Adult Swallowing EBP Group Extravaganza Presentation 2010 by 4sPcVF0


									Adult Swallowing EBP Group
Extravaganza Presentation 2010

        Does weight lifting for the tongue
        improve the swallow?
Taking EBP back to the workplace

   2009 CAT: In patients with dysphagia is there a
    relationship between oral hygiene and pneumonia?

   Oral Care Project at St Vincent’s Hospital.

   This CAT was a lead into our next CAT (2011) on
    the Free Water Protocol.
The Function of The Tongue In
Normal Swallowing

   The tongue is made entirely of muscle1.

   Major role is propulsion of the bolus1,2.

   Other roles include oral clearance and secondary
    roles in the pharyngeal phase

   What happens when the tongue function is
Muscle Strength Training

   Good for improving limb function.

   If tongue strengthening exercises are good for
    improving tongue function then what is the impact
    on swallowing function particularly in dysphagia?
Clinical Question

     Do tongue strengthening
    exercises affect the impaired
      oropharyngeal swallow?
Critically Appraised Papers

   62 identified and accessible articles identified.

   6 were deemed relevant but 2 of these were in
    abstract form only so not suitable for “capping”.
Yates, E.M., Molfenter, S,M., &
Steele, C.M (2008)6

   Level of Evidence: IV - Case studies

   Dysphagia of neurological origin

   Tongue pressure generation exercises conducted
    with biofeedback from the Iowa Oral Performance
    Instrument (IOPI).
Results: Yates et al (2008)6

Case   Functional outcomes          Physiological

A      commenced oral intake for     isometric tongue
       total nutrition and thin     pressure
       fluids, ceased PEG feeds
B      steady increase in oral       isometric tongue
       intake, and reduction in     pressure and accuracy
       PEG feeds
C      Functional swallow did not   Gradual  in tongue
       return. Total intake via     pressure measures, and
       PEG.                         transient opening of
                                    cricoesophageal sphincter.
Strengths & Limitations: Yates et al
   Strengths                   Limitations
    Need for further research  Small sample size
   acknowledged.                Varying Rx design and
    Functional outcomes       duration amongst subjects.
   included                    Difficult to understand
    Need to measure           methodology in relation to
   temporal procession in      Rx.
   tongue pressure generation
Clinical Bottom Line: Yates et al

   Tongue strengthening exercises may result
    in positive functional outcomes for some
    patients with an impaired oropharyngeal
    swallow of neurological aetiology,
    depending on the severity of the swallowing
Carroll, W.R., Locher, J.L., Canon, C.L.,
Bohannon, I.A., McCulloch, N.L. &
Magnuson, J.S. (2008)7.

   Level of Evidence: III (2) – Retrospective case
    control design
   Dysphagia due to advanced SCC of the
    oropharynx, hypopharynx and larynx treated with
    combined chemo and radiotherapy (CRT).
   The experimental group received pre-treatment
    swallowing exercises.
   The control group received post-treatment
    swallowing exercises as problems arose.
Results: Carroll et al (2008)7

   The experimental group showed significantly
     Epiglottic inversion
     Posterior tongue base position during the
    than the control group on MBS 3 months
    after treatment.
   No other statistically significant results were found
    on other outcome measures, including timing of
    PEG removal.
Strengths & Limitations: Carroll et
al (2008)7
Strengths                     Limitations
 Objective evaluation          No randomisation

 Attempts made to match        No baseline MBS

participants in experimental  The control group received post-treatment
and control groups.            swallowing exercises as problems arose
 Use of statistical analysis.  MBS only 3 months post CRT but patients
                               followed up for 12 months.
12 month follow-up
                               Small sample size
                               No comment on oral intake prior to study or
                              compliance with Rx.
                               Only 1 radiologist to interpret MBS – no
                              peer review
Clinical Bottom Line: Carroll et al

   The limited improvements in epiglottic inversion
    and tongue base to posterior wall approximation
    are promising with regard to pre-treatment
    exercises in head and neck cancer.

   Further research, including baseline functional and
    instrumental swallow measures, is needed to
    determine the potential for functional outcomes.
Ibayashi, H., Fujino, Y., Pham, T.M., &
Matsuda, S. (2008)8

   Level of evidence: II – RCT

   54 healthy elderly without dysphagia

   The experimental group were given a 6 month
    exercise program for oral function.
Results: Ibayashi et al (2008)8

   All oral functions in the experimental group
    (overall) showed significant improvement.

   In the experimental group, only participants with
    20 or more teeth showed significant improvement,
    while those with less than 20 teeth showed no
    significant improvement.
Strengths & Limitations: Ibayashi
et al (2008)8

   Strengths                    Limitations
    RCT                        Smaller sample size than

    Multiple measures used to anticipated.
   assess oral function and     Tongue strength not a
   swallowing, including       specific measure of the oral
   Repetitive Saliva Swallow   functions measured.
   Test.                        No instrumental
                               evaluation of swallowing or
                               aspiration status conducted.
Clinical Bottom Line: Ibayashi et al

   In healthy elderly people with 20 or more teeth,
    daily oral musculature and swallowing exercises
    (including tongue exercises) can result in enhanced
    oral movements and swallowing function.
   However, a direct link between tongue
    strengthening and an enhancement in swallow
    function cannot be made from this paper, nor can
    these results be extrapolated to the dysphagia
Robbins, J., Kays, S.A., Gangnan, R.,
Hweitt, A. & Hind, J. (2007)9

   Level of evidence: III (3) - Prospective cohort
    intervention study

   10 participants with ischemic strokes.

   8 week lingual exercise program using the IOPI

   Outcome measures
Results: Robbins et al (2007)9

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

   Strengths                     Limitations
    Large number of              No control group
   different measures             Small number or
   including muscular,           participants.
   neurological, physiological    Wide age range.
   and QOL.
                                  Not all subjects could
    Use of MBS and MRI
                                 complete all aspects of the
                                 data collection.
Clinical Bottom Line: Robbins et al

   In 10 stroke patients with dysphagia confirmed on
    MBS, an 8 week program of isometric tongue
    exercises significantly improved swallow function
    and QOL.
Abstract # 1:
  Sullivan, Hind & Robbins (2001)10

Single case study
 Participant: 48 yr old male, 3-4 yrs post chemo-radiation
    and surgery for right neck SCC, with residual dysphagia
 Outcome measures (pre- and post- treatment): isometric
    pressures, MBS data and info on dysphagia-specific QOL
 Treatment: 8 week exercise protocol using IOPI
 Results:
      tongue pressure
      speed of pressure generation during swallow
      diet (soft to normal diet)
      QOL
Abstract # 2:
    Prasse et al (2009) 11
Randomised Trial
  Participants: 22 adults post chemo-radiation therapy for
   oral/oropharyngeal ca
  Outcome measures (pre- and post-treatment): isometric pressures
  Control Group: ‘traditional’ swallowing exercises
  Experimental Group: tongue strengthening + ‘traditional’ exercises
  Results:
       No significant improvement in tongue strength or swallow
        measures for either group
       BUT significantly  QOL for Experimental Group post-
Critically Appraised Topic
   Do tongue strengthening exercises affect the impaired
    oropharyngeal swallow?

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

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