It’s getting intense! Part 3 – A novel approach for intensive swallow therapy in healthy, dysphagic adults

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Title: An intensive swallowing exercise protocol for improving swallowing physiology in older adults with radiographically confirmed dysphagia
Authors: Balou, Herzberg, Kamel, & Molfenter
Journal: Clinical Interventions in Aging
Year of Publication: 2019
Design Type: Retrospective case series
Purpose: “The aim of this study was to investigate improvements in swallowing function and physiology in a series of healthy older adults with radiographically confirmed dysphagia, following completion of an exercise-based swallowing intervention”
Population: medically healthy adults with confirmed dysphagia impairments via VFSS
Inclusion criteria: any single swallow with a safety impairment (PAS 3>) and/or any single swallow with an efficiency impairment (MBSImP Component 16 Pharyngeal Residue score 2> )

Hopefully you guys have a little energy left after all these intense revelations to learn about the last and final intensive swallowing protocol of the series. While not as well known as the Pelaton approach, this protocol out of New York University is still in the preliminary stages but I’m sure we can expect bigger and better results to come for exercise-based interventions in dysphagia🤩

Some things like fashion trends and seasons come and go, but others pass the true test of time. Two of these permanent principles are exercise science and neuroplasticity. As mentioned before in the previous intensive swallowing approaches (See It’s getting intense! Part 1 – Intensive Dysphagia Rehabilitation (IDR) & Part 2-MD Anderson’s “Swallow Boot Camp” Approach), both are the foundational blocks that rehabilitation builds off. Yes, exercises might become more advanced or more specific like Crossfit crazes or P90X, but just like the 1980s theme of “aerobics, resistance, and stretching” shows, the basics are what matter most😉.

This study is interesting for many reaasons, the first being not only that the participants are medically healthy adults, but they had already been recruited from a different study. In this other non-related study, out of the sample of 100 healthy older individuals who had MBS studies completed for control data, 9 of these participants were found to have evidence of impairments in safety and/or efficiency of swallowing.

Whether a chance occurence or a blessing in disguise, the authors jumped at this opportunity and offered these 9 participants to complete their intense 8-week swallowing exercise protocol, now knowing they had dysphagia despite being healthy community-dwelling older adults from a range of 67-86 years old (average age 75 years).

Why were the authors so excited to look into this population in this way?

“Exploring methods to prevent and/or reverse these changes is critical for our rapidly aging society especially given the known health and quality of life disruptions associated with dysphagia. Unfortunately, the rehabilitative potential of most swallowing exercises is poorly understood, despite being widely adopted in clinical practice.” p.4

Because we know that instrumental swallow studies are not definitively objective (no matter how hard we’ve tried), it’s important to know just how the authors decided these participants actually had swallowing problems (I mean, that’s what we always have to think about at work anyway, right?!).

All MBS studies (before and after procotol completion) were completed at 30 frames per second with availability to review recorded frames, and followed a clinically standardized setup of 2 of the following Varibar barium boluses:

  • 1 mL thin liquid
  • 3 mL thin liquid
  • 5 mL thin liquid
  • 10 ml thin liquid
  • uncalibrated cup sip thin liquid
  • continuous thin liquid drinking
  • 5 mL pudding
  • 1/4 hard solids (cracker) coating
    • All self-fed, liquids via medicine cup
    • Clinical judgment used to ensure patient safety

While their PO protocol is a slight deviation from MBSImP, they did utilize its impairment profile using the single impairment component for Pharyngeal Residue (Component 16) to determine any score >2 warranted a swallowing efficiency concern. Using the PAS, they established any score >3 or higher (PAS 3-8) warranted a swallowing safety concern.

“Specifically, three participants demonstrated impaired swallowing safety only (PAS score of 3 or higher), two participants demonstrated impaired efficiency only (MBSImP Component 16 Pharyngeal Residue score 2 or higher) and the remaining four participants had both safety and efficiency concerns.” p.4

When reviewing and rating each MBS, certified clinicians were blinded to the pre vs post treatment and used the overall impression where “the worst score for a given component is assigned across all bolus volumes and consistencies.” The “oral total” (excluding lip closure) and “pharyngeal total” were used with the esophageal phase excluded, as the authors stated “it was not a target of these rehabilitative exercises.” The worst PAS score across the whole study was recorded. Reliability ended up being in the low-mid 90% for both intra- and inter-rater reliability, and 20% for the PAS across the whole dataset(😳).

Even though ignoring the UES feels wrong for my clinical conscience, we all gotta start somewhere (including researchers!) I for one would rather start like this versus alternatives!

If you’ve been scrolling to see just what the exercises protocol entails, here it is (or you can go back to Phew!😓 Intensifying Approaches for Dysphagia Management to get a general glimpse!):

  • Effortful Swallow (20 reps)
  • Tongue-hold swallow (20 reps)
  • Supraglottic swallow (20 reps)
  • Shaker Exercise (20 reps)
  • Mendelsohn maneuver (20 reps)
  • Effortful pitch glide (10 reps)
    • Total swallow exercises per session= 110

If you have a bunch of questions popping up in your head, you’re not alone!

Why these?

Where did they do them?

How did they track it?

How did they know they were doing them correctly?

These were just some of the things I needed answers too, asap!

With sessions being held once a week in outpatient clinic for 45 minutes, the researchers established at home practice for the above regimen for the participants to complete 3 times a day outside of sessions (totalling 330 swallow reps per day!).

Luckily, the authors provide a nice table outlining the specific physiological target for each exercise for us to remember (no matter how many times we might need to drill it into our heads!). However, unlike Dr. Malandraki’s IDR model, these exercises were not individualized for each participant–meaning, even if a participant’s physiological impairment was not laryngeal vestibule closure, for example, they and everyone else still completed all the same regimen of exercises.

Some of us might be on the side of the fence thinking this is great in order to work on everything at once, others might stand on the opposite side pondering why work on something if it’s not broken?🤔

Luckily, the authors do provide their rational methods to their madness:

“These exercises were applied to all participants regardless of their underlying swallowing physiology. This regimen was designed with several important factors in mind. First, it balances a mix of both swallowing and non-swallowing exercises and therefore draws on the neuroplasticity principles of both specificity and transference.”

Furthermore, the number of repetitions is high with the principle of intensity in mind. Finally, the duration of the protocol was selected to extend beyond the minimum of 5 weeks of exercise which are recommended to demonstrate improvements in skeletal muscle function.” p.3

And for those still waiting to know about how they knew if homework was completed? Don’t hold your breath, because apparently adherence to homework was not tracked for the study😩.

Let’s get to it:

“Analysis of PAS scores indicated that the swallowing safety did not improve significantly post-treatment, despite the median score improving from a 3 (unsafe/penetration) to 1 (safe/normal) post-treatment. Given that there are other methods to analyzing the PAS data we ran a second test to confirm our finding. The result was unchanged when we categorized the PAS data in a binary fashion.”

“However, the analysis of MBSImP scores showed significant reductions (improvements) in both OT scores and in PT scores.” p.4

“Analysis of individual MBSImP components revealed that three components demonstrated significant differences from pre- to post-treatment scores. Component 6, initiation of the pharyngeal swallow…Component 8, laryngeal elevation…and Component 16, pharyngeal residue, improved from pre-treatment to post-treatment.” p.4

And there we have it folks!

While the overall impact of airway safety didn’t change in a statistically significant way, it did result in a pretty clinically meaningful change decreasing from a PAS 3 to a PAS 1! I don’t know about you, but as a clinician anything that reduces anything out of the “danger zone” in the airway is pretty dang significant in my book! And the cherry on top? Some pretty big time physiological players that we likely frequently target significantly improved as well!👏👏

Before applying this set of exercises to any and all older adults who also happen to have dysphagia, let’s stop, sit, and think a moment about some pretty serious limitations…

Despite the fact that these results are going less than all your fingers (less “powerful” study) with no control group, we can’t forget that we have no way of knowing which exercises or combination of exercises might have led to the improved changes in physiological impairments. Because we’re still missing a couple pieces to this ever-complicated swallowing puzzle, we don’t know if all, 1, or only a few exercises might be necessary to facilitate this change.😨

Another interesting perspective to keep in mine (which the authors even point out), is that the change in ‘initiation of paryngeal swallow’ is really hard to totally trust since we know this complex trigger can be highly variable in healthy populations (and older individuals)!

The authors luckily do share some theories as to how the above resulting improvements happened despite the lack of individualized physiological exercise program by suggesting that working on volitional airway closure could contribute to improvement in bolus location at the swallow onset, reduced pharyngeal residue could be attributed to targeting strengthening the pharyngeal constrictors, and improved laryngeal elevation might’ve been related to shortening effects.

While this specific study only gives us a few steps down a new path for intense intervention options, we can still keep looking forward while keeping in mind all the theories, principles, and other approaches in the meantime!

That does it for all the current intensive exercise approaches for dysphagia guys! I know I’ll be crossing my fingers and wishing every night for more to come while helping my patients’ swallow get some bulk🤞🤞

This reminds me of kinesiology tape or electrodes around muscles😅

Need to rewind? Check out the previous part of the 3-Part Series:

Article Referenced: FREE ACCESS

Balou, M., Herzberg, E., Kamelhar, D., & Molfenter, S. (2019). <p>An intensive swallowing exercise protocol for improving swallowing physiology in older adults with radiographically confirmed dysphagia</p>. Clinical Interventions In AgingVolume 14, 283-288. doi: 10.2147/cia.s194723

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