As speech-language pathology students we learn about the Shaker exercise. We learn about the research studies that say it decreased aspiration (Logemann, et al, 2009) and even helped people with PEG tubes return to p.o. diets (Easterling, et al, 2000; Shaker, et al, 1997; 2002). Then, we enter the real world and discover how difficult it can be to transfer patients to a bed or a sofa, or even to find a bed or a sofa in some settings!
As I struggled to get my patients to do the Shaker exercise over the years, I kept thinking that there had to be an easier way. There must be a way to do the Shaker exercise in a seated position and get the same great results without all the trouble. That’s how the concept of the ISO Swallowing Exercise Device (ISO-SED) was born (swallowingexercises.com).
I enlisted the help of my very handy husband and we experimented with every imaginable way to provide resistance under the chin or against the forehead to create an upright version of the Shaker exercise (e.g. balls, springs, stretch bands, etc.) Some of the things we tried were quite comical and not very comfortable or fun for the patient.
Eventually we created the ISO-SED out of flexible, clear plastic and padding so that it bends, providing smooth resistance, when the chin is pressed down against it and then returns to normal when the chin is elevated again. I began using it with my patients to do a chin tuck against resistance (CTAR) exercise and a jaw-opening against resistance (JOAR) exercise in an upright, seated position. I was delighted as my patients started making better and faster progress than ever before. The response after they tried it for the first time was almost always the same. They looked at it for a minute, nodding in approval, and then looked at me and asked, “Can I keep it?”.
Recent research has been favorable to support the use of the ISO-SED in dysphagia therapy. A poster session at the 21st Annual Dysphagia Research Society compared using a plastic ball for chin tuck against resistance (CTAR) to the Shaker exercise using sEMG and found no significant difference in suprahyoid muscle activity between CTAR and Shaker for isokinetic exercise (Khoon, et al, 2013). Another study found that the jaw-opening exercise improved hyoid movement, UES opening and time for pharynx passage (Wada, et al, 2012). An online article published by Watts (2013) also supported the jaw opening exercise to increase hyolaryngeal elevation.
The research needed in this area has definitely begun to emerge and it is an exciting area for future research.
Links of Interest
- Watts, CR Measurement of Hyolaryngeal Muscle Activation Using Surface Electromyography for Comparison of Two Rehabilitative Dysphagia Exercises, Archives of Physical Medicine and Rehabilitation, Available online 28 April 2013
- Khoon, J., Liow, S.J.R., Lam Yoon, W. (2013, March). Comparison of suprahyoid muscles activity between chin-tuck-against-resistance (CTAR) and the shaker exercises. Poster session presented at the 21st Annual Meeting of The Dysphagia Research Society, Seattle, WA.
- Satoko Wada, Haruka Tohara, Takatoshi Iida, Motoharu Inoue, Mitsuyasu Sato, Koichiro Ueda, Jaw-Opening Exercise for Insufficient Opening of Upper Esophageal Sphincter, Archives of Physical Medicine and Rehabilitation, Available online 10 May 2012, ISSN 0003-9993, 10.1016/j.apmr.2012.04.025.
- Jeri A. Logemann; Alfred Rademaker; Barbara Roa Pauloski; Amy Kelly; Carrie Stangl-Mcbreen; Jodi Antinoja; Barbara Grande; Julie Farquharson; Mark Kern; et al. (Profiled Authors: Jerilyn A Logemann; Barbara Roa Pauloski; Alfred W Rademaker) A randomized study comparing the Shaker exercise with traditional therapy: A preliminary study. Dysphagia. 2009;24(4):403-411.
- Shaker, R., Easterling, C., Kern, M., Nitschke, T., Massey, B., Daniels, S., Grand, B., Kazandjiam, M., Dikeman, K.. Rehabilitation of swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening. Gastroenterology. 2002 May; 122(5): 1314-21
- Easterling, C., Kern, M., Nitschke, T., Grande, B., Kazandjian, M., Dikeman, K., Massey, B.T., & Shaker, R. Restoration of oral feeding in 17 tube fed patients by the Shaker Exercise. Dysphagia, 15: 105, 2000.
- Shaker, R., Kern, M., Bardan, E., Taylor, A., Stewart, E., Hoffmann, R.G., Arndorfer, R.C., Hoffmann, C., & Bonnevier, J. Augmentation of deglutitive upper esophageal sphincter opening in the elderly by exercise. AJR, 272: G1518-1522, 1997.