Effects of Device-Facilitated Isometric Progressive Resistance Oropharyngeal Therapy on Swallowing and Health-Related Outcomes in Older Adults with Dysphagia.

Swallowing disorders (dysphagia) are associated with malnutrition, aspiration pneumonia, and mortality in older adults. Strengthening interventions have shown promising results, but the effectiveness of treating dysphagia in older adults remains to be established. The Swallow STRengthening OropharyNGeal (Swallow STRONG) Program is a multidisciplinary program that employs a specific approach to oropharyngeal strengthening-device-facilitated (D-F) isometric progressive resistance oropharyngeal (I-PRO) therapy-with the goal of reducing health-related sequelae in veterans with dysphagia. Participants completed 8 weeks of D-F I-PRO therapy while receiving nutritional counseling and respiratory status monitoring. Assessments were completed at baseline, 4, and 8 weeks. At each visit, videofluoroscopic swallowing studies were performed. Dietary and swallowing-related quality of life questionnaires were administered. Long-term monitoring for 6-17 months after enrollment allowed for comparison of pneumonia incidence and hospitalizations to the 6-17 months before the program. Veterans with dysphagia confirmed with videofluoroscopy (N = 56; 55 male, 1 female; mean age 70) were enrolled. Lingual pressures increased at anterior (effect estimate = 92.5, P < .001) and posterior locations (effect estimate = 85.4, P < .001) over 8 weeks. Statistically significant improvements occurred on eight of 11 subscales of the Quality of Life in Swallowing Disorders (SWAL-QOL) Questionnaire (effect estimates = 6.5-19.5, P < .04) and in self-reported sense of effort (effect estimate = -18.1, P = .001). Higher Functional Oral Intake Scale scores (effect estimate = 0.4, P = .02) indicated that participants were able to eat less-restrictive diets. There was a 67% reduction in pneumonia diagnoses, although the difference was not statistically significant. The number of hospital admissions decreased significantly (effect estimate = 0.96; P = .009) from before to after enrollment. Findings suggest that the Swallow STRONG multidisciplinary oropharyngeal strengthening program may be an effective treatment for older adults with dysphagia.

Age-Related Differences in Pressures Generated During Isometric Presses and Swallows by Healthy Adults.

The aim of this prospective observational study was to determine the associations among age, maximum lingual isometric pressures, and maximum swallow pressures in specific regions of the tongue. Individuals 21 years and older who reported normal swallowing were enrolled. Seventy-one healthy adults were stratified by age into young (21-40 years), middle (41-60), and old (61-82) groups. Maximum pressures were measured for each individual during isometric tongue press tasks as well as saliva, 5, and 10 mL thin liquid bolus swallows at 5 sensors located on the hard palate: front, middle, left, right, and back. Lower maximum lingual pressures for all tasks were associated with increased age (p < 0.04). Saliva pressures exhibited a different pressure pattern than bolus swallows with pressures higher than bolus swallows on middle (p < 0.03) and back (p < 0.05) tongue sensors but not in the front. Diminished swallow pressure reserve (maximum isometric pressure-maximum swallow pressure) also was found with increased age (p < 0.03). Isometric pressures were greater than swallow pressures in young and middle age groups at both the front (p < 0.04) and back (p < 0.03) sensors, but only significantly greater at the front sensor for the oldest group (p < 0.04). Older healthy adults have lower lingual isometric pressures and lower swallow pressures than younger healthy adults. Elders have a decreased swallow pressure reserve to draw upon during occasions of physiological stress. While the exact mechanisms for age-related decline in lingual pressures remain unclear, they are likely due, at least in part, to sarcopenia. Saliva, 5, and 10 mL thin boluses also exhibit different age-related declines in pressure at specific sensors, indicating they may elicit different muscle activation patterns.

Comparison of Maximal Lingual Pressure Generation During Isometric Gross and Fine Sensorimotor Tasks in Healthy Adults.

OBJECTIVES: To (1) compare 2 distinct isometric lingual press tasks, fine sensorimotor versus gross sensorimotor, at multiple sensor locations in relation to age and sex; and (2) provide a normative data set using a lingual-strengthening device. DESIGN: Cohort study. SETTING: University. PARTICIPANTS: Healthy men and women (N=71; age range, 21-82y) recruited from the community. INTERVENTIONS: Participants were stratified by age and sex and divided into 3 age groups. Participants completed, in random order, 2 isometric tasks: (1) fine sensorimotor: tongue press maximally and discreetly against each of 5 sensors; and (2) gross sensorimotor: tongue press maximally against all 5 sensors simultaneously. MAIN OUTCOME MEASURES: Primary outcome was maximum isometric pressure in hectopascals (hPa). Secondary outcomes were time to reach peak pressure (s) and pressure gradient (hPa/s). RESULTS: Maximum pressures were significantly lower in those of older age for both fine and gross sensorimotor lingual tasks (P<.01), with the front and back sensors showing the greatest decline (35% and 45%, respectively). Pressure differences between tasks (P=.0012) resulted in the fine sensorimotor task generating higher pressures at the front sensor for all age groups. However, the gross sensorimotor task generated faster maximum pressures at all sensor locations for all age groups. For both sensorimotor tasks, subjects of older age as a whole generated less steep pressure gradients (P<.001). CONCLUSIONS: Age-related decline in tongue strength is greater at the anterior and posterior tongue. Results indicate a simpler gross sensorimotor task may be more beneficial for targeting timing as a biomechanical parameter during therapy, and the fine sensorimotor task may be more beneficial for targeting strength.

Nutrient intake from thickened beverages and patient-specific implications for care.

Dysphagia, or difficulty swallowing, affects more than 15 million Americans and can result in adverse and potentially fatal consequences, including poor quality of life, depression, dehydration, malnutrition, aspiration pneumonia, and airway obstruction. Although many treatment options are available, provision of thickened liquids is a common intervention for achieving slower, more controlled bolus manipulation and propulsion. To meet this therapeutic demand, commercially available products containing starch and/or gum-based components have been developed for use by patients and institutions. The nutrient content of thickened products has been neglected, although dysphagic patients are often at significant nutrition risk. Thus, there are no clinical guidelines for selection of thickened products based on patient characteristics. To consider whether such guidelines are warranted, it is necessary to quantify nutrition differences among common thickened beverages. An analysis was conducted to quantify energy, carbohydrate, and sodium provided through daily consumption of thickened beverages. To determine the relevance of these nutrition contributions in the context of total dietary intake, we compared values with dietary recommended intakes. This analysis revealed that there are substantial disparities in the nutrient content of thickened beverages. These differences suggest that product selection can be optimized based on patient-specific characteristics such as weight status and presence of comorbidities. Future research focusing on the effect of this strategy on patient outcomes will facilitate the development of evidence-based recommendations to elevate the standard of care for this population.

Case study: application of isometric progressive resistance oropharyngeal therapy using the Madison Oral Strengthening Therapeutic device.

PURPOSE: Isometric progressive resistance oropharyngeal (I-PRO) therapy improves swallowing function; however, current devices utilize a single sensor that provides limited information or are prohibitively expensive. This single-subject study presents results of I-PRO therapy, detraining, and maintenance using the 5-sensor Madison Oral Strengthening Therapeutic (MOST) device combined with upper esophageal sphincter (UES) dilatation. METHODS: A 56-year-old female nurse who was 27 months post stroke and subsequent to traditional behavioral interventions and UES dilatations presented limited to gastrostomy tube intake only and expectorating all saliva. She completed 8 weeks of I-PRO therapy, 5 weeks of detraining, and 9 weeks of I-PRO maintenance (reduced frequency) followed by a third UES dilatation post intervention. Data included diet inventory, lingual pressures (MOST), lingual volume (magnetic resonance imaging), postswallow residue (videofluoroscopy), UES and pharyngeal pressures (high-resolution manometry), and quality of life (QOL). RESULTS: Findings after 8 weeks of I-PRO therapy were progression to general oral diet, 15 lb weight gain, increased isometric pressures (Δ â‰¯16 kPa) with transference to swallowing pressures, increased lingual volume (8.3%), reduced pharyngeal wall residue (P = .03), increased pharyngeal pressures (Δ â‰¯ 43 mm Hg) and increased UES opening (nadir) pressures (Δ â‰¯ 9 mm Hg) with improved temporopressure coordination across the pharynx, and improved QOL. After detraining, decreased isometric pressures and reduced UES opening were noted. After I-PRO maintenance, isometric anterior lingual pressures returned to levels noted after the 8 weeks of intervention. CONCLUSION: I-PRO therapy, facilitated by the MOST device combined with instrumental UES dilatation, improved swallow safety, increased oropharyngeal intake, and facilitated UES opening while enriching QOL.

Tongue strength is associated with jumping mechanography performance and handgrip strength but not with classic functional tests in older adults.

OBJECTIVES: To determine whether classic muscle function tests and jumping mechanography (JM) are related to tongue strength. DESIGN: Cross-sectional. SETTING: Community. PARTICIPANTS: Ninety-seven community-dwelling individuals aged 70 and older (49 female, 48 male, mean age 80.7, range 70-95) with and without identified sarcopenia. MEASUREMENTS: Participants performed muscle function tests including the Short Physical Performance Battery (SPPB), grip strength, and JM. Isometric tongue strength was evaluated using the Iowa Oral Performance Instrument (IOPI). JM consisted of maximal countermovement jumps performed on a force plate to calculate weight-corrected peak power and jump height. Total body dual-energy X-ray absorptiometry was used to assess appendicular lean mass (ALM) to define sarcopenia based on commonly used ALM/height(2) cutoffs. Associations between IOPI measures and other muscle function tests were evaluated. RESULTS: Sarcopenia was present in 23.7% (23/97) of this cohort. Anterior isometric tongue pressure was positively correlated with grip strength (P = .003), jump height (P = .01), and power (P = .04). Individuals in the lowest tertile of tongue pressure had lower scores on these muscle function tests than individuals in the other tertiles. Classic functional tests and ALM/height(2) were unrelated to tongue strength. CONCLUSION: In older adults with and without sarcopenia, isometric tongue pressure is positively correlated with grip strength and jump height and power. These data support consideration of oropharyngeal functional decline as part of the sarcopenia syndrome.

The effects of lingual intervention in a patient with inclusion body myositis and Sjögren's syndrome: a longitudinal case study.

OBJECTIVE: To report the 5-year course of a patient's swallowing disorder in the context of progressive neuromuscular disease and the effectiveness of a lingual strengthening treatment program. DESIGN: This is a case report that describes a lingual treatment protocol that was repeated 3 times over a 5-year period with and without maintenance periods. SETTING: The study was completed in 2 settings-an outpatient swallowing clinic at an acute care hospital and the patient's home. PARTICIPANT: The subject was a 77-year-old woman who was diagnosed with inclusion body myositis and Sjögren's syndrome. INTERVENTION: The patient participated in an intensive 8-week lingual strengthening protocol 3 times (at years 1, 4, and 5) and a subsequent maintenance program twice (at years 4 and 5). MAIN OUTCOME MEASURES: Three outcome measures were collected during the study: (1) lingual manometric pressures at the anterior and posterior tongue, measured by using a lingual manometric device, (2) airway invasion measured by using an 8-point Penetration-Aspiration Scale, and (3) clearance of the bolus measured by using a 3-point residue scale. RESULTS: Isometric lingual strengthening was effective in maintaining posterior tongue lingual pressure and Penetration-Aspiration Scale scores during the treatment periods. Residue scale scores did not significantly change during treatment. CONCLUSIONS: We conclude that, in this patient, lingual strengthening slowed the progression of disease-related lingual strength loss and extended functional swallowing performance. Thus, this type of intervention may hold promise as an effective swallowing treatment option for patients with neurodegenerative inflammatory diseases such as inclusion body myositis and Sjögren's syndrome.

Comparison of standardized bariums with varying rheological parameters on swallowing kinematics in males.

This study measured dose-response of a range of commercially available liquid barium materials designed for use in videofluoroscopic oropharyngeal swallowing assessments, particularly as they relate to the necessity of adding a thickening agent for swallow safety. A group of 25 adult males representing various medical diagnoses consented to participate, with 16 qualifying to complete a videofluoroscopic swallowing assessment with liquid barium materials of three viscosities (nectar: 300 cP, thin honey: 1,500 cP, thick honey: 3,000 cP). Outcome measures included airway invasion (Penetration-Aspiration score), postswallow residue, and patient preference. Penetration-Aspiration and residue scores did not significantly differ between thin honey and thick honey bariums. Significantly more severe airway invasion was observed with nectar boluses than with two levels of honey boluses (p < 0.001). Significantly more residue was observed in the oral cavity (p < 0.002) and valleculae (p < 0.001) with thin and thick honey bariums than with nectar barium. Thin honey was rated as "easy" or "average" to drink by 67% of subjects, compared with 54% for thick honey. This study supports the use of thin honey barium over thick honey barium during videofluoroscopic swallowing assessments because the two honey bariums were comparable in terms of airway protection and postswallow residue in the oropharynx and the thin honey was preferred by patients.

The utility of pitch elevation in the evaluation of oropharyngeal Dysphagia: preliminary findings.

PURPOSE: To evaluate the utility of a pitch elevation task in the assessment of oropharyngeal dysphagia. METHOD: This study was a pilot prospective cohort study including 40 consecutive patients (16 male and 24 female) who were referred by their physician for a swallowing evaluation. Patients were evaluated with a noninstrumental clinical examination and a videofluoroscopic swallow study, and participated in a pitch elevation task during videofluoroscopic image acquisition. Relationships between pitch elevation measurements (acoustic and perceptual) and swallow parameters (penetration/aspiration and residue) were investigated. RESULTS: Results of this pilot study revealed that both maximum fundamental frequency (F(0)) and perceptual evaluation of pitch elevation independently significantly predicted Penetration-Aspiration Scale scores for thin liquid swallows (p = .01 and .03, respectively). Vocal range (average pitch to falsetto) was not sensitive in predicting likelihood of oropharyngeal dysphagia. CONCLUSIONS: Findings indicate that reduced pitch elevation can be indicative of reduced airway protection and swallowing impairment in some dysphagia patients and may be a useful supplement to dysphagia screening and diagnosis. Further investigation is warranted to determine the optimal utility of this procedure for different diagnostic categories of patients.

Omission of dysphagia therapies in hospital discharge communications.

Despite the wide implementation of dysphagia therapies, it is unclear whether these therapies are successfully communicated beyond the inpatient setting. The aim of this study was to examine the rate of dysphagia recommendation omissions in hospital discharge summaries for high-risk subacute care (i.e., skilled nursing facility, rehabilitation, long-term care) populations. We performed a retrospective cohort study that included all stroke and hip fracture patients billed for inpatient dysphagia evaluations by speech-language pathologists (SLPs) and discharged to subacute care from 2003 through 2005 from a single large academic medical center (N=187). Dysphagia recommendations from final SLP hospital notes and from hospital (physician) discharge summaries were abstracted, coded, and compared for each patient. Recommendation categories included dietary (food and liquid), postural/compensatory techniques (e.g., chin tuck), rehabilitation (e.g., exercise), meal pacing (e.g., small bites), medication delivery (e.g., crush pills), and provider/supervision (e.g., 1-to-1 assist). Forty-five percent of discharge summaries omitted all SLP dysphagia recommendations. Forty-seven percent (88/186) of patients with SLP dietary recommendations, 82% (93/114) with postural, 100% (16/16) with rehabilitation, 90% (69/77) with meal pacing, 95% (21/22) with medication, and 79% (96/122) with provider/supervision recommendations had these recommendations completely omitted from their discharge summaries. Discharge summaries omitted all categories of SLP recommendations at notably high rates. Improved post-hospital communication strategies are needed for discharges to subacute care.

Effects of dining on tongue endurance and swallowing-related outcomes.

PURPOSE: The purpose of this study was to test the hypothesis that eating a meal reduces tongue strength and endurance in healthy old and young adults. It was predicted that older adults would show greater declines in tongue endurance while demonstrating higher perceived effort, longer meal durations, and clinical signs of swallowing difficulty. METHOD: Twenty-two healthy adults were enrolled into 2 groups (ages 20-35 years and ages 65-82 years; 5 males and 6 females each). Maximum tongue strength (Pmax) and endurance (duration 50% of Pmax could be maintained) were measured twice at baseline and once postmeal. Subjects consumed half of a bagel with peanut butter, carrot sticks, and milk between measures. RESULTS: All subjects demonstrated reduced tongue strength and endurance postmeal. Young adults showed a greater decline in anterior tongue endurance compared with older adults (p=.05). There was no evidence that changes in tongue strength, perceived effort, or meal duration varied by age or gender. The 3 oldest subjects reported the highest effort and displayed signs of difficulty swallowing while dining. CONCLUSIONS: Young and old adults demonstrated reduced tongue strength and endurance after dining, but younger subjects showed greater declines in anterior tongue endurance, whereas older adults exhibited signs of swallowing difficulty.

Esophageal clearance patterns in normal older adults as documented with videofluoroscopic esophagram.

Normal esophageal bolus transport in asymptomatic healthy older adults has not been well defined, potentially leading to ambiguity in differentiating esophageal swallowing patterns of dysphagic and healthy individuals. This pilot study of 24 young (45-64 years) and old (65+years) men and women was designed to assess radiographic esophageal bolus movement patterns in healthy adults using videofluoroscopic recording. Healthy, asymptomatic adults underwent videofluoroscopic esophagram to evaluate for the presence of ineffective esophageal clearance, namely, intraesophageal stasis and intraesophageal reflux. Intraesophageal stasis and intraesophageal reflux were visualized radiographically in these normal subjects. Intraesophageal stasis occurred significantly more frequently with semisolid (96%) compared with liquid (16%) barium, suggesting that a variety of barium consistencies, as opposed to only the traditional fluids, would better define the spectrum of esophageal transport. Intraesophageal reflux was observed more frequently in older males than in their younger counterparts. The rates of intraesophageal stasis and intraesophageal reflux were potentially high given that successive bolus presentations were spaced 10 seconds apart. These findings suggest a need for a more comprehensive definition regarding the range of normal esophageal bolus transport to (a) prevent misdiagnosis of dysphagia and (b) to enhance generalization to functional eating, which involves solid foods in addition to liquids.

Comparison of trained clinician ratings with expert ratings of aspiration on videofluoroscopic images from a randomized clinical trial.

Accurate detection and classification of aspiration is a critical component of videofluoroscopic swallowing evaluation, the most commonly utilized instrumental method for dysphagia diagnosis and treatment. Currently published literature indicates that interjudge reliability for the identification of aspiration ranges from poor to fairly good depending on the amount of training provided to clinicians. The majority of extant studies compared judgments among clinicians. No studies included judgments made during the use of a postural compensatory strategy. The purpose of this study was to examine the accuracy of judgments made by speech-language pathologists (SLPs) practicing in hospitals compared with unblinded expert judges when identifying aspiration and using the 8-point Penetration/Aspiration Scale. Clinicians received extensive training for the detection of aspiration and minimal training on use of the Penetration/Aspiration Scale. Videofluoroscopic data were collected from 669 patients as part of a large, randomized clinical trial and include judgments of 10,200 swallows made by 76 clinicians from 44 hospitals in 11 states. Judgments were made on swallows during use of dysphagia compensatory strategies: chin-down posture with thin liquids and head-neutral posture with thickened liquids (nectar-thick and honey-thick consistencies). The subject population included patients with Parkinson's disease and/or dementia. Kappa statistics indicate high accuracy for all interventions by SLPs for identification of aspiration (all kappa > 0.86) and variable accuracy (range = 69-76%) using the Penetration/Aspiration Scale when compared to expert judges. It is concluded that while the accuracy of identifying the presence of aspiration by SLPs is excellent, more extensive training and/or image enhancement is recommended for precise use of the Penetration/Aspiration Scale.

Neurophysiology of swallowing: effects of age and bolus type.

This study examined age-related changes in swallowing from an integrated biomechanical and functional imaging perspective in order to more comprehensively characterize changes in swallowing associated with age. We examined swallowing-related fMRI brain activity and videoflouroscopic biomechanics of three bolus types (saliva, water and barium) in 12 young and 11 older adults. We found that age-related neurophysiological changes in swallowing are evident. The group of older adults recruited more cortical regions than young adults, including the pericentral gyri and inferior frontal gyrus pars opercularis and pars triangularis (primarily right-sided). Saliva swallows elicited significantly higher BOLD responses in regions important for swallowing compared to water and barium. In separate videofluoroscopy sessions, we obtained durational measures of supine swallowing. The older cohort had significantly longer delays before the onset of the pharyngeal swallow response and increased residue of ingested material in the pharynx. These findings suggest that older adults without neurological insult elicit more cortical involvement to complete the same swallowing tasks as younger adults.

Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial.

BACKGROUND: Aspiration pneumonia is common among frail elderly persons with dysphagia. Although interventions to prevent aspiration are routinely used in these patients, little is known about the effectiveness of those interventions. OBJECTIVE: To compare the effectiveness of chin-down posture and 2 consistencies (nectar or honey) of thickened liquids on the 3-month cumulative incidence of pneumonia in patients with dementia or Parkinson disease. DESIGN: Randomized, controlled, parallel-design trial in which patients were enrolled for 3-month periods from 9 June 1998 to 19 September 2005. SETTING: 47 hospitals and 79 subacute care facilities. PATIENTS: 515 patients age 50 years or older with dementia or Parkinson disease who aspirated thin liquids (demonstrated videofluoroscopically). Of these, 504 were followed until death or for 3 months. INTERVENTION: Participants were randomly assigned to drink all liquids in a chin-down posture (n = 259) or to drink nectar-thick (n = 133) or honey-thick (n = 123) liquids in a head-neutral position. MEASUREMENTS: The primary outcome was pneumonia diagnosed by chest radiography or by the presence of 3 respiratory indicators. RESULTS: 52 participants had pneumonia, yielding an overall estimated 3-month cumulative incidence of 11%. The 3-month cumulative incidence of pneumonia was 0.098 and 0.116 in the chin-down posture and thickened-liquid groups, respectively (hazard ratio, 0.84 [95% CI, 0.49 to 1.45]; P = 0.53). The 3-month cumulative incidence of pneumonia was 0.084 in the nectar-thick liquid group compared with 0.150 in the honey-thick liquid group (hazard ratio, 0.50 [CI, 0.23 to 1.09]; P = 0.083). More patients assigned to thickened liquids than those assigned to the chin-down posture intervention had dehydration (6% vs. 2%), urinary tract infection (6% vs. 3%), and fever (4% vs. 2%). LIMITATIONS: A no-treatment control group was not included. Follow-up was limited to 3 months. Care providers were not blinded, and differences in cumulative pneumonia incidence between interventions had wide CIs. CONCLUSION: No definitive conclusions about the superiority of any of the tested interventions can be made. The 3-month cumulative incidence of pneumonia was much lower than expected in this frail elderly population. Future investigation of chin-down posture combined with nectar-thick liquid may be warranted to determine whether this combination better prevents pneumonia than either intervention independently.

A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson's disease.

PURPOSE: This study was designed to identify which of 3 treatments for aspiration on thin liquids-chin-down posture, nectar-thickened liquids, or honey-thickened liquids-results in the most successful immediate elimination of aspiration on thin liquids during the videofluorographic swallow study in patients with dementia and/or Parkinson's disease. METHOD: This randomized clinical trial included 711 patients ages 50 to 95 years who aspirated on thin liquids as assessed videofluorographically. All patients received all 3 interventions in a randomly assigned order during the videofluorographic swallow study. RESULTS: Immediate elimination of aspiration on thin liquids occurred most often with honey-thickened liquids for patients in each diagnostic category, followed by nectar-thickened liquids and chin-down posture. Patients with most severe dementia exhibited least effectiveness on all interventions. Patient preference was best for chin-down posture followed closely by nectar-thickened liquids. CONCLUSION: To identify best short-term intervention to prevent aspiration of thin liquid in patients with dementia and/or Parkinson's disease, a videofluorographic swallow assessment is needed. Evidence-based practice requires taking patient preference into account when designing a dysphagic patient's management plan. The longer-term impact of short-term prevention of aspiration requires further study.

Standardized instrument for lingual pressure measurement.

Disease-related atrophy of the tongue muscles can lead to diminished lingual strength and swallowing difficulties. The devastating physical and social consequences resulting from this condition of oropharyngeal dysphagia have prompted investigators to study the effects of tongue exercise in improving lingual strength. We developed the Madison Oral Strengthening Therapeutic (MOST) device, which provides replicable mouth placement, portability, affordability, and a simple user interface. Our study (1) compared the MOST to the Iowa Oral Performance Instrument (IOPI), a commercial pressure-measuring device, and (2) identified the optimal tongue pressure sampling rate for isometric exercises. While initial use of the MOST is focused on evaluating and treating swallowing problems, it is anticipated that its greatest impact will be the prevention of lingual muscle mass and related strength diminishment, which occurs even in the exponentially increasing population of healthy aging adults.

The effects of lingual exercise in stroke patients with dysphagia.

OBJECTIVE: To examine the effects of lingual exercise on swallowing recovery poststroke. DESIGN: Prospective cohort intervention study, with 4- and 8-week follow-ups. SETTING: Dysphagia clinic, tertiary care center. PARTICIPANTS: Ten stroke patients (n=6, acute: < or =3mo poststroke; n=4, chronic: >3mo poststroke), age 51 to 90 years (mean, 69.7y). INTERVENTION: Subjects performed an 8-week isometric lingual exercise program by compressing an air-filled bulb between the tongue and the hard palate. MAIN OUTCOME MEASURES: Isometric and swallowing lingual pressures, bolus flow parameters, diet, and a dysphagia-specific quality of life questionnaire were collected at baseline, week 4, and week 8. Three of the 10 subjects underwent magnetic resonance imaging at each time interval to measure lingual volume. RESULTS: All subjects significantly increased isometric and swallowing pressures. Airway invasion was reduced for liquids. Two subjects increased lingual volume. CONCLUSIONS: The findings indicate that lingual exercise enables acute and chronic dysphagic stroke patients to increase lingual strength with associated improvements in swallowing pressures, airway protection, and lingual volume.

Challenges in the design and conduct of a randomized study of two interventions for liquid aspiration.

BACKGROUND: Liquid aspiration during swallowing has been linked to pneumonia, the most common cause of infectious death in the elderly. This paper examines the key issues in the design and implementation of the first multisite, randomized behavioral trial in dysphagia in an aging population. The study evaluated two commonly used treatments with respect to short-term and long-term management of liquid aspiration and subsequent pneumonia in dysphagic geriatric participants with dementia and/or Parkinson's disease. METHODS: Discussed are lessons learned during the conduct of this trial and include (1) ethical and methodological design issues, (2) pragmatic implementation of procedures and forms, (3) importance of multiple communication and monitoring strategies, (4) response to funding issues, and (5) changes in staff and facilities. RESULTS: In order to complete this trial the researchers were required to provide more support than anticipated in tasks such as completion of regulatory requirements by sites, supplementing site staff to identify potential study participants using a 'circuit rider' approach, continued recruitment of new sites and staff throughout the course of the trial, adapting forms and procedures and managing within economic constraints in a changing trial environment. LIMITATIONS: Many of the challenges faced by the researchers were not anticipated when the study began. Successful strategies are described for these unanticipated difficulties, based on retrospective evaluation. CONCLUSIONS: Successful conduct of clinical trials in long-term care environments that are heavily impacted by changes extraneous to the trial design and with staff typically new to clinical trials is possible but success depends on logistical flexibility.

The effects of lingual exercise on swallowing in older adults.

OBJECTIVES: To determine the effects of an 8-week progressive lingual resistance exercise program on swallowing in older individuals, the most "at risk" group for dysphagia. DESIGN: Prospective cohort intervention study. SETTING: Subjects were recruited from the community at large. PARTICIPANTS: Ten healthy men and women aged 70 to 89. INTERVENTION: Each subject performed an 8-week lingual resistance exercise program consisting of compressing an air-filled bulb between the tongue and hard palate. MEASUREMENTS: At baseline and Week 8, each subject completed a videofluoroscopic swallowing evaluation for kinematic and bolus flow assessment of swallowing. Swallowing pressures and isometric pressures were collected at baseline and Weeks 2, 4, and 6. Four of the subjects also underwent oral magnetic resonance imaging (MRI) to measure lingual volume. RESULTS: All subjects significantly increased their isometric and swallowing pressures. All subjects who had the MRI demonstrated increased lingual volume of an average of 5.1%. CONCLUSION: The findings indicate that lingual resistance exercise is promising not only for preventing dysphagia due to sarcopenia, but also as a treatment strategy for patients with lingual weakness and swallowing disability due to frailty or other age-related conditions. The potential effect of lingual exercise on reducing dysphagia-related comorbidities (pneumonia, malnutrition, and dehydration) and healthcare costs while improving quality of life is encouraging.