Swallow stronger-Swallow safer: Contributions by Dr. JoAnne Robbins and the Swallow Solutions Team

Oromotor exercises have been used widely as a treatment modality in the practice of speech pathology for many decades.¹  However only in recent years has oropharyngeal strengthening therapy been applied to swallowing rehabilitation.^2-5 Age-related loss of skeletal muscle and strength, the condition known as sarcopenia, has been known for decades to affect striated limb musculature. More recently, work by JoAnne Robbins, PhD and others indicates that striated head and neck muscles also are affected by sarcopenia, where it manifests as changes in muscle fiber density, tension, strength, and contraction in facial, masticatory, and lingual musculature. These changes are primary contributors to dysphagia.

Just as participation in progressive resistance training can strengthen limb musculature⁶, device facilitated isometric progressive resistance oropharyngeal (I-PRO) therapy also has been shown to strengthen muscles of the head and neck.  The increases in strength and structural volume were carried over to critical swallowing functions such as reduced airway invasion, decreased oropharyngeal residue and improved quality of life^2-5.

Encouraging outcomes from these initial studies lead to the development of the Madison Oral Strengthening Therapeutic (MOST) device and the recently released newer version, SwallowSTRONG^® by Swallow Solutions (U.S. patent # 6702765 US 6,702,765 B2, US 7,238,145 B2, US 7,438,667 B2). These devices provide manometric/pressure readings from multiple sensors on an easily and quickly modifiable custom-molded mouthpiece. The mouthpiece offers an individualized fit, reproducible sensor placement with an easy-to-use touch screen interface that indicates performance levels and automatically calculates therapy targets. Speech Pathologists are able to develop objective, systematic therapeutic goals with quantifiable outcomes. Additionally, the SwallowSTRONG device monitors patient compliance with therapy.

In 2012, under the direction of JoAnne Robbins, PhD, the William S. Middleton Memorial Veterans Hospital, in Madison WI initiated the Swallow STRengthening OropharyNGeal (Swallow STRONG) Clinical Demonstration Project. The clinic uses the MOST and SwallowSTRONG devices to facilitate I-PRO therapy with the primary goal of improving swallowing/eating-related care for dysphagic veterans. Patients complete 8 weeks of intensive I-PRO therapy, 3x/day, 3days/week for 8 weeks. Results from the first 40 patients enrolled in this clinic were recently presented at the Dysphagia Research Society Conference in Nashville, TN by Nicole Pulia, PhD.

Dr. Pulia reported that Penetration-aspiration scale scores (a quantified measure of airway invasion) decreased for thin liquid boluses;  maximum isometric pressures increased at front and back sensors (p<.001);  swallowing-specific quality of life questionnaire subscale scores improved significantly (p<.03) and  Functional Oral Intake Scale⁷ scores improved overall demonstrating patients move to less restrictive diets (p<.02). Several patients progressed from feeding tube dependency to full oral intake. The members of this clinic also collected data on more generalized health outcomes. The number of pneumonia diagnoses decreased by 88% and hospital admissions decreased by 79%. This critical link from improved swallowing to better health status is unique and noteworthy for patients, care providers, third party payers and medical institutions.  These encouraging outcomes have resulted in the Swallow Strong Clinic being funded for an additional year with a key goal of dissemination of clinic structure for replication in other acute and sub-acute healthcare settings.

One patient who completed device-facilitated I-PRO therapy offers her story to provide a patient’s perspective. Jan Blume, a 54 year-old nurse who suffered a brainstem stroke, arrived at the University of Wisconsin Swallowing clinic taking all nutrition via g-tube and expectorating all secretions into a spittoon. She had spent the prior two years trying “every therapy known to man,” including swallow-specific maneuvers such as the Mendelsohn maneuver, electrical stimulation and repeated dilations of the UES with no appreciable gains. Videofluoroscopic evaluation showed reduced (almost non-existent) opening of the upper esophageal sphincter (UES), significant post-swallow residue in the pyriform sinuses and aspiration on all consistencies.  Jan initiated I-PRO therapy and proved to be a dedicated, hard-working patient who completed the lingual presses faithfully 3 times a day on 3 days per week. Every two weeks, the pressure targets were increased relative to her strength gains to provide continued therapeutic challenge. Subsequent objective  radiographic and manometric evaluations indicated that additional pressure provided by a stronger lingual “pump” facilitated greater UES opening. Jan first began taking small sips of liquid by mouth and ultimately progressed to full oral intake of a general diet. She reports that the day she had her g-tube removed was “one of the best days.” “It’s so isolating to not swallow. It adds hours to your day. You can’t go out with friends, have a quick snack or share a meal with family. Now I eat well, I sleep well and I can fully enjoy my time spent with friends and family.” A Case Study detailing Jan’s interesting and inspiring course of therapy was recently published in Topics in Stroke Rehabilitation⁸ .

Change to  “For more about the SwallowSTRONG device, please contact,Thomas Gould at SwallowSTRONG, tgould@swallow–strong.com.

Visit SwallowSTRONG on the web at wwww.Swallow–strong.com

Thanks to Dr. JoAnne Robbins and the team at Swallow Solutions for their contributions to this article

References

1. McCauley RJ, Strand E, Lof GL, Schooling T, Frymark T. Evidence-based systematic review: effects of nonspeech oral motor exercises on speech. Am J Speech Lang Pathol 2009;18:343-60.
2. Robbins J, Gangnon R, Theis S, Kays SA, Hind J. The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatrics Society 2005;53:1483-1489.
3. Robbins J, Kays SA, Gangnon R, Hewitt A, Hind J. The effects of lingual exercise in stroke patients with dysphagia. Arch Phys Med Rehabil 2007;88:150-158.
4. Lazarus C, Logemann J, Huang C, Rademaker A. Effects of two types of tongue strengthening exercises in young normals. Folia Phoniatrica et Logopedica 2003;55  199-205.
5. Clark HM, O’Brien K, Calleja A, Corrie SN. Effects of directional exercise on lingual strength. J Speech Lang Hear Res 2009;52:1034-47.
6. Fiatarone MA, Marks EC, Ryan ND, Meredith CN, Lipsitz LA, Evans  WJ.  High-intensity strength training in nonagenarians.  Effects on skeletal muscle.  JAMA 1990; 263(22): 3029-34.
7. Crary m, Mann G, Gorher M. Initial Psychometric Assessment of a Functional Otal Intake Sclae for Dysphagia in Stroke Patients. Arch Phys Med Rehabil 2005; 86 August.
8. Juan J, Hind J, Jones C, McCulloch T, Gangnon R, Robbins J. Case Study: Application of Isometric Progressive Resistance Oropharyngeal Therapy Using the Madison Oral Strengthening Therapeutic Device 2013;20(5):450-470.