Clinical Reference Guide

Abilex* oral exerciser is designed to help improve swallowing function and oral control. It adapts and builds-on existing oral exercise techniques combining them into a multi-functional tool for comprehensive therapy.

It is designed to help with:

  • improving tongue and lip strength through isometric resistance exercises,
  • building tongue coordination and range of motion through manipulation and lateralization exercises,
  • promotion of neuroplastic changes in swallowing through daily therapy, and;
  • enabling safe practice of swallowing through simulation of a food bolus.

Exercises with the device are engaging and encourage independence and compliance to therapy. Patients can use Abilex* device on their own throughout the day, both in the hospital and at-home. Abilex* device is designed to support more therapy time for patients while letting SLPs focus on the more complex cases.

This Clinical Reference Guide is intended to be a resource for clinicians on the existing research related to the potential fields of use for the Abilex* oral exerciser. The Guide includes abstracts from some of the leading articles that have been published on tongue strength and oral exercise therapy over the years.


 

Clinical Review of Oral Exercises

 


    Tongue Strength Exercises

    1. The Effects of Lingual Exercise in Stroke Patients with Dysphagia

    Robbins JA, Kays A, Gangnon R, Hind J, Hewitt A, Gentry L, Taylor A.  Arch Phys Med Rehabil. Vol 88, Feb 2007: 150-158.

    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: ≤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.

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

    Rogus‐Pulia N, Rusche N, Hind JA, Zielinski J, Gangnon R, Safdar N, Robbins JA. J Am Geriatr Soc. 2016 Feb;64(2):417-24

    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.

    3. Improvements in tongue strength and pressure-generation precision following a tongue-pressure training protocol in older individuals with dysphagia: Three case reports.

    Yeates EM, Molfenter SM, Steele CM. Clinical Interventions in Aging. 2008;3(4):735-747.

    Dysphagia, or difficulty swallowing, often occurs secondary to conditions such as stroke, head injury or progressive disease, many of which increase in frequency with advancing age. Sarcopenia, the gradual loss of muscle bulk and strength, can place older individuals at greater risk for dysphagia. Data are reported for three older participants in a pilot trial of a tongue-pressure training therapy. During the experimental therapy protocol, participants performed isometric strength exercises for the tongue as well as tongue pressure accuracy tasks. Biofeedback was provided using the Iowa Oral Performance Instrument (IOPI), an instrument that measures tongue pressure. Treatment outcome measures show increased isometric tongue strength, improved tongue pressure generation accuracy, improved bolus control on videofluoroscopy, and improved functional dietary intake by mouth. These preliminary results indicate that, for these three adults with dysphagia, tongue-pressure training was beneficial for improving both instrumental and functional aspects of swallowing. The experimental treatment protocol holds promise as a rehabilitative tool for various dysphagia populations.

    4. Outcomes of tongue-pressure strength and accuracy training for dysphagia following acquired brain injury.

    Steele CM, Bailey GL, Polacco REC, et al. International Journal of Speech-Language Pathology. 2013;15(5):492-502.

    The purpose of this study was to measure treatment outcomes in a group of six adults with chronic dysphagia following acquired brain injury, who each completed 24 sessions of tongue-pressure resistance training, over a total of 11–12 weeks. The treatment protocol emphasized both strength and accuracy. Biofeedback was provided using the Iowa Oral Performance Instrument. Amplitude accuracy targets were set between 20–90% of the patient's maximum isometric pressure capacity. Single subject methods were used to track changes in tongue strength (maximum isometric pressures), with functional swallowing outcomes measured using blinded ratings of a standard pre- and post-treatment videofluoroscopy protocol. Improvements were seen in post-treatment measures of tongue pressure and penetration–aspiration. No improvements were seen in pharyngeal residues, indeed worsening residue was seen in some patients.

    5. The effects of lingual exercise on swallowing in older adults.

    Robbins J, Gangnon RE, Theis SM, Kays SA, Hewitt AL, Hind JA. J Am Geriatr Soc. 2005 Sep;53(9):1483-9.

    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.

    6. Tongue-to-palate resistance training improves tongue strength and oropharyngeal swallowing function in subacute stroke survivors with dysphagia

    Kim HD, Choi JB, Yoo SJ, Chang MY, Lee SW, Park JS. J Oral Rehabil. 2017 Jan;44(1):59-64.

    Tongue function can affect both the oral and pharyngeal stages of the swallowing process, and proper tongue strength is vital for safe oropharyngeal swallowing. This trial investigated the effect of tongue-to-palate resistance training (TPRT) on tongue strength and oropharyngeal swallowing function in stroke with dysphagia patients. This trial was performed using a 4-week, two-group, pre-post-design. Participants were allocated to the experimental group (n = 18) or the control group (n = 17). The experimental group performed TPRT for 4 weeks (5 days per week) and traditional dysphagia therapy, whereas the control group performed traditional dysphagia therapy on the same schedule. Tongue strength was measured using the Iowa Oral Performance Instrument. Swallowing function was measured using the videofluoroscopic dysphagia scale (VDS) and penetration-aspiration scale (PAS) based on a videofluoroscopic swallowing study. Experimental group showed more improved in the tongue strength (both anterior and posterior regions, P = 0·009, 0·015). In addition, the experimental group showed more improved scores on the oral and pharyngeal phase of VDS (P = 0·029, 0·007), but not on the PAS (P = 0·471), compared with the control group. This study demonstrated the effectiveness of TPRT in increasing tongue muscle strength and improving swallowing function in patients with post-stroke dysphagia. Therefore, we recommend TPRT as an easy and simple rehabilitation strategy for improving swallowing in patients with dysphagia.

    7. Effect of tongue strength training using the Iowa Oral Performance Instrument in stroke patients with dysphagia

    Park J-S, Kim H-J, Oh D-H. Journal of Physical Therapy Science. 2015;27(12):3631-3634.

    Purpose: The aim of this study was to evaluate the effectiveness of a structured program of resistance training for the tongue in order to improve swallowing function in stroke patients with dysphagia. Subjects and Methods: Twenty-seven stroke patients with dysphagia were randomly divided into two groups. The experimental group participated in a resistance-training program involving a 1-repetition maximum, with an intensity of 80%, along with 50 repetitions per day each for the anterior and posterior regions of the tongue. Both groups received conventional therapy for dysphagia for 30 min per day, 5 times per week, for 6 weeks. Results: The experimental group showed statistically significant improvements in both, the anterior and posterior regions of the tongue. In contrast, the control group showed significant improvements only in the anterior region of the tongue. In the videofluoroscopic dysphagia scale evaluation, improvement was noted at both, the oral and pharyngeal stages in the experimental group, whereas significant improvements were only noted in the oral stage and total score in the control group. Conclusion: Our study confirmed that tongue resistance training is an effective intervention for stroke patients with dysphagia, offering improved tongue muscle strength and overall improvement in swallowing.

    8. Effects of Lingual Effort on Swallow Pressures Following Radiation Treatment.

    Lenius K, Stierwalt J, LaPointe LL, Bourgeois M, Carnaby G, Crary M. J Speech Lang Hear Res. 2015 Jun;58(3):687-97.

    PURPOSE: This article investigated the effects of increased oral lingual pressure on pharyngeal pressures during swallowing in patients who have undergone radiotherapy for head and neck cancer. It was hypothesized that increased oral lingual pressure would result in increased pharyngeal pressures. METHOD: A within-subject experimental design was used with 20 participants who were status post external beam radiotherapy for head and neck cancer. Participants completed typical swallows and swallows with increased lingual force during manofluoroscopic swallow studies. The swallow condition order was randomized across participants. RESULTS: Manometric data revealed significant differences in swallow pressure by condition at the base of tongue and upper esophageal sphincter sensor locations without significant pressure differences in the lower pharynx. The effortful lingual swallows resulted in higher mean pressures at all locations. CONCLUSIONS: The results of this study suggest that use of a maneuver designed to increase oral tongue effort can also increase pharyngeal tongue base pressure. Therefore, therapeutic activities used to generate greater pressure of the oral tongue may also alter pharyngeal response. Further research is needed to determine the direct clinical effect on swallow function for individuals with head and neck cancer.

    9. Tongue strength and exercise in healthy individuals and in head and neck cancer patients.

    Lazarus C. Semin Speech Lang. 2006 Nov;27(4):260-7.

    The tongue plays a critical role in bolus propulsion through the oral cavity and pharynx. This manuscript reviews the types of lingual impairment and overall oropharyngeal swallowing impairment present after treatment for head and neck cancer; specifically, surgery and primary chemoradiotherapy. Oral tongue impairment in surgically treated patients can include reduced range of motion, reduced control, and reduced ability to manipulate, seal, and propel a bolus into the pharynx. Tongue base impairment can result in reduced bolus clearance through the pharynx, resulting in pharyngeal residue and aspiration. The biologic effects of radiotherapy are described, with tissue fibrosis being a primary contributor to development of oropharyngeal swallow disorders. In patients treated with primary chemoradiotherapy, lingual strength has been found to be reduced, as has oral and pharyngeal structural movement during the swallow. The effects of skeletal muscle strengthening programs on muscle physiology are discussed, as are the effects of tongue strengthening exercise programs on tongue strength and swallowing. Future research needs are addressed.

    10. Effects of two types of tongue strengthening exercises in young normals.

    Lazarus C, Logemann JA, Huang CF, Rademaker AW. Folia Phoniatr Logop. 2003 Jul-Aug;55(4):199-205.

    This pilot study examines the effects of two types of tongue strengthening exercises on tongue function measures of strength and endurance in a group of 31 healthy young subjects. Subjects underwent baseline and 1 month post-baseline assessments of tongue function and were randomized to one of three groups, including: (1) no exercise; (2) exercise group receiving standard tongue strength exercises using a tongue depressor, and (3) exercise group receiving tongue strengthening exercises using the Iowa Oral Performance Instrument. Results revealed a significantly greater change in maximum tongue strength in the group that received any treatment compared with the group receiving no treatment (p = 0.04). Results provide support for the theory that tongue strengthening exercises improve tongue strength in healthy young subjects.

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

    Juan J, Hind J, Jones C, McCulloch T, Gangnon R, Robbins J. Top Stroke Rehabil. 2013 Sep-Oct;20(5):450-70.

    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 ≯16 kPa) with transference to swallowing pressures, increased lingual volume (8.3%), reduced pharyngeal wall residue (P = .03), increased pharyngeal pressures (Δ ≯ 43 mm Hg) and increased UES opening (nadir) pressures (Δ ≯ 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.

    12. Effects of tongue pressing effortful swallow in older healthy individuals.

    Park T, & Kim Y. (2016). Archives of Gerontology and Geriatrics, 66:127-133.

    INTRODUCTION:  The risk of swallowing disorders is increased for older individuals due to weak tongue and pharyngeal muscle strength. This study was appraised the value of a preventative approach by developing the tongue pressing effortful swallow (TPES) applied using a home-based and self-administered procedure. The TPES was developed by combining two swallowing exercises: tongue strengthening exercise and the effortful swallow. The purpose of this study was to examine the effects of the TPES on maximum tongue pressure and peak amplitude of submental muscle activity in older individuals.  MATERIAL AND METHODS:  27 older individuals (mean 73 years) performed a 4-week TPES. The exercise program was adapted to a home-based and self-administered procedure. The maximum tongue pressure was measured by the Iowa Oral Performance Instrument and peak amplitude of submental muscle activity by surface electromyography (sEMG). Statistical comparisons were made by a matched pairs t-test (p<0.05).  RESULTS:  The results of this study showed that the TPES had statistically significant and positive effects on increasing maximum tongue pressure, but the peak amplitude of the submental sEMG did not differ between before and after exercises.  CONCLUSIONS:  The TPES had a positive impact in older individuals. The TPES, a combining exercise, was possible because two exercises had common physiological events. The TPES was a more innovative and efficient approach than the tongue strengthening exercise alone. In addition, older individuals were able to perform the swallowing exercise at home and by themselves with little assistance. Future research needs to refine the TPES and apply it to patients with dysphagia. 

    13. Tongue-Strengthening Exercises in Healthy Older Adults: Specificity of Bulb Position and Detraining Effects.

    Van den Steen L, Schellen C, Verstraelen K, Beeckman AS, Vanderwegen J, De Bodt M, Van Nuffelen G. Dysphagia. 2018 Jun;33(3):337-344.

    Clinical tongue-strengthening therapy programs are generally based on the principles of exercise and motor learning, including the specificity paradigm. The aim of this study was to investigate the specific effect of anterior and posterior tongue-strengthening exercises (TSE) on tongue strength (TS) in healthy older adults and to measure possible detraining effects. Sixteen healthy elderly completed 8 weeks of TSE by means of the Iowa Oral Performance Instrument (IOPI). They were distributed in two different treatment arms and performed either exclusively anterior or posterior TSE (ATSE, n = 9 or PTSE, n = 7) depending on the treatment arm. Anterior and posterior maximal isometric pressures (MIPA, MIPP) were measured at baseline, halfway, and after completion of the training sessions. Detraining was measured by repeating MIPA and MIPP measures 4 weeks after the last session of TSE. MIPA and MIPP increased significantly in both treatment arms. MIPA was significantly higher in the ATSE group compared to the PTSE group across all measures in time. No significant differences were observed in MIPP between the ATSE and PTSE groups. Regardless of treatment arm, there was no significant detraining effect measured 4 weeks after the last TSE session. This study suggests that TSE show partial specificity concerning bulb position. We conclude that especially anterior training results in higher anterior TS in comparison with posterior exercises. Furthermore, we found no detraining effects, independent of bulb location.

    14. Effects of Anterior Tongue Strengthening Exercises on Posterior Tongue Strength in Healthy Young Adults

    Yano, J. et al. Archives of Oral Biology. 2019. 98:238-242

    OBJECTIVE: The aim of the present study was to investigate whether anterior tongue muscle strengthening exercises can affect the strength of posterior tongue muscles. DESIGN: Eleven healthy subjects (20.6 ± 1.2 years) were included. The subjects exercised by pushing the anterior tongue to the palate 30 times, three times a day, 3 days a week for 8 weeks. The exercise intensity was set at 60% of maximum tongue pressure (MTP) in the first week and 80% of MTP for the remainder of training. After the completion of training, MTP measurements were continued every month for another 3 months to evaluate whether training effects were sustained. RESULTS: MTP was significantly increased after 8 weeks of training compared with before training. No significant differences were seen between MTP immediately after completion of training and MTP 1–3 months after completion of training. However, MTP was significantly higher 1–3 months after completion of training than before training. CONCLUSIONS: The present study showed significant increases in both anterior and posterior MTPs by anterior tongue muscle strengthening exercises. In the future, a database on tongue muscle strengthening exercises in elderly persons, patients with dysphagia, etc. will need to be generated, with the aim of preventing frailty.

    15. Tongue-Strengthening Exercises in Healthy Older Adults: Does Exercise Load Matter? A Randomized Controlled Trial.

    Van den Steen, L., Vanderwegen, J., Guns, C. et al. Dysphagia. 2018 Sep 12.

    Tongue-strengthening exercises (TSE) are based on the principles of exercise and motor learning, including intensity. Intensity is manipulated by gradually adjusting the resistive load. This randomized controlled trial (RCT) investigates the effect of three different values resistive load during TSE in healthy older adults. Sixty subjects completed 8 weeks of TSE while exercising with Iowa Oral Performance Instrument (IOPI). They were randomly distributed to 4 different treatment arms: 3 exercise groups (EG1: n = 15; EG2: n = 16, EG3: n = 16) and 1 control group performing lip-strengthening exercises (CG: n = 13). Values of resistive load for EG1, EG2, and EG3 were 100, 80, and 60% 1RM, respectively. Anterior and posterior maximal isometric pressures (MIPA, MIPP) were measured at baseline, after 4 and 8 weeks of training and 4 weeks post-training. MIPA and MIPP in the EG were significantly higher than in the CG at all time points, except baseline. No significant differences between EG were found, but some trends were observable. Anteriorly, the higher the resistive load, the higher the increase in MIP. Posteriorly, 100% 1RM caused the highest values, followed by 60% and 80% 1RM. No detraining effects were measured. The degree of exercise load had a significant negative effect on the registered success rate. This RCT confirms the efficacy of TSE in healthy older adults. For MIPA and MIPP, TSE at a resistive load of 100% 1RM are the most efficient choice in this population, while lowering the resistive load will lead to an increased success rate. No detraining effects were registered.

    16. The Relationship of Aspiration Status With Tongue and Handgrip Strength in Healthy Older Adults

    Butler SG, et al. J Gerontol A Biol Sci Med Sci. 2011 April;66A(4):452–458

    BACKGROUND. Recently, subclinical aspiration has been identified in approximately 30% of community-dwelling older adults. Given that the tongue is a key component of the safe swallow, we hypothesized healthy older adults who aspirate will generate less tongue strength than adults who do not aspirate. Furthermore, as muscle weakness may reflect a global effect of aging, we further investigated whether tongue strength is correlated with handgrip strength. METHODS. We assessed 78 healthy community-dwelling older adults (M = 77.3 years, SD = 7.26) for aspiration status (37% aspirators) via flexible endoscopic evaluation of swallowing. Maximal isometric anterior and posterior tongue strength, anterior and posterior swallowing tongue strength, and maximum handgrip strength were measured. RESULTS. Isometric tongue strength was significantly lower in aspirators versus nonaspirators (p = .03) at both the anterior (463 vs 548 mmHg, respectively) and posterior lingual locations (285 vs 370 mmHg, respectively). Likewise, swallowing tongue strength was significantly lower in aspirators versus nonaspirators at both the anterior (270 vs 317 mmHg, respectively) and posterior lingual locations (220 vs 267 mmHg, respectively). There was no difference between aspirators and nonaspirators’ handgrip strength (p > .05), although handgrip strength was correlated with posterior tongue strength (r = .34, p = .005). CONCLUSIONS. Lower anterior and posterior isometric and swallowing tongue strength were dependent on aspiration status. Lower lingual strength in healthy adults may predispose them to aspiration. The correlation between tongue and handgrip strength is consistent with the hypothesis that impaired oropharyngeal strength reflects global age-related declines in muscle strength.

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    Lip Strength Exercises

    17. Lip muscle training in stroke patients with dysphagia.

    Hägg M, Anniko M. Acta Otolaryngol. 2008 Sep;128(9):1027-33

    CONCLUSION: Training with an oral screen can improve lip force (LF) and swallowing capacity (SC) in stroke patients with oropharyngeal dysphagia, irrespective of the duration of pretreatment of dysphagia, and irrespective of the presence or absence of central facial paresis. It is more plausible that treatment results are attributable to sensory motor stimulation and the plasticity of the central nervous system than to the training of the lip muscles per se. OBJECTIVES: A close relationship has been demonstrated between LF and SC in stroke patients whether or not they are affected by facial paresis. It is not known how training of lip function can improve swallowing capacity. The present study was therefore designed to ascertain: (i) if training with an oral screen can improve the LF and SC of stroke patients with oropharyngeal dysphagia; to establish (ii) if improvement in LF and SC is connected with the presence or absence of central facial palsy, (iii) on the interval between stroke onset and initiation of treatment, (iv) on age, or (v) on sex. SUBJECTS AND METHODS: This was a retrospective study of 30 stroke patients, 49-88 years old, who were investigated with a Lip Force Meter, LF100 (LF100) and a swallowing capacity test (SCT) before and after a period of self-training lasting at least 5-8 weeks, using an oral screen. Initial central facial paresis was present in 24 patients. RESULTS: The median LF was 7 Newtons (N) (range 0-27) before treatment and 18.5 N (range 7-44) after treatment (p < 0.001). The median SC was 0 ml/s (range 0-9.1) before treatment and 12.1 ml/s (range 0-36.7) at follow-up (p < 0.001). There was no significant difference in swallowing improvement between patients with versus those without facial paresis. The interval between stroke attack and start of treatment, ranging from a few days up to 10 years, had no significant influence on the treatment results, nor did age or sex. The facial paresis was improved or at least ameliorated in all patients after the lip training period.

    18. Longstanding Effect and Outcome Differences of Palatal Plate and Oral Screen Training on Stroke-Related Dysphagia

    Hägg M, Tibbling L. The Open Rehabilitation Journal, 2013, 6, 35-42

    Aim: This study aimed at evaluating (1) if the oral training effect on stroke related dysphagia differs between two different oral appliances, a palatal plate (PP) and an oral screen (OS), and (2) if the training effect remains at a late follow-up. Methods: We included patients with stroke-related dysphagia at two different time periods: the first group of 12 patients studied in 1997- 2 002 had to train with a PP, the other one of 14 patients studied in 2003-2008 had to train with an OS. All patients were evaluated by a swallowing capacity test (SCT), and by a self-assessed visual analogue scale (VAS) of water swallowing capacity at entry of the study, after 13 weeks of training, and at a late follow-up. Results: At end of treatment the SCT had normalized in 33% of PP patients and in 71% of OS patients. There was a significant SCT improvement difference between the PP and OS groups in the period from baseline to late follow-up (p < 0.002) in favor of the OS group. VAS as tested at baseline and at end of treatment did not differ significantly between the two groups. Training with PP and with OS produced remaining improvement of SCT and of VAS as assessed at a late follow-up. Conclusion: The outcome of OS training on SCT in patients with stroke-related dysphagia seems to be superior to PP training. The improvement as assessed with VAS did not differ between the two groups. Training with PP or OS gives a longstanding improvement of SCT and VAS.

    19. Influence of lip force on swallowing capacity in stroke patients and in healthy subjects.

    Hägg M, Anniko M. Acta Otolaryngol. 2010 Nov;130(11):1204-8.

    CONCLUSION: In spite of no clinical signs of facial paresis, a pathological lip force (LF) will strongly influence swallowing capacity (SC). Stroke patients with impaired SC suffer a subclinical facial paresis. The results support earlier findings that LF training can be used to treat dysphagia. OBJECTIVES: Lip muscle training with an oral screen can improve both LF and SC in stroke patients, irrespective of the presence or absence of facial palsy. The aim was therefore to study the influence of LF on SC. METHODS: This prospective study included 22 stroke patients, aged 38–90 years, with dysphagia, 12 with initial unilateral facial paresis and 45 healthy subjects, aged 25–87 years. All were investigated with a Lip Force Meter (LF100), and with an SC test. RESULTS: A significant correlation was found between LF/SC (p = 0.012) in stroke patients but not in healthy subjects. LF/SC was not age-related in stroke patients. LF was not age-dependent in healthy subjects, but SC decreased with increasing age (p < 0.0001). However, SC did not reach a pathological value and a regression analysis showed that 73% of the variation in SC is attributable to LF and age. 

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    Neural Plasticity: Brain Activation

    20. Principles of Experience-Dependent Neural Plasticity: Implications for Rehabilitation After Brain Damage

    Kleim JA, Jones TA. J Speech Lang Hear Res. 2008 Feb;51(1):S225-39.

    PURPOSE: This paper reviews 10 principles of experience-dependent neural plasticity and considerations in applying them to the damaged brain. METHOD: Neuroscience research using a variety of models of learning, neurological disease, and trauma are reviewed from the perspective of basic neuroscientists but in a manner intended to be useful for the development of more effective clinical rehabilitation interventions. RESULTS: Neural plasticity is believed to be the basis for both learning in the intact brain and relearning in the damaged brain that occurs through physical rehabilitation. Neuroscience research has made significant advances in understanding experience-dependent neural plasticity, and these findings are beginning to be integrated with research on the degenerative and regenerative effects of brain damage. The qualities and constraints of experience-dependent neural plasticity are likely to be of major relevance to rehabilitation efforts in humans with brain damage. However, some research topics need much more attention in order to enhance the translation of this area of neuroscience to clinical research and practice. CONCLUSION: The growing understanding of the nature of brain plasticity raises optimism that this knowledge can be capitalized upon to improve rehabilitation efforts and to optimize functional outcome.

    21. Swallowing and Dysphagia Rehabilitation: Translating Principles of Neural Plasticity Into Clinically Oriented Evidence

    Robbins, et al. Journal of Speech Language and Hearing Research. 2008. V. 51:S276-S300

    PURPOSE: This review presents the state of swallowing rehabilitation science as it relates to evidence for neural plastic changes in the brain. The case is made for essential collaboration between clinical and basic scientists to expand the positive influences of dysphagia rehabilitation in synergy with growth in technology and knowledge. The intent is to stimulate thought and propose potential research directions. METHOD: A working group of experts in swallowing and dysphagia reviews 10 principles of neural plasticity and integrates these advancing neural plastic concepts with swallowing and clinical dysphagia literature for translation into treatment paradigms. In this context, dysphagia refers to disordered swallowing associated with central and peripheral sensorimotor deficits associated with stroke, neurodegenerative disease, tumors of the head and neck, infection, or trauma. RESULTS AND CONCLUSIONS: The optimal treatment parameters emerging from increased understanding of neural plastic principles and concepts will contribute to evidence based practice. Integrating these principles will improve dysphagia rehabilitation directions, strategies, and outcomes. A strategic plan is discussed, including several experimental paradigms for the translation of these principles and concepts of neural plasticity into the clinical science of rehabilitation for oropharyngeal swallowing disorders, ultimately providing the evidence to substantiate their translation into clinical practice.

    22. Brain activation during oral exercises used for dysphagia rehabilitation in healthy human subjects: a functional magnetic resonance imaging study.

    Ogura E, Matsuyama M, Goto TK, Nakamura Y, Koyano K. Dysphagia. 2012 Sep;27(3):353-60.

    Oral exercises, including tongue, lip, and jaw movements, are commonly used in clinical practice as training to improve oral and pharyngeal swallowing in dysphagia patients. These rehabilitation exercises are believed to affect the peripheral and central nervous system at various levels. However, few studies have examined healthy subjects' brain activity while performing oral exercises used in dysphagia rehabilitation. The current study sought to measure brain activation during oral exercises in healthy subjects using functional magnetic resonance imaging (fMRI). Lip-pursing and lip-stretching, tongue protrusion, lateral tongue movement, and oral ball-rolling were selected as tongue and lip exercise tasks. The tasks were performed by eight healthy subjects, and the fMRI data were submitted to conjunction analyses. The results confirmed that head movements during all tasks exhibited translation of <1.0 mm and rotation of <1.0° in x, y, and z coordinates. We found several clear regions of increased brain activity during all four oral exercises. Commonly activated regions during tongue and lip exercises included the precentral gyrus and cerebellum. Brain activation during ball-rolling was more extensive and stronger compared to the other three oral exercises.

    23. Clinical Effects and Differences in Neural Function Connectivity Revealed by MRI in Subacute Hemispheric and Brainstem Infarction Patients With Dysphagia After Swallowing Therapy

    Huang Y-C, Hsu T-W, Leong C-P, Hsieh H-C, Lin W-C. Frontiers in Neuroscience. 2018;12:488.

    Background: Early detection and intervention for post-stroke dysphagia could reduce the incidence of pulmonary complications and mortality. The aims of this study were to investigate the benefits of swallowing therapy in swallowing function and brain neuro-plasticity and to explore the relationship between swallowing function recovery and neuroplasticity after swallowing therapy in cerebral and brainstem stroke patients with dysphagia. Methods: We collected 17 subacute stroke patients with dysphagia (11 cerebral stroke patients with a median age of 76 years and 6 brainstem stroke patients with a median age of 70 years). Each patient received swallowing therapies during hospitalization. For each patient, functional oral intake scale (FOIS), functional dysphagia scale (FDS) and 8-point penetration-aspiration scale (PAS) in videofluoroscopy swallowing study (VFSS), and brain functional magnetic resonance imaging (fMRI) were evaluated before and after treatment. Results: FOIS (p = 0.003 in hemispheric group and p = 0.039 in brainstem group) and FDS (p = 0.006 in hemispheric group and p = 0.028 in brainstem group) were both significantly improved after treatment in hemispheric and brainstem stroke patients. In hemispheric stroke patients, changes in FOIS were related to changes of functional brain connectivity in the ventral default mode network (vDMN) of the precuneus in brain functional MRI (fMRI). In brainstem stroke patients, changes in FOIS were related to changes of functional brain connectivity in the left sensorimotor network (LSMN) of the left postcentral region characterized by brain fMRI. Conclusion: Both hemispheric and brainstem stroke patients with different swallowing difficulties showed improvements after swallowing training. For these two dysphagic stroke groups with corresponding etiologies, swallowing therapy could contribute to different functional neuroplasticity. 

    24. Neuroplasticity and Swallowing

    Martin, R.E. Dysphagia (2009) 24: 218.

    Recent research has suggested that the central nervous system controlling swallowing can undergo experience-dependent plasticity. Moreover, swallowing neuroplastic change may be associated with behavioural modulation. This article presents research evidence suggesting that nonbehavioural and behavioural interventions, as well as injury, can induce swallowing neuroplasticity. These studies indicate that while swallowing and limb neuroplasticity share certain features, certain principles of swallowing neuroplasticity may be distinct. Thus, an understanding of swallowing neuroplasticity is necessary in terms of explaining and predicting the (1) behavioural effects of injury to the swallowing nervous system and (2) effects of swallowing interventions applied in rehabilitation.

    These studies on sensory neuroplastic effects are highly significant because they provide the first evidence that sensory experience can drive plasticity within the neural system that mediates swallowing.

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    Oral Exercises for Head and Neck Cancer Therapy

    25. Swallow Preservation Exercises during Chemoradiation Therapy Maintains Swallow Function.

    Duarte VM, Chhetri DK, Liu YF, Erman AA, Wang MB. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2013;149(6):878-884

    Objective: To evaluate a swallow preservation protocol (SPP) in which patients received swallow therapy before, during, and after radiation treatment and its efficacy in maintaining swallowing function in head and neck cancer patients. Design: Case series with chart review. Setting: Tertiary care academic medical center. Subjects and Methods: Eighty-five patients who received radiation (RT) or chemoradiation (CRT) participated in the SPP from 2007 to 2012. Subjects were divided into 2 groups: compliant and noncompliant with SPP. At each SPP visit, the diet of each patient was recorded as regular (chewable), puree, liquid, or gastrostomy tube (G-tube) dependent, along with their compliance with the swallow exercises. Patients were stratified by age, gender, tumor stage, type of treatment, radiation dose, diet change, dysguesia, odynophagia, pain, and stenosis. Statistical analysis was performed comparing the 2 compliance groups in regards to swallowing-related outcomes at 1 month after completion of therapy. Results: Fifty-seven patients were compliant and 28 were non-compliant with SPP during treatment. The compliant group had a higher percentage of patients tolerating a regular diet (54.4% vs 21.4%, P = .008), a lower G-tube dependence (22.8% vs 53.6%, P = .008), and a higher rate of maintaining or improving their diet (54.4% vs 25.0%, P = .025) compared to noncompliant patients. Conclusion: A swallow preservation protocol appears to help maintain or improve swallow function in head and neck cancer patients undergoing RT or CRT. Patients who are able to comply with swallow exercises are less likely to worsen their diet, receive a G-tube, or develop stenosis.

    26. Use It Or Lose It: Eat And Exercise During Radiotherapy Or Chemoradiotherapy For Pharyngeal Cancers.

    Hutcheson KA, Bhayani MK, Beadle BM, et al. JAMA otolaryngology-- head & neck surgery. 2013;139(11):1127-1134.

    IMPORTANCE: Data support proactive swallowing therapy during radiotherapy (RT) or chemoradiotherapy (CRT) for pharyngeal cancers. The benefits of adherence to a regimen of swallowing exercises and maintaining oral intake throughout treatment are reported, but independent effects are unclear. OBJECTIVE: To evaluate the independent effects of maintaining oral intake throughout radiotherapy and adherence to preventive swallowing exercise. DESIGN: Retrospective observational study. SETTING: The University of Texas MD Anderson Cancer Center, Houston. PATIENTS: The study included 497 patients treated with definitive RT or CRT for pharyngeal cancer (458 oropharynx, 39 hypopharynx) between 2002 and 2008. MAIN OUTCOMES AND MEASURES: Swallowing-related end points were final diet after RT or CRT and duration of gastrostomy dependence. Primary independent variables included oral intake status at the end of RT or CRT (no oral intake, partial oral intake, or full oral intake) and adherence to a swallowing exercise regimen. Multiple linear regression and ordered logistic regression models were analyzed. RESULTS: At the conclusion of RT or CRT, 131 patients (26%) had no oral intake and 74% maintained oral intake (167 partial [34%], 199 full [40%]). Fifty-eight percent (286 of 497) reported adherence to swallowing exercises. Maintenance of oral intake during RT or CRT and swallowing exercise adherence were independently associated with better long-term diet after RT or CRT (P = .045 and P < .001, respectively) and shorter duration of gastrostomy dependence (P < .001 and P = .007, respectively) in models adjusted for tumor and treatment burden. CONCLUSIONS AND RELEVANCE: The data indicate independent, positive associations of maintenance of oral intake throughout RT or CRT and swallowing exercise adherence with long-term swallowing outcomes. Patients who either eat or exercise fare better than those who do neither. Patients who both eat and exercise have the highest rate of return to a regular diet and shortest duration of gastrostomy dependence.

    27. Speech and Swallowing Rehabilitation for Head and Neck Cancer Patients

    Logemann J, Pauloski BR, Rademaker A, and Colangelo JA. ONCOLOGY 11(5):651-659, 1997

    Head and neck cancer and its treatment frequently cause changes in both speech and swallowing, which affect the patient's quality of life and ability to function in society. The exact nature and severity of the post-treatment changes depend on the location of the tumor, the choice of treatment, and the availability and use of speech and swallowing therapy during the first 3 months after treatment. This paper reviews the literature on speech and swallowing problems in various types of treated head and neck cancer patients. Effective swallowing rehabilitation depends on the inclusion of a video-fluorographic assessment of the patient's oropharyngeal swallow in the post-treatment evaluation. Pilot data support the use of range of motion (ROM) exercises for the jaw, tongue, lips, and larynx in the first 3 months after oral or oropharyngeal ablative surgical procedures, as patients who perform ROM exercises on a regular basis exhibit significantly greater improvement in global measures of both speech and swallowing, as compared with patients who do not do these exercises.

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    Oral Exercises in Parkinson’s and Cerebral Palsy

    28. Do swallowing exercises improve swallowing dynamic and quality of life in Parkinson's disease?

    Argolo N, Sampaio M, Pinho P, Melo A, Nóbrega AC. NeuroRehabilitation. 2013;32(4):949-55.

    OBJECTIVE: To investigate the effect of motor swallowing exercises on swallowing dynamic, quality of life and swallowing complaints in Parkinson's disease (PD). DESIGN: A before-after trial. SETTING: University Medical Center. PARTICIPANTS: Parkinson's disease patients with dysphagia complaints. INTERVENTIONS: Motor swallowing exercises designed to increase the strength and range of motion of the mouth, larynx and pharyngeal structures, coordination between breathing and swallowing, and airway protection. Patients should perform the exercises twice a day, five days a week, for five weeks. MAIN OUTCOME MEASURE(S): The primary outcome was the difference before and after the intervention in number of swallowing videofluoroscopic events (Swallowing Score). The secondary outcomes were quality of life (QOL) and swallowing complaints. RESULTS: Fifteen patients concluded the study (10 man/5 woman; mean age 59.2 ± 9.17). The videofluoroscopic events with greater improvement were loss of bolus control (P < 0.03), piecemeal swallow (P = 0.05) and residue on the tongue (P < 0.01), valleculae (P = 0.01) and pyriform sinuses (P = 0.05). Lingual pumping and dental absence were interfering factors associated with treatment failure (beta standardized coefficient = −16.6, 26.2; P = 0.02, 0.002, respectively). The domains with greater improvements in QOL were fear (P = 0.02) and symptom frequency (P = 0.05). Regarding swallowing complaints, patients reported to have reduced mainly their difficulty in moving food in the mouth when chewing (P = 0.02). Reduction in swallowing disorders was not related with QOL improvement (cor = 0.13, [95% CI, 0.6–0.4], P = 0.63). CONCLUSIONS: Motor swallowing exercises may reduce swallowing disorders in PD patients without lingual pumping and dental absence and impact positively QOL and swallowing complaints in individuals with PD.

    29.   Effects of oral motor therapy in children with cerebral palsy.

    Sığan SN, Uzunhan TA, Aydınlı N, Eraslan E, Ekici B, Çalışkan M. Annals of Indian Academy of Neurology. 2013;16(3):342-346.

    Aim: Oral motor dysfunction is a common issue in children with cerebral palsy (CP). Drooling, difficulties with sucking, swallowing, and chewing are some of the problems often seen. In this study, we aimed to research the effect of oral motor therapy on pediatric CP patients with feeding problems. Materials and Methods: Included in this single centered, randomized, prospective study were 81 children aged 12-42 months who had been diagnosed with CP, had oral motor dysfunction and were observed at the Pediatric Neurology outpatient clinic of the Children's Health and Diseases Department, Istanbul Medical Faculty, Istanbul University. Patients were randomized into two groups: The training group and the control group. One patient from the training group dropped out of the study because of not participating regularly. Following initial evaluation of all patients by a blinded physiotherapist and pedagogue, patients in the training group participated in 1 h oral motor training sessions with a different physiotherapist once a week for 6 months. All patients kept on routine physiotherapy by their own physiotherapists. Oral motor assessment form, functional feeding assessment (FFA) subscale of the multidisciplinary feeding profile (MFP) and the Bayley scales of infant development (BSID-II) were used to evaluate oral motor function, swallowing, chewing, the gag reflex, the asymmetrical tonic neck reflex, tongue, jaw, and mouth function, severity of drooling, aspiration, choking, independent feeding and tolerated food texture during the initial examination and 6 months later. Results: When the initial and post-therapy FFA and BSID-II scores received by patients in the training and the study group were compared, the training group showed a statistically significant improvement (P < 0.05). Conclusion: Oral motor therapy has a beneficial effect on feeding problems in children with CP. 

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    Opportunities for intervention

    30. Intensive Therapies for Dysphagia: Implementation of the Intensive Dysphagia Rehabilitation and the MD Anderson Swallowing Boot Camp Approaches

    Malandraki, GA, Hutcheson, KA. Perspectives of the ASHA Special Interest Groups. SIG 13, Vol. 3(Part 4), 2018,

    PURPOSE: In the past 15–20 years, many promising rehabilitative regimens (strength or skill based) were introduced for the management of oropharyngeal dysphagia. Despite their positive outcomes, single intervention regimens, even when performed frequently, may be inadequate to rehabilitate the complex swallowing deficits often seen in patients with moderate to severe or persistent dysphagia. Developing protocols to help clinicians select and implement personalized, intensive exercise training protocols has the potential to standardize clinical methods and maximize patient outcomes. To begin addressing this clinical need, the authors each developed personalized, intensive approaches that combine oropharyngeal exercise and skill-based training approaches in a systematic and evidence-based way for their particular clinical settings. The 1st approach is known as the Intensive Dysphagia Rehabilitation approach and is designed for patients with neurogenic dysphagia. The 2nd protocol is the MD Anderson Swallowing Boot Camp protocol designed for patients with persistent moderate to severe dysphagia after treatment for head and neck cancer. CONCLUSION: Standardization of intensive models of swallowing therapy is feasible to offer reproducible but personalized therapy options for diverse populations. This article discusses the evolution and implementation of 2 such personalized approaches, their main components, and preliminary outcomes.

    31. Early intervention to promote oral feeding in patients with intracerebral hemorrhage: a retrospective cohort study.

    Takahata H, Tsutsumi K, Baba H, Nagata I, Yonekura M. BMC Neurology. 2011;11:6. doi:10.1186/1471-2377-11-6.

    Background: Stroke is a major cause of dysphagia, but little is known about when and how dysphagic patients should be fed and treated after an acute stroke. The purpose of this study is to establish the feasibility, risks and clinical outcomes of early intensive oral care and a new speech and language therapist/nurse led structured policy for oral feeding in patients with an acute intracerebral hemorrhage (ICH). Methods: A total of 219 patients with spontaneous ICH who were admitted to our institution from 2004 to 2007 were retrospectively analyzed. An early intervention program for oral feeding, which consisted of intensive oral care and early behavioral interventions, was introduced from April 2005 and fully operational by January 2006. Outcomes were compared between an early intervention group of 129 patients recruited after January 2006 and a historical control group of 90 patients recruited between January 2004 and March 2005. A logistic regression technique was used to adjust for baseline differences between the groups. To analyze time to attain oral feeding, the Kaplan-Meier method and Cox proportional hazard model were used. Results: The proportion of patients who could tolerate oral feeding was significantly higher in the early intervention group compared with the control group (112/129 (86.8%) vs. 61/90 (67.8%); odds ratio 3.13, 95% CI, 1.59-6.15; P < 0.001). After adjusting for baseline imbalances, the odds ratio was 4.42 (95% CI, 1.81-10.8; P = 0.001). The incidence of chest infection was lower in the early intervention group compared with the control group (27/129 (20.9%) vs. 32/90 (35.6%); odds ratio 0.48, 95% CI, 0.26-0.88; P = 0.016). A log-rank test found a significant difference in nutritional supplementation-free survival between the two groups (hazard ratio 1.94, 95% CI, 1.46-2.71; P < 0.001). Conclusions: Our data suggest that the techniques can be used safely and possibly with enough benefit to justify a randomized controlled trial. Further investigation is needed to solve the eating problems that are associated with patients recovering from a severe stroke 

    32. Association of Post-extubation Dysphagia With Tongue Weakness and Somatosensory Disturbance in Non-neurologic Critically Ill Patients.

    Park HS, Koo JH, Song SH. Ann Rehabil Med. 2017 Dec;41(6):961-968.

    OBJECTIVE: To prospectively assess the association between impoverished sensorimotor integration of the tongue and lips and post-extubation dysphagia (PED). METHODS: This cross-sectional study included non-neurologic critically ill adult patients who required endotracheal intubation and underwent videofluoroscopic swallowing study (VFSS) between October and December 2016. Participants underwent evaluation for tongue and lip performance, and oral somatosensory function. Demographic and clinical data were retrieved from medical records. RESULTS: Nineteen patients without a definite cause of dysphagia were divided into the non-dysphagia (n=6) and the PED (n=13) groups based on VFSS findings. Patients with PED exhibited greater mean duration of intubation (11.85±3.72 days) and length of stay in the intensive care unit (LOS-ICU; 13.69±3.40 days) than those without PED (6.83±5.12 days and 9.50±5.96 days; p=0.02 and p=0.04, respectively). The PED group exhibited greater incidence of pneumonia, higher videofluoroscopy swallow study dysphagia scale score, higher oral transit time, and lower tongue power and endurance and lip strength than the non-dysphagia groups. The differences in two-point discrimination and sensations of light touch and taste among the two groups were insignificant. Patients intubated for more than 7 days exhibited lower maximal tongue power and tongue endurance than those intubated for less than a week. CONCLUSION: Duration of endotracheal intubation, LOS-ICU, and oromotor degradation were associated with PED development. Oromotor degradation was associated with the severity of dysphagia. Bedside oral performance evaluation might help identify patients who might experience post-extubation swallowing difficulty.

    33. National Outcomes Measurement System: Adults in Healthcare National Data Report 2017.

    American Speech-Language-Hearing Association. (2017). Rockville, MD: National Center for Evidence-Based Practice in Communication Disorders.

    In general, in Acute Hospitals, increases in number of sessions and hours of treatment for the top Functional Communication Measures (FCM) addressed resulted in more patients making progress. In In-Patient Rehab, increases in number of sessions and hours of treatment for the top FCMs addressed resulted in more patients making progress. For Outpatient Rehab, Comprehensive Outpatient Rehab Facility, Office-Based Services, and Day Treatment, increases in number of sessions and hours of treatment for the top FCMs addressed resulted in more patients making

    34. Economic and survival burden of dysphagia among inpatients in the United States

    Patel DA, Krishnaswami S, Steger E, Conover E, Vaezi MF, Ciucci MR, Francis DO. Dis Esophagus. 2018 Jan 1;31(1):1-7.

    The inpatient burden of dysphagia has primarily been evaluated in patients with stroke. It is unclear whether dysphagia, irrespective of cause, is associated with worse clinical outcomes and higher costs compared to inpatients with similar demographic, hospital, and clinical characteristics without dysphagia. The aim of this study is to assess how a dysphagia diagnosis affects length of hospital stay (LOS), costs, discharge disposition, and in-hospital mortality among adult US inpatients. Annual and overall dysphagia prevalence, LOS, hospital charges, inpatient care costs, discharge disposition, and in-hospital mortality were measured using the AHRQ Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (2009-2013). Patients aged 45 years or older with ≤180 days of stay in hospital with and without dysphagia were included. Multivariable survey regression methods with propensity weighting were used to assess associations between dysphagia and different outcomes. Overall, 2.7 of 88 million (3.0%) adult US inpatients had a dysphagia diagnosis (50.2% male, 72.4% white, 74.6% age 65-90 years) and prevalence increased from 408,035 (2.5% of admissions) in 2009 to 656,655 (3.3%) in 2013. After inverse probability of treatment weighting adjustment, mean hospital LOS in patients with dysphagia was 8.8 days (95% CI 8.66-8.90) compared to 5.0 days (95% CI 4.97-5.05) in the non-dysphagia group (P < 0.001). Total inpatient costs were a mean $6,243 higher among those with dysphagia diagnoses ($19,244 vs. 13,001, P < 0.001). Patients with dysphagia were 33.2% more likely to be transferred to post-acute care facility (71.9% vs. 38.7%, P < 0.001) with an adjusted OR of 2.8 (95% CI 2.73-2.81, P < 0.001). Compared to non-cases, adult patients with dysphagia were 1.7 times more likely to die in the hospital (95% CI 1.67-1.74). Dysphagia affects 3.0% of all adult US inpatients (aged 45-90 years) and is associated with a significantly longer hospital length of stay, higher inpatient costs, a higher likelihood of discharge to post-acute care facility, and inpatient mortality when compared to those with similar patient, hospital size, and clinical characteristics without dysphagia. Dysphagia has a substantial health and cost burden on the US healthcare system.

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