Abstract Seven institutions participated in this small clinical trial that included 19 patients who exhibited oropharyngeal dysphagia on videofluorography VFG involving the upper esophageal sphincter UES and who had a 3-month history of aspiration. All patients were randomized to either traditional swallowing therapy or the Shaker exercise for 6 weeks. Each patient received a modified barium swallow pre- and post-therapy, including two swallows each of 3 ml and 5 ml liquid barium and 3 ml barium pudding. Each videofluorographic study was sent to a central laboratory and digitized in order to measure hyoid and larynx movement as well as UES opening. Fourteen patients received both pre-and post-therapy VFG studies. There was significantly less aspiration post-therapy in patients in the Shaker group.
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Abstract Seven institutions participated in this small clinical trial that included 19 patients who exhibited oropharyngeal dysphagia on videofluorography VFG involving the upper esophageal sphincter UES and who had a 3-month history of aspiration. All patients were randomized to either traditional swallowing therapy or the Shaker exercise for 6 weeks.
Each patient received a modified barium swallow pre- and post-therapy, including two swallows each of 3 ml and 5 ml liquid barium and 3 ml barium pudding. Each videofluorographic study was sent to a central laboratory and digitized in order to measure hyoid and larynx movement as well as UES opening.
Fourteen patients received both pre-and post-therapy VFG studies. There was significantly less aspiration post-therapy in patients in the Shaker group. Residue in the various oral and pharyngeal locations did not differ between the groups.
With traditional therapy, there were several significant increases from pre- to post-therapy, including superior laryngeal movement and superior hyoid movement on 3-ml pudding swallows and anterior laryngeal movement on 3-ml liquid boluses, indicating significant improvement in swallowing physiology. After both types of therapy there is a significant increase in UES opening width on 3-ml paste swallows.
Keywords: Dysphagia, Shaker exercise, Upper esophageal sphincter, Deglutition, Deglutition disorders Over the past 25 years, a number of laboratories around the world have studied and defined the factors responsible for the opening of the upper esophageal sphincter UES [ 1 — 4 ]. In all cases, the results were similar, i. Since this physiology was described, the Shaker exercise was defined [ 5 , 6 ].
The Shaker exercise is based on the upward and forward movement of the hyolaryngeal structures resulting from the pull of the thyrohyoid, mylohyoid, geniohyoid, and anterior belly of diagastric muscles contracting. This information was used to develop an isometric and isotonic exercise to strengthen these muscles and thereby increase the opening width of the UES.
Research on this exercise began with examining how the exercise improved the duration and the width of the UES opening in the normal elderly [ 5 ]. The exercise was done over 6 weeks, 3 times per day, to strengthen muscles that pull the larynx and hyoid up and forward.
Application of this exercise in normal elderly resulted in a wider UES opening. This was followed by a study of the effect of the exercise in tube-fed patients with severe oropharyngeal dysphagia secondary to an abnormal UES opening [ 6 ]. The natural next step in the study of the application of the Shaker exercise to patients with dysphagia was to complete a randomized multi-institutional clinical trial. Our trial compared the Shaker exercise with traditional swallowing therapy to determine if either treatment is better at reducing aspiration and improving swallow function in patients with documented aspiration.
Methods For this study, we sought patients with prolonged oropharyngeal dysphagia and aspiration of at least 3-month duration. After IRB approval each speech-language pathologist at each institution searched their records for patients with dysphagia involving the UES or the tongue base and were instructed to be NPO by their clinician.
These individuals were then invited to participate in this study for a 6-week period. A total of 19 patients were identified and agreed to participate; they were recruited between April and May All patients were randomized to either traditional swallowing therapy as described below or the Shaker exercise.
Lee Moffitt Cancer Center. All head and neck cancer patients had chemoradiation and some had secondary surgical intervention after chemoradiation. Patients with head and neck cancer had to be at least 3 months post chemoradiation therapy and at 1 month postsurgery before study entry. Hypopharyngeal pyriform sinus residue or vallecular residue alone or in combination.
Videofluorographically documented aspiration of at least a 3-month duration. Able to comply with protocol mandates, willing to perform the exercise programs, and ability to attend study sessions. Exclusion criteria included: Pharyngeal surgical procedures of the strap muscles mylohyoid, geniohyoid, anterior digastric, and thyrohyoid muscles Lack of cognition Patients who could not lift their head and flex the neck Individuals unable to exercise independently or with a caregiver Currently using anticholinergics: benzodiazapine, antihistamines Absent pharyngeal swallow on VFG Aspiration during the swallow intradeglutitive aspiration Other neuromuscular disorders such as metabolic myopathies, steroid myopathy, Kerns-Sayers Syndrome, oculopharyngeal and other dystrophies, or myasthenia gravis, which make active exercise inappropriate Description of the Two Therapies Patients were randomly assigned, stratified by etiology head and neck cancer, stroke , to one exercise program and were seen by the speech-language pathologist SLP at each institution for swallowing therapy twice per week for 6 weeks.
All SLPs were educated to provide both types of therapy with equal competence. The Shaker exercise consisted of three 1-min head lifts in the supine position with a 1-min rest between lifts [ 5 ].
These sustained head-raising exercises were followed by 30 consecutive repetitions of head raisings in the same supine position. For both sustained and repetitive head raising, volunteers were instructed to raise the head high enough to be able to observe their toes without raising their shoulders.
The traditional swallowing therapy involved a series of exercises, including the super-supraglottic swallow holding the breath with effort while swallowing, followed by a cough [ 7 — 10 ]; the Mendelsohn maneuver involving swallowing normally and as the larynx elevates, catching it with neck muscles and holding it at maximum elevation for a count of 6 while swallowing [ 2 , 11 — 13 ]; tongue base exercises, including pulling the tongue straight back and holding it in that extreme retracted position for a count of 5; yawning and holding the tongue in its backward position for a count of 5, pretending to gargle and holding the tongue in the extreme retracted position for the count of 5, and pulling the tongue straight back and holding it in the extreme retracted position for a count of 5 [ 14 ].
These traditional exercises were practiced for 5 min ten times per day for 6 weeks. Data Collection Prior to beginning either therapy program, the patient underwent a videofluoroscopic evaluation of the oropharyngeal swallow using the modified barium swallow [ 15 — 17 ]. During this procedure, patients were seated and viewed in the lateral plane and had to swallow two each of 3 and 5 ml of liquid barium and 3 ml of barium pudding.
The image clearly reflected the lips anteriorly, the soft palate superiorly, the seventh cervical vertebra inferiorly, and the cervical vertebrae posteriorly. Then patients were turned and examined in the anterior-posterior plane while performing two swallows each of 3 and 5 ml of barium liquid and 3 ml of barium pudding. This modified barium swallow procedure was repeated for both the pretherapy program assessment Pre and the post-therapy program assessment Post.
The videotapes of each videofluoroscopic study, whether pre- or post-treatment, were sent to a central laboratory at the Medical College of Wisconsin where they were tested for quality control, i. Then, each videofluoroscopic study was digitized to measure hyoid and larynx movement as well as the UES opening. Videofluoroscopic recordings were analyzed after the treatment group traditional or Shaker and exercise status pre- or postexercise were masked. Video loops of the swallows were reviewed by two blinded analysts.
Swallows with sufficient image contrast and content were converted and saved as individual bitmaps onto a password-protected computer using VirtualDub 1. For each swallow, every third image 0. Ten percent of the data were reanalyzed as a measure of reliability. Outcome Measures The primary swallow outcome measure was any occurrence of aspiration preswallow, intraswallow, postswallow at the 6-week follow-up period.
Other outcomes included the occurrence of residue in the oral cavity, valleculae, or pyriform sinuses and the Performance Status Scale for Diet [ 18 ]. Video recordings were analyzed for the presence or absence of aspiration and pharyngeal residue by the swallowing clinician during the modified barium swallow study. In addition, the following measures were made by computer analysis of hyoid, larynx, and UES movements: anterior hyoid movement: the distance of movement of the hyoid bone the anterior superior corner of the body of the hyoid in a forward direction; superior hyoid movement: the vertical movement of the anterior superior corner of the hyoid bone; anterior laryngeal movement: the forward movement of the larynx as defined by the point on the anterior superior portion of the subglottic air column; superior laryngeal movement: measured by the vertical component of movement of the anterior superior corner of the subglottic air column; the maximum width of the UES opening as defined by the line between the anterior and posterior walls of the pharyngoesophageal segment at its narrowest area during its maximum opening in a lateral view; and the maximum width of the UES opening as viewed anteriorly.
These measures were made from each of the swallows taken during the pre- and post-therapy videofluoroscopic studies. Minutes of practice and the change in the diet performance status scale were compared between groups using the Wilcoxon rank sum test. Continuous videofluorographic data were analyzed using two-factor repeated-measures analysis of variance ANOVA , with therapy group as the between-group factor and time of observation as the within-group factor.
Post hoc comparisons were done within the context of the ANOVA model, with independent sample t tests for between-group comparisons and paired t tests for within-group comparisons. All analyses were on an intent-to-treat basis. No adjustments were made for multiple significance testing. All patients were required to have postdeglutitive aspiration at baseline. Results Limited patient availability and premature ending of funding resulted in fewer patients being recruited than were originally planned.
Table 1 presents the demographic information on the 19 patients by therapy group. This number of patients is significantly less than was anticipated when the study began, but this was what an intensive search for patients who met the entry criteria found. There were no significant differences between the groups with respect to age, gender, race, ethnicity, education, and etiology of swallowing problem. Table 1 Demographic characteristics for the two groups of patients Shaker.
Evaluation and Treatment of Swallowing Disorders–Second Edition E-Book
The natural swallowing process The natural swallowing process - from mouth to stomach During a day a normal person swallows approximately times: of these are during the day, when eating, and 50 times when asleep . Here we will look at all the phases of swallowing and how the signals flow from mouth — to brain — to pharynx, esophagus, diaphragm and stomach. After this we close our lips, chew, reduce the food to manageable pieces and mix it with saliva. At the same time the floor of the mouth is raised. The decrease in pressure in the mouth eases the transport of the food mixture from the mouth to the pharynx.
The natural swallowing process - from mouth to stomach
Evaluation and Treatment of Swallowing Disorders
Evaluation and Treatment of Swallowing Disorders, Second Edition