Running Head: EXERCISE PHYSIOLOGY IN DYSPHAGIA

Exercise Physiology in Dysphagia

Lauren Lanphere
University of Wisconsin-Whitewater
Center for Communication Sciences and Disorders

EXERCISE PHYSIOLOGY IN DYSPHAGIA

Within the past two decades, dysphagia treatment has experienced a shift towards
exercise rehabilitation. Dysphagia therapy aims to increase safe oral intake of food and liquid
and often incorporates compensatory strategies (Crary, Carnaby, LaGorio & Carvajal, 2012).
While compensatory strategies allow the patient to increase safe oral intake immediately, they
are not long-term solutions. The goal of exercise therapy in dysphagia is to produce
physiological changes in the musculature for a more permanent treatment of dysphagia (Crary &
Carnaby, 2014).
Exercise physiology has been used in many different fields to increase muscle strength
and similar principles can be applied to the swallowing musculature. Human skeletal muscle can
be grouped into two different types: slow twitch (type I) and fast twitch (type II). Slow twitch
muscle fibers have slower contraction rates and are more resistant to fatigue, whereas fast twitch
muscle fibers contract faster and are more likely to fatigue (Burkhead, Sapienza & Rosenbek,
2007). Muscles of the human body have both slow and fast twitch muscles and typically one type
is predominant; however, muscles involved with swallowing, specifically oral, pharyngeal, and
laryngeal muscles, have hybrid fibers unlike any other skeletal muscle groups. Burkhead et al.
state the spectrum of actions undertaken, including respiration and verbal communication as
well as mastication and swallowing might explain the unique properties of these muscles (p.
253). When creating an exercise plan to strengthen muscles involved in deglutition, their unique
properties need to be taken into consideration.
Research has shown early effects of strength training leads to a modification of how the
nervous system activates muscle. As strength training progresses, morphologic changes within
the muscle tissue begin to take place (Burkhead et al., 2007). There are two types of
morphologic adaptations that are the result of strength training; fiber type shifts and hypertrophy.

EXERCISE PHYSIOLOGY IN DYSPHAGIA

With exercise, muscle fibers generally shift to slow twitch muscles becoming more fatigue
resistant. Hypertrophy, the enlargement of muscle fiber, increases the force generating capacity
of a muscle (Burkhead et al., 2007). Typically, hypertrophy is the main goal of strength training.
To create morphologic changes in muscle, the system needs to be taxed beyond its normal
use, specifically using the principles of intensity, specificity, and recovery (Crary & Carnaby,
2014). Intensity, or practice, allows muscles to develop and adapt to a particular movement
creating improved performance. Without this practice, muscles decondition creating the reverse
affect. Specificity encompasses the movements or exercises being used to strengthen muscle.
The movement practiced needs to target the muscle group, movement, or skill specifically to
generate a positive response (Crary & Carnaby, 2014). Exercising muscles indirectly will not
create fiber type shifts or hypertrophy relevant to the intended outcome. Finally, recovery needs
to be incorporated into strength training plans. Rest between exercises facilitates muscle fiber
development and muscle healing (Cary & Carnaby, 2014). Like other strength training plans,
intensity, specificity, and recovery should be incorporated into dysphagia exercise therapy to
maximize the benefits of exercise.
When developing an exercise program for dysphagia, it is important to keep the
principles of exercise at the forefront; simply swallowing food, liquids, or salivais not an
activity that can provide the degree of load that is necessary to force adaptations in the
neuromuscular system to increase strength (Burkhead et al., 2007, p. 261). Instead, exercises
that place an increased load involving the specific activity of swallowing should be used.
Determining the aspect of the swallow the patient is having difficulties with is an important part
of developing an exercise program. Specific exercises should be used if there is reduced
hyolaryngeal movement whereas different exercises should be incorporated if there is reduced

EXERCISE PHYSIOLOGY IN DYSPHAGIA

tongue base pharyngeal wall contact (Burkhead et al., 2007). Tailoring exercise programs to the
patient is an important key to successful rehabilitation.
Research has shown many exercise programs facilitate safe oral intake of food and liquid.
Examples of dysphagia exercises include, effortful swallow, Mendelsohn maneuver, lingual
exercises, supersupraglottic swallow, McNeill dysphagia therapy program, tongue-hold
maneuver, and Shaker exercise. Each exercise targets a specific aspect of the swallow and
should be selected based on the patient and the patients needs (Logemann et al. 2009). A brief
review of the research supporting the tongue-holding maneuver, effortful swallow, Mendelsohn
maneuver, the supersupraglottic swallow, and the Shaker exercise was completed to determine
the efficacy of dysphagia exercises.
Fujiu and Logemann (1996) studied the tongue-holding maneuver and its effect on
anterior bulging of the posterior pharyngeal wall. The tongue-holding maneuver can be described
as swallowing while holding the tongue between the front teeth. It is incorporated into
dysphagia rehabilitation programs when there is reduced tongue base-pharyngeal wall contact
during a swallow. Tongue base-pharyngeal wall contact is critical for swallowing because it is
the primary pressure generator and facilitates continuous bolus movement though the pharynx
(Fujiu & Logemann, 1996, p. 23). This study utilized videofluoroscopy and looked at ten
healthy male adults swallowing normally and swallowing using the tongue-holding maneuver.
Images were then analyzed to measure the anterior movement of the posterior pharyngeal wall.
Results showed all ten subjects had an increase in posterior pharyngeal wall movement when
utilizing the tongue-holding maneuver; t-tests indicated the movement of the posterior
pharyngeal wall was significantly greater with the tongue-hold maneuver than without the
maneuver (Fujiu & Logemann, 1996). This study showed the amount of anterior bulging of the

EXERCISE PHYSIOLOGY IN DYSPHAGIA

posterior pharyngeal wall can be altered and potentially strengthened with the tongue-holding
maneuver (Fujiu & Logemann, 1996). In patients with reduced posterior pharyngeal wall
movement, this technique can be applied to increase the anterior bulge creating higher pressure
to transport the bolus through the pharynx.
Additionally, Lazarus, Logemann, Song, Rademaker, and Kahrilas (2002) studied the
effect of swallowing exercises on tongue base-pharyngeal wall pressures in three dysphasic
patients. Specifically they looked at the effortful swallow, tongue-hold maneuver, Mendelsohn
maneuver, and the supersupraglottic swallow. Tongue base-pharyngeal wall pressures were
addressed because the tongue base produces pressures that propel the bolus through the upper
pharynx during a swallow in addition to meeting the posterior pharyngeal wall to clear the bolus
(Lazarus et al., 2002). These are fundamental components to a successful swallow. The effortful
swallow and the tongue-hold maneuver are designed to increase strength of the tongue base and
posterior pharyngeal wall, therefore increasing propulsive force and clearing the bolus more
efficiently. Directions for completing the effortful swallow in the study were as follows, as you
swallow, squeeze hard with all of your muscles (p. 173). Instructions for the tongue-hold
maneuver were, put your tongue between your teeth, keep it there and swallow (p. 173). The
Mendelsohn maneuver and the supersupraglottic swallow are exercises designed to increase
laryngeal elevation and airway closure, creating less aspiration and a safer swallow. Directions
for the Mendelsohn maneuver and the supersupraglottic swallow are described respectively as
follows, swallow your saliva several times and pay attention to your neck as you swallow. Tell
me if you can feel that something (your Adams apple or voice box) lifts and lowers as you
swallow. Now, this time when you swallow, dont let your Adams apple drop. Hold it up with
your muscles for several seconds and supersupraglottic, inhale and hold your breath very

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tightly, bearing down. Keep holding your breath and bearing down as you swallow. Cough when
you are finished (p. 173). Directions were standardized throughout the study to determine the
effectiveness of each exercise.
Manometry and examination of videofluoroscopic swallow studies were utilized to
determine the effectiveness of voluntary swallow maneuvers. While under fluoroscopy, patients
were instructed to (1) swallow normally, (2) use the effortful swallow, (3) use the
supersupraglottic swallow, (4) use the Mendelsohn maneuver, and (5) use the tongue-hold
maneuver (Lazarus et al., 2002). Results of the study indicate increased tongue base-pharyngeal
wall pressures during dysphagia exercises in comparison to baseline swallows. Furthermore, the
duration of tongue base to pharyngeal wall contact increased with the exercises. Not only did the
effortful swallow and tongue-holding maneuver improve tongue base-pharyngeal wall contact,
the Mendelsohn maneuver and the supersupraglottic swallow were also shown to improve tongue
base-posterior wall movement (Lazarus et al., 2002). Based on the findings of this pilot study,
dysphagia exercises such as effortful swallow, tongue-holding maneuver, Mendelsohn maneuver,
and supersupraglottic swallow can be used to improve tongue base-pharyngeal wall contact and
pressure to improve swallow functions.
The Shaker exercise has also been studied to determine its effectiveness when treating
dysphagia. Logemann et al. (2009) looked at nineteen patients from seven different institutions
that displayed oralpharyngeal dysphagia. Patients were randomly separated into two groups,
traditional dysphagia treatment and the Shaker exercise program. Traditional dysphagia therapy
included the supersupraglottic swallow, the Mendelsohn maneuver, and tongue base exercises.
The Shaker exercise program involved three one-minute head lifts while lying in the supine
position with one-minute rest between each lift. Thirty head raises in the same position followed

EXERCISE PHYSIOLOGY IN DYSPHAGIA

the head lifts; patients were instructed to raise their heads without raising their shoulders
(Logemann et al., 2009). Patients completed the exercise program for six weeks with video
swallow studies pre and post therapy. The purpose of the exercise program was to determine if
traditional dysphagia therapy and/or the Shaker exercise program increased the opening of the
upper esophageal sphincter (UES) during swallowing. Results from this study indicate
traditional dysphagia therapy and the Shaker exercise achieved wider UES opening (Logemann
et al., 2009).
At the completion of the six-week exercise program, patients video swallow studies were
analyzed to determine if there was an increase in UES opening. After both treatment programs,
traditional and Shaker, there was a significant increase in UES opening. Differences were found
when comparing post swallow aspiration and biomechanical measures of swallowing (Logemann
et al., 2009). Patients in the traditional dysphagia therapy group showed significant
improvements on biomechanical measures (laryngeal/hyoid movement) whereas patients in the
Shaker exercise group showed less post swallow aspiration. Logemann et al. theorized this
difference might be due to the fact that traditional dysphagia therapy often utilizes greater
muscle effort than the Shaker exercise (2009, p. 408). Increased muscle effort leads to stronger
muscles, therefore increasing the pressure used to swallow. The authors note these findings can
guide speech-language pathologist when creating an exercise program. If a patient aspirates post
swallow, the Shaker exercise should be recommended, whereas if the patient has reduced range
of movement or reduced strength, traditional dysphagia therapy should be implemented. Based
on these findings, traditional dysphagia therapy and the Shaker exercise program are both
effective rehabilitation strategies for patients exhibiting oralpharyngeal dysphagia (Logemann et
al., 2009).

EXERCISE PHYSIOLOGY IN DYSPHAGIA

A brief sampling of the literature indicates applying principles of exercise physiology to
dysphagia rehabilitation has positive outcomes for increasing the safety of swallowing.
Specifically, the tongue-holding maneuver, supersupraglottic swallow, Mendelsohn maneuver,
and Shaker exercise have proven successful in dysphagia therapy (Logemann et al., 2009,
Lazarus et al., 2002, Fujiu & Logemann, 1996). Keeping in mind the principles of exercise and
selecting appropriate swallowing rehabilitation therapy will give patients the best prognosis for
long-term safe continued intake of food and liquids.

EXERCISE PHYSIOLOGY IN DYSPHAGIA

References
Burkhead, L. M., Sapienza, C. M., & Rosenbek, J. C. (2007). Strength-training exercise
in dysphagia rehabilitation: Principles, procedures, and directions for future research.
Dysphagia, 22, 251-265.
Crary, M. A. & Carnaby G. D. (2014). Adoption into clinical practice of two therapies to
manage swallowing disorders: Exercise based swallowing rehabilitation and electrical
stimulation. Current Opinion in Otolaryngology & Head and Neck Surgery, 22, 172-180.
Crary, M. A., Carnaby, G. D., LaGorio, L. A., & Carvajal, P. J. (2012). Functional and
physiological outcomes from an exercise based dysphagia therapy: A pilot investigation
of the McNeill dysphagia therapy program. Archives of Physical Medicine and
Rehabilitation, 93, 1173-1178.
Fujiu, M. & Logemann, J. A. (1996). Effect of a tongue-holding maneuver on posterior
pharyngeal wall movement during deglutition. American Journal of Speech-Language
Pathology, 5, 23-30.
Lazarus, C., Logemann, J. A., Song, C. W., Rademaker, A. W., & Kahrilas, P. J. (2002).
Effects of voluntary maneuvers on tongue base function for swallowing. Folia
Phoniatrica et Logopaedica, 54, 171-176.
Logemann, J. A., Rademaker, A., Roa Pauloski, B., Kelly, A., Stangl-McBreen, C.,
Antinoja, J., Shaker, R. (2009). A randomized study comparing the shaker exercise
with traditional therapy: A preliminary study. Dysphagia, 24, 403-411.