tongue pressure ? speed of pressure generation during swallow ? diet (soft to normal diet) ? QOL Sullivan et al (2001) � present the effects of an 8-week lingual resistance protocol on lingual pressures, diet and dysphagia specific QOL. 48 yo male with recurrent SCC of the right neck treated with a combination of CRT and radical neck dissection. The exercise program consisted of compression of the IOPI b/w the tongue and hard palate. No comment on STATISTICAL SIGNIFICANCE of results in the abstract Sullivan et al (2001) � present the effects of an 8-week lingual resistance protocol on lingual pressures, diet and dysphagia specific QOL. 48 yo male with recurrent SCC of the right neck treated with a combination of CRT and radical neck dissection. The exercise program consisted of compression of the IOPI b/w the tongue and hard palate. No comment on STATISTICAL SIGNIFICANCE of results in the abstract

24. Abstract # 2:  Prasse et al (2009) 11 Randomised Trial Participants: 22 adults post chemo-radiation therapy for oral/oropharyngeal ca Outcome measures (pre- and post-treatment): isometric pressures (IOPI), MBS, QOL Control Group: �traditional� swallowing exercises Experimental Group: tongue strengthening + �traditional� exercises Results: No significant improvement in tongue strength or swallow measures for either group BUT significantly ? QOL for Experimental Group post-treatment * Prasse et al (2009) � examine the effects of two swallow exercise programs on tongue function and swallowing in oral and oropharyngeal Ca in patients having undergone CRT. Group one: had traditional swallowing exercises Group two: had traditional swallowing exercises + tongue strengthening exercises. The results indicated no significant change in tongue strength or swallowing measures. NOTE Difficult to critique abstracts due to lack of detail * Prasse et al (2009) � examine the effects of two swallow exercise programs on tongue function and swallowing in oral and oropharyngeal Ca in patients having undergone CRT. Group one: had traditional swallowing exercises Group two: had traditional swallowing exercises + tongue strengthening exercises. The results indicated no significant change in tongue strength or swallowing measures. NOTE Difficult to critique abstracts due to lack of detail

25. Critically Appraised Topic Do tongue strengthening exercises affect the impaired oropharyngeal swallow? "There is early evidence to suggest that tongue strengthening exercises improve some aspects of swallowing physiology in adults with dysphagia of varying aetiologies. It is a potentially effective treatment for patients with neurogenic dysphagia, and possibly those with head and neck cancer, however further research that includes functional outcomes in the head and neck caseload is warranted.�

26. References 1) Robbins, J., Gangnon, R.E., Theis, M.S., Kays, S.A., Hewitt, A.L. & Hind, J.A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatrics Society, 53:1483-1489. 2) Lazarus, C., Logemann, J.A., Huang, C., Rademaker, A.W. (2003). Effcets of two types of tongue strengthening exercises in young normals. Folia Phoniatrica et Logopaedica, 55: 199-205. 3) Logemann J.A. (1983) Evaluation and Treatment of Swallowing Disorders. San Diego, CA: College Hill.. 4) Palmer, J.B. (1998). Bolus aggregation in the oropharynx does not depend on gravity. Archives of Physical Medical Rehabilitation, 79: 691-696. 5) Lazarus, C. (2006). Tongue strength and exercise in healthy individuals and in head and neck cancer patients. Seminars in Speech and Language, 27: 260-270. 6) Yates, E.M., Molfenter, S.M., & Steele, C.M. (2008). Improvements in tongue strength and pressure � generation precision following a tongue-pressure training protocol in older individuals with dysphagia: Three case reports. Clinical Interventions in Aging, 3(4): 735-747. 7) Carroll, W.R., Locher, J.L. Canon, C.L., Bohannon, I.A., McCulloch, N.L. & Magnuson, J.S. (2008). Pretreatment swallowing exercises improve swallow function after chemoradiation. Laryngoscope, 118: 39-43. 8) Ibayashi, H., Fujino, Y., Pham, T.M., & Matsuda, S. (2008). Intervention study of exercise program for oral function in healthy elderly people. Tohoku, J. Exp. Med. 215: 237-245. 9) Robbins, J., Kays, S.A., Gangnan, R., Hewitt, A., & Hind, J. (2007). The effects of lingual exercise in stroke patients. Archives of Physical Medicine, 88: 150-158. 10) Prasse, J., Sanfilippo, N., DeLacure, M., Falciglia, D., Branski, R., Ho, M., Ganz, C., Kraus, D., Lee, N. & Lazarus, C. (2009) Tongue strength and swallowing in oral cancer patients. 11) Sullivan, P., Hind, J.A., & Robbins, J.A. (2001) Lingual exercise protocol for head and neck cancer: A case study.