EFFORTFUL SWALLOW NICOLE ZIEGLER APRIL 16, 2020 WHAT IS EFFORTFUL SWALLOW? ASHA Pryor, 2019 Effortful swallow is used both as a compensatory maneuver to improve pharyngeal clearance and has been proposed as an exercise to improve pharyngeal and base of tongue strength. The purpose of effortful swallowing is to activitate base of tongue retraction and the pharyngeal muscles in a non-passive matter to encourage less residual bolus. Effortful swallows lead to better airway protection and less of a risk for aspiration/penetration. Compensatory - Compensate for weak or ineffective base of tongue or pharyngeal muscles. - Used to push bolus and residue through the pharynx - Base of tongue retraction and pharyngeal wall are key components. Exercise - Used to recruit more motor units to create a muscle training/strengthening effect in the tongue and pharynx - Targets an increase in base of tongue retraction, as well as the pressure during the pharyngeal phase of swallowing through consistent training Population Who uses Effortful Swallow? Disorder ************ ************ People who have impaired base of tongue All age groups can benefit from retraction and/or weakened pharyngeal muscles effortful swallow if they are can benefit from this technique. experiencing pharyngeal dysphagia- It can also be helpful during temporary specifically pharyngeal residue in pharyngeal dysphagia (e.g., feeling like the valleculae. something is stuck in your throat). Severity Etiology ************ ************ Any level of severity can use There are many possible causes of effortful swallow. pharyngeal dysphagia. Some are: Temporary → mild → moderate → Stroke severe Head and Neck Temporary includes experiencing Cancer/Trauma something stuck in your throat, or Natural Aging being NPO and working towards a Degenerative Disorders typical diet. Park et. al., 2019 Wheeler-Hegland et. al., 2008 MATERIALS AND ADMINISTRATION Materials Instruments » The patient needs something to swallow, it can be: ~saliva ~food ~liquid (Direct or indirect therapy) To measure tongue strength: » Surface Electromyography (sEMG) » Iowa Oral Performance Instrument (IOPI) To observe oral and pharyngeal residue: » Videofluoroscopic Swallow Study (VFSS) Administration » The SLP can train the patient to use effortful swallows. » Training can involve a plan like: 15 effortful swallows per session, and there are 6 sessions per week » As the patient becomes more efficient, it is expected that they start utilizing effortful swallows spontaneously. Gomes, 2019 PROCEDURE CHEW & REST TONGUE PRESS Prep the food/liquid/saliva for swallowing. Prior to the swallow, have your tongue in a resting position Press your tongue against the roof of your mouth as hard as you can SQUEEZE & SWALLOW Squeeze all your muscles in your pharynx (throat) and swallow the bolus If a client is struggling, tell them to imagine they are swallowing something large- like a whole grape or a large vitamin with no water- to help them activate that effortful swallow. Effortful swallows are fairly visible. DEMONSTRATION Speech Therapy Swallowing Exercise - Effortful Swallow. (2017). Retrieved from https://www.youtube.com/watch?v=mevAcMkWm2o Comparison of Effortful and Noneffortful Swallows in Healthy Middle-Aged and Older Adults by: Hind et. al., 2001 THEORETICAL BASIS » Weakened/impaired muscles in the base of tongue (retraction) and pharynx lead to issues with residual bolus. » This potentially can lead to penetration/aspiration, or other health complications. » Effortful swallow maneuver helps to strengthen these muscles and remove the bolus from the pharynx (typically the in the valleculae) » There’s limited research on clinical populations, but most studies tend to study its effectiveness This study focuses on finding differences between effortful swallows and normal swallows in older, healthy adults. Their findings support why it is beneficial to use effortful swallow. Effect of effortful swallowing training on tongue strength and oropharyngeal swallowing function in stroke patients with dysphagia: a double-blind,randomized controlled trial by: Park et. al., 2019 This study focuses on the effect of using effortful swallowing as a maneuver to compensate for weakness in the oropharyngeal muscles. Comparison of Effortful and Noneffortful Swallows in Healthy Middle-Aged and Older Adults HIND ET. AL., 2001 METHODS DESIGN » 64 healthy adults aged 45 to 93 from the community. » To study oral pressure, oropharyngeal residue, and durational measures in effortful swallowing and noneffortful swallowing. » Participants swallowed 3-mL thin liquid boluses both normally and using the effortful swallow strategy. » Instruments: VFSS & oral pressure bulbs RESULTS »Pressure: increased oral pressure in effortful swallow. »Durational measures: the effortful swallow produced longer: pharyngeal response duration, hyoid maximum anterior excursion, duration of UES opening, and total swallowing duration »Residue: trend of less residue in effortful swallowing. EBP ARTICLE #1 IMPLICATIONS » Findings indicate that the airway is protected better/for a longer time, which helps to prevent aspiration » Less residue means less spillage after the swallow » Effortful swallowing provides a safer way to swallow Effect of effortful swallowing training on tongue strength and oropharyngeal swallowing function in stroke patients with dysphagia: a double-blind, randomized controlled trial METHODS DESIGN » 24 patients who experienced a stroke were split into a control and experimental group. » To study the effects of effortful swallow training on tongue strength & oropharyngeal swallowing function. »Experimental: Received training for 30 mins/day, 5 days/week, for 4 weeks. »Control: Same sessions but with normal swallow » Tongue strength was measured using IOPI » VFSS was used to look at the oropharynx and its function. PARK ET. AL., 2019 RESULTS » The experimental group experienced greater improvements in the anterior and posterior locations of the tongue. » Better oral function due to stronger tongue EBP ARTICLE #2 IMPLICATIONS » Increased tongue strength and oral function → increase oral pressure and oral bolus clearance; as well as a more effective pharyngeal phase regarding vallecular clearance. » Effortful swallowing training increases strength and overall function GOALS GOAL #1 GOAL #2 Patient will complete 15 effortful swallows during a session when provided with moderate cues with 100% accuracy. Patient will independently utilize effortful swallows during mealtime for every swallow with 100% accuracy. REFERENCES American Speech-Language-Hearing Association. (n.d.). Retrieved from https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589942550§ion Gomes, A. (2019). Swallowing Exercises - For patients with head and neck cancer starting radiation treatment. Toronto, Canada: University Health Network. Retrieved from https://www.uhn.ca/PatientsFamilies/Health_Information/Health_Topics/Documents/Swallowing_Exercises_for_Patients_with_Head_and_Neck_Cancer_ Receiving_Radiation_Treatment.pdf Groher, M. E., & Crary, M. A. (2016). Dysphagia: clinical management in adults and children. St. Louis, MO: Elsevier. Hind, J. A., Nicosia, M. A., Roecker, E. B., Carnes, M. L., & Robbins, J. (2001). Comparison of effortful and noneffortful swallows in healthy middle-aged and older adults. Archives of Physical Medicine and Rehabilitation, 82(12), 1661–1665. doi: 10.1053/apmr.2001.28006 Park, H. S., Oh, D. H., Yoon, T., & Park, J. S. (2019). Effect of effortful swallowing training on tongue strength and oropharyngeal swallowing function in stroke patients with dysphagia: a double‐blind, randomized controlled trial. International Journal of Language & Communication Disorders, 54(3), 479–484. doi: 10.1111/1460-6984.12453 Pryor, J. C. (2019, August 27). The Effortful Swallow Exercise: National Foundation of Swallowing Disorders - A community for those impacted by dysphagia. Retrieved from https://swallowingdisorderfoundation.com/effortful-swallow-exericise/ Speech Therapy Swallowing Exercise - Effortful Swallow. (2017). Retrieved from https://www.youtube.com/watch?v=mevAcMkWm2o Wheeler-Hegland, K. M., Rosenbek, J. C., & Sapienza, C. M. (2008). Submental sEMG and Hyoid Movement During Mendelsohn Maneuver, Effortful Swallow, and Expiratory Muscle Strength Training. Journal of Speech, Language, and Hearing Research, 51(5), 1072–1087. doi: 10.1044/1092-4388(2008/07-0016)
