Rethinking the Importance of Skill Training for Dysphagia
Several years ago, I went to an ASHA Convention and attended a talk that addressed whether it is better to train skill or strength when working with patients with dysphagia. I found the idea rather intriguing, especially when considering the possible advantages and disadvantages of focusing on one over the other, rather than focusing on both equally.
Recently, I was invited to speak at the Alaska Speech Language and Hearing Association Convention. Part of my talk was about skill versus strength training. Throughout the course of my research for that presentation, it occurred to me that while both are vital to swallowing, skill training may prove beneficial in areas where strength training fails.
The Limits of Strength Training
When talking about strength training, it’s helpful to start with some basic definitions:
- Strength is the ability to produce force against resistance.
- Weakness is the reduced ability to produce force.
- Fatigue is weakness that becomes evident during sustained force production or over repeated trials.
As it relates to swallowing, strength cannot be the only means of assessment. We need to also assess and treat neuromuscular coordination, precision, timing, reaction speed, and motor movement planning.
Typically, when we describe weakness in the laryngeal and pharyngeal structures, we are inferring a weakness from the reduced range of motion of the structures. Reduced range of motion can be derived from many factors, not weakness alone.
Strengthening may not be the best approach for swallowing rehabilitation as swallowing does not require maximal muscle contraction and weakness may not be the underlying generation of adequate force.1,2 We may also have potential adverse effects from strength training, including fatigue, increased muscle tone, and detraining effects following treatment.
There are few means available to us to measure the strength of the laryngeal and pharyngeal structures. We can measure the force of the tongue with a tool such as the Iowa Oral Performance Instrument® or the Tongueometer™.
We also need to evaluate the treatment strategies that we use to “strengthen the swallow.” Many do not incorporate the principles of exercise, including:
- Individuality—Exercise should be specific to the individual completing the training.
- Specificity— Exercise should be specific to the client’s needs and capabilities.
- Overload— Exercise should overload the body for a positive adaptation to occur.
- Progression— Exercise needs to continually overload the body if positive adaptations are to continue to take place.
- Adaptation— The body becomes accustomed to a particular exercise through repeated exposure and can modify based on increased and decreased physical demands.
- Recovery— Rest and recovery are required to allow the body time to adapt to exercise.
- Reversibility (Use/Disuse)— Adaptations from exercise will be lost if left unused.
If you’re primarily focused on strength training and you find that your patient is not progressing as expected, you may consider this quote: “Does the error lie with the clinician and the clinical inaccuracy of the diagnosis to improper selection of rehabilitation approaches?”3
The Influence of Skill Training
Huckabee and MacCrae stated “Skill-based training can be defined at a basic level as the acquisition of skill through functional repetition and refinement of movement patterns, task challenge and feedback.” The goal of skill training as it pertains to swallowing is to improve the precision of swallow muscle contraction by developing conscious control of timing and strength. With skill training, increasing levels of difficulty and proficiency are required at each level before moving to the next.3
Current rehabilitation approaches for swallowing impairment are limited by a general lack of specificity to associated pathophysiology, with many of our practices focusing on increasing strength of muscle activation. Skill training has been documented to influence greater gains than strength training alone. Additionally, skill training has been found to influence greater strength.4
Skill-based training is defined as having three elements:
- Specificity of practice (actually practicing swallowing)
- Task challenge with increased demand
- Feedback (typically through use of sEMG)
When a patient practices a dysphagic swallow with no adaptation to the task, progress is unlikely. The use of skill-based training has been studied in patients with Parkinson’s disease,5 patients with head and neck cancer,6 and patients who have not been successful with traditional treatment.7 All studies showed improvements not only in swallowing, but also in retention of that progress in follow-up studies.
The following exercises have been found to influence swallowing both with and without using an actual swallow. Many of these exercises are available through MedBridge’s HEP library.
Skill-based swallowing exercises incorporating the swallow:
- Effortful swallow
- Tongue-hold maneuver (Masako)
- Mendelsohn maneuver
- McNeill Dysphagia Therapy Program (MDTP)
Skill-based swallowing exercises without a swallow:
- Head-lift exercise (Shaker)
- Expiratory muscle strength training (EMST)
- Lingual exercises
Other promising programs include:
- The Intensive Dysphagia Rehabilitation Program (IDR)
- MD Anderson Boot Camp
To learn more about exercises that support swallowing therapy for dysphagia, check out this course, Dysphagia and the Older Adult: Exercise in Swallow Rehabilitation, by MedBridge instructor Angela Mansolillo, MA/CCC-SLP, BCS-S.
- 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(3), 251-265.
- Langmore, S. E., & Pisegna, J. M. (2015). Efficacy of exercises to rehabilitate dysphagia: a critique of the literature. International Journal of Speech-Language Pathology, 17(3), 222-229.
- Huckabee, M. L., & Lamvik-Gozdzikowska, K. (2018). Reconsidering rehabilitation for neurogenic dysphagia: Strengthening skill in swallowing. Current Physical Medicine and Rehabilitation Reports, 6(3), 186-191.
- Huckabee, M. L., & Macrae, P. (2014). Rethinking rehab: Skill-based training for swallowing impairment. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 23(1), 46-53.
- Athukorala, R. P., Jones, R. D., Sella, O., & Huckabee, M. L. (2014). Skill training for swallowing rehabilitation in patients with Parkinson's disease. Archives of Physical Medicine and Rehabilitation, 95(7), 1374-1382.
- Martin-Harris, B., McFarland, D., Hill, E. G., Strange, C. B., Focht, K. L., Wan, Z., ... & McGrattan, K. (2015). Respiratory-swallow training in patients with head and neck cancer. Archives of Physical Medicine and Rehabilitation, 96(5), 885-893.
- Baker, S., Davenport, P., & Sapienza, C. (2005). Examination of strength training and detraining effects in expiratory muscles. Journal of Speech, Language, and Hearing, 46(6), 1325-33.
- Burkhead, L. M. (2009). Applications of exercise science in dysphagia rehabilitation. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 18(2), 43-48.
- Carnaby, G. D., LaGorio, L., Silliman, S., & Crary, M. (2020). Exercise‐based swallowing intervention (McNeill Dysphagia Therapy) with adjunctive NMES to treat dysphagia post‐stroke: A double‐blind placebo‐controlled trial. Journal of Oral Rehabilitation, 47(4), 501-510.
- Carnaby-Mann, G. D., & Crary, M. A. (2010). McNeill dysphagia therapy program: a case-control study. Archives of Physical Medicine and Rehabilitation, 91(5), 743-749.
- Clark, H. M. (2003). Neuromuscular treatments for speech and swallowing. American Journal of Speech-Language Pathology, 12(4), 400-415.
- Clark, H. M. (2005). Food for thought: therapeutic exercise in dysphagia management: philosophies, practices, and challenges. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 14(2), 24-27.
- 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(7), 1173-1178.
- 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(3), 172.
- Crary, M. A. (2015). McNeill Dysphagia Therapy Program–10 years of research experience with an exercise based dysphagia rehabilitation approach. Dysphagia Café. Retrieved from https://dysphagiacafe.com/2015/11/19/mcneill-dysphagia-therapy-program-10-years-of-research-experience-with-an-exercise-based-dysphagia-rehabilitation-approach/
- Hutcheson, K. A., Kelly, S., Barrow, M. P., Barringer, D. A., Perez, D. P., Little, L. G., ... & Lewin, J. S. (2015). Offering more for persistent dysphagia after head & neck cancer: The evolution of boot camp swallowing therapy. Age, 28, 82.
- Malandraki, G. A., & Hutcheson, K. A. (2018). Intensive therapies for dysphagia: implementation of the intensive dysphagia rehabilitation and the MD Anderson Swallowing Boot Camp Approaches. Perspectives of the ASHA Special Interest Groups, 3(13), 133-145.
- Malandraki, G. A., Rajappa, A., Kantarcigil, C., Wagner, E., Ivey, C., & Youse, K. (2016). The intensive dysphagia rehabilitation approach applied to patients with neurogenic dysphagia: a case series design study. Archives of Physical Medicine and Rehabilitation, 97(4), 567-574
- Moldover, J. R., & Stein, J. (1994). Cardiopulmonary physiology. In The Physiological Basis of Rehabilitation Medicine (pp. 127-147). Butterworth-Heinemann.
- Robbins, J., Butler, S. G., Daniels, S. K., Gross, R. D., Langmore, S., Lazarus, C. L., ... & Rosenbek, J. (2008). Swallowing and dysphagia rehabilitation: translating principles of neural plasticity into clinically oriented evidence. Journal of Speech, Language, and Hearing Research, 51(1), S276-300.
- Sia, I., Carvajal, P., Lacy, A. A., Carnaby, G. D., & Crary, M. A. (2015). Hyoid and laryngeal excursion kinematics–magnitude, duration and velocity–changes following successful exercise‐based dysphagia rehabilitation: MDTP. Journal of Oral Rehabilitation, 42(5), 331-339.
- Zimmerman, E., Carnaby, G., Lazarus, C. L., & Malandraki, G. A. (2020). Motor learning, neuroplasticity, and strength and skill training: moving from compensation to retraining in behavioral management of dysphagia. American Journal of Speech-Language Pathology, 29(2S), 1065-1077.