EC presented with dysphagia shortly after birth, and was determined to have impaired function of cranial nerves IX, X and XII. Due to aspiration risk, liquids were ...
Tongue-Pressure Resistance Training for Dysphagia in a 4.5-year old Child Catriona M. Steele Ph.D., S-LP(C), CCC-SLP, BCS-S, Reg. CASLPO, ASHA Fellow 1. Toronto Rehabilitation Institute – University Health Network; 2. University of Toronto.
Introduction Several recent studies point to an increased risk of penetration-aspiration in adults with reduced tongue strength, and suggest that interventions targeting increased tongue-strength may lead to improved swallowing function. Although preliminary normative data on tongue strength are available for children, it remains unknown whether tongue-pressure resistance training can be used to improve tongue strength in children and whether this leads to improved swallowing function. In this poster, we report data for an exploratory tongue-pressure resistance training intervention delivered to a 4.5-year old child with dysphagia (known as EC).
Case History
Tongue Strength Measurement and Training
EC presented with dysphagia shortly after birth, and was determined to have impaired function of cranial nerves IX, X and XII. Due to aspiration risk, liquids were administered via N/G tube throughout infancy. During the toddler stage, liquids thickened to a syrup consistency with Simply Thick™, Carobel™ or gelatin were introduced without adverse effect. Solid foods were also introduced gradually, and are currently eaten without modification.
Tongue-strength was initially measured using the Iowa Oral Performance Instrument (IOPI). The average (+/- SD) value for a set of 5 repeated maximum isometric pressure tasks with the pressure bulb located in an anterior oral position, just behind the incisors, was 15 (+/- 5) kPa. This falls well below the reported normative value of 35 (+/- 9) kPa for 4-year old girls (Potter & Short, 2009).
In 2014, a comprehensive videofluoroscopic swallowing assessment was performed to evaluate current risk and determine the potential for diet advancement from gelled thickened liquids. The following findings were observed: • Premature spillage of large sips of thin liquid was identified as a factor contributing to trace penetrationaspiration. • Pyriform sinus residue was also noted to be a risk for aspiration on secondary clearing swallows. Reduced tongue-strength was queried as a possible factor contributing to both of these observations. An experimental course of tongue-pressure resistance training was recommended.
An interactive game-format was designed to facilitate the practice of 3 different types of tonguepressure resistance exercise with a child. Flashcards of 3 dogs were created using pictures from Google Images and used with corresponding puppets to orient the child to the treatment tasks:
The IOPI was used for biofeedback during treatment.
A BIG St. Bernard was used to represent a maximum effort tongue-palate press.
A LONG dachshund was used to represent a prolonged pressure endurance task.
Training sessions involved 10 repetitions of each task for a total of 30 repetitions per session. A generalization task of saliva swallows (using an unsweetened Polo mint, secured with a dentalfloss leash) were interspersed throughout the session for reward and motivation. Additionally, 10 repetitions of the Shaker exercise head lifting task were included in each training session. Twice-daily practice was conducted by EC’s parent with supervision from the consulting clinician (CMS). Tongue strength was monitored on a weekly basis using a tracking form. After 5 months, the treatment schedule was reduced to once daily. An outcome endoscopic swallowing assessment (FEES) was conducted after 7 months (224 sessions) of tongue pressure training. After this, 2 months of twice weekly training was monitored to observe the effects of de-training.
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Swallowing Outcomes
Tongue Strength Outcomes
Maximum Isometric Tongue Pressure (kPa)
A small JUMPY terrier was used to represent a power task with rapid rise to peak pressure.
Overall, there was positive support for: • the framework and number of levels • the use of colours • the pyramid schema • names of levels (except for slightly thick) • the food texture diagram • the IDDSI syringe flow test •• Over the name ‘minced moist’ for 5 the course ofand 5 months, EC level achieved a 54% increase in tongue strength vs. baseline. • This the detailed outcomedescriptors surpassed a 2 standard deviation band with outcome values well within the
normal range for children aged 5 (Potter & Short, 2009). • A 16-week de-training phase with twice weekly practice showed no decline in tongue strength.
• Compared to historical FEES examinations, the post-treatment assessment appeared to show less pooling of salivary secretions in and around the larynx. • A pattern of pre-swallow accumulation of thin liquids in the post-cricoid region continued at the post-treatment assessment. No episodes of aspiration were observed. • Although comparisons between VFSS and FEES exams are not direct, the posttreatment assessment appeared to show improvements in post-swallow vallecular residue.
Discussion
Acknowledgments
In this case study, tongue-pressure resistance training was successfully used to improve tongue strength in a young child with dysphagia. Associated improvements in post-swallow vallecular residue were seen. Aspiration was not seen in the post-treatment assessment, however risk for aspiration related to pre-swallow bolus accumulation in the pharynx remained.
Dr. Steele gratefully acknowledges funding support for her research on tongue-pressure resistance training from the Heart & Stroke Foundation of Canada and from the Toronto Rehabilitation Institute – University Health Network, Toronto, Canada.
