Effortful Pitch Glide: An Exercise for Potential Swallow Rehabilitation Evaluated by Dynamic MRI

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Keri Vasquez Miloro, MS, CCC-SLP, BRS-S William G.

1 Effortful Pitch Glide: An Exercise for Potential Swallow Rehabilitation Evaluated by Dynamic MRI Keri Vasquez Miloro, MS, CCC-SLP, BRS-S William G. Pearson, Jr. PhD Susan Langmore, PhD, CCC-SLP, BRS-S

2 Disclosures Keri Vasquez Miloro: No relevant financial or nonfinancial relationships to disclose William Pearson:Training grant No. F31DC from the National Institute on Deafness and Other Communication Disorders Susan Langmore:NIH-NCI R01-CA

3 Board Recognized Specialist in Swallowing and Swallowing Disorders (BRS-S) Do you have advanced knowledge, skills and expertise in dysphagia? Would you like to be recognized as an expert in the field and join a select group of clinicians dedicated to patients with dysphagia? Consider becoming a Board Recognized Specialist in Swallowing and Swallowing Disorders

Benefits of Obtaining BRS-S Recognition of advanced skills to consumers, colleagues, and healthcare practitioners Facilitate career advancement Marketing of clinical services Expand referral sources

4 Benefits of Obtaining BRS-S Recognition of advanced skills to consumers, colleagues, and healthcare practitioners Facilitate career advancement Marketing of clinical services Expand referral sources ADVANCED Continuing Education programs Connect with fellow Specialists Clinical and Academic/Administrative tracks available For more information on Specialty Recognition, Mentorship and Continuing Education programs, go to

5 Presentation Objectives 1. Principles of exercise training 2. EBP review of current swallow therapy Application of training principles, targeted kinematics & comprehensibility 3. Overview of study examining the EPG

6 Training Principles 1. Specificity Muscular response action or contraction Swallow therapies kinematic specificity 2. Overload Intensity, freq, duration (reps, sets, rest)

7 Training Principles Goal - Adaptation Muscle response Fiber shifts and hypertrophy (Burkhead et al 2007) Maintenance/Detraining Loss of adaptations gained

8 Other Principles Transference the ability of plasticity within one set of neural circuits to promote concurrent or subsequent plasticity (Kleim&Jones, 2008, p. S232) Behavioral plasticity (Robbins et al 2008)

9 Rehabilitative Swallow Therapies Goal Improve physiology Force, speed and timing Exercise program to promote LT effects

10 Two types of exercise 1. Swallow maneuvers: task- specific exercises 2. Non-swallow (non-specific) exercises Aim: long-term make the swallow stronger, quicker, more coordinated

11 Part 1: Swallow Exercises 1. Mendelsohn maneuver 2. Effortful swallow 3. Supraglottic swallow maneuver 4. Tongue-hold 5. MDTP

12 Mendelsohn Maneuver (MM) laryngeal elevation, greater amplitude during swallow (Kahrilas et al 1991) Sig. improved superior and ant hyoid post 2 weeks of MM (McCullough et al 2012) semg Application of training principles: specificity, overload Kinematics: hyolaryngeal elevation, anterior hyoid Comprehensibility*: Difficult *Based on clinical experience

13 Effortful Swallow (ES) Principle: BOT PPW Lengthened laryngeal closure, improved hyoid excursion, UES opening duration, higher oral pressures(hind et al 2001) in submental activity vs swallow (Wheeler Hegland et al 2008) Delayed pharyngeal & UES events but > pharyngeal pressure and UES relaxation (Hiss & Huckabee, 2005) Increases esophageal amplitude (Nekl et al 2012) Application to training principles: specificity, overload Kinematics: Pharyngeal contraction, airway closure, UES Comprehensibility: Difficult, often taught w/ biofeedback

14 Cortical Activity ES and MM elicited widespread neural network of activation in both hemispheres Elicited more response in regions associated related to swallowing suggesting enhanced cortical activation (Peck et al 2010)

15 SGS VF closure before and during swallow (Martin et al 1993) Increased posterior and superior excursion of hyoid w/ longer displacement vs swallow (Kasahara et al 2009) Application to training principles: specificity, overload Kinematics: Laryngeal closure, hyoid excursion Comprehensibility: Difficult

16 Tongue-Hold Significant increase in anterior bulging of PPW (Fujiu et al 1996) Immediate effects No difference in pharyngeal pressures between tongue-hold and saliva swallows (Umeki at al 2009) Healthy subjects: RCT x s 4 weeks No change in swallow (hyolaryngeal ex, pharyngeal constriction or ant movement of PPW) (Oh et al 2012) Application to training principles: specificity, overload Kinematics: pharyngeal bolus transport, BOT Comprehensibility: Difficult

17 McNeill Dysphagia Tx Protocol (MDTP) Swallow hard and fast - follows a dietary hierarchy with advancing steps of altered bolus volume (load) and consistency Increased laryngeal and hyoid elevation, lingualpalatal pressures, FOIS, oral and pharyngeal temporal events (Crary et al 2012, Lan et al 2012 ) Pilot studies/small sample size Application to training principles: specificity, overload Kinematics: laryngeal and hyoid elevation Comprehensibility:Difficult (MMSE > 23)

18 Part 2:Non-swallow exercises 1. Shaker 2. Tongue strengthening 3. LSVT 4. EMST Falsetto Pharyngeal squeeze maneuver more on these later..

Shaker Exercise Strengthens suprahyoids for forward movement; Reduces post-swallow pyriform sinus residue d/t decreased UES excursion Significant improvement - UES opening, anterior laryngeal

19 Shaker Exercise Strengthens suprahyoids for forward movement; Reduces post-swallow pyriform sinus residue d/t decreased UES excursion Significant improvement - UES opening, anterior laryngeal excursion and elimination of aspiration post swallow (Shaker et al 2002) Application of training principles: Overload, transference Kinematics: Anterior laryngeal movement Comprehensibility: easy BUT tx compliance

20 Shaker Exercise Elderly subjects - Increase in frequency range and intensity (Easterling 2008) Suggestive of transference

airway protection and improved QOL; increased lingual muscle mass(robbins et al,

21 Tongue Strengthening Isometric lingual resistance exercise using the Iowa Oral Performance Instrument (IOPI) residue, pen/asp, oral transit duration, lengthened airway protection and improved QOL; increased lingual muscle mass(robbins et al, 2007) Improved tongue strength and swallow fxn; improved diet levels (Yeates et al 2008)

Tongue Strengthening(cont) Tongue depressors Young normals - no differences in strength between depressors versus IOPI (Lazarus et al, 2003) Healthy adults -

22 Tongue Strengthening(cont) Tongue depressors Young normals - no differences in strength between depressors versus IOPI (Lazarus et al, 2003) Healthy adults - increased lingual strength elevation, lateralization and protrusion Detraining effects - lingual strength decreased 2-4 weeks after training (Clark et al, 2009)

23 Tongue Strengthening(cont) Application of training principles: Overload, transference Kinematics: bolus flow, airway closure Comprehensibility: easy difficult

24 Lee Silverman Voice Tx (LSVT) Improve speech intelligibility in PD MPD, F0, fxnl phrases, speech tasks; Talk and think LOUD! (Ramig et al 1995) Improved lingual motility, quicker swallow, oropharyngeal TT, < vall residue No change in penetration (El Sharkawi et al 2002) Pilot study Application of training principles: Overload, transference Kinematics: oral transit Comprehensibility: easy

Expiratory Muscle Strength Training (EMST) Respiratory strengthening - resistive loading w/ a pressure threshold device Improves cough, speech,

25 Expiratory Muscle Strength Training (EMST) Respiratory strengthening - resistive loading w/ a pressure threshold device Improves cough, speech, breathing and swallow function (Sapienza et al 2006, Troche et al 2010) Increased activation & higher amplitude of submentals vs. swallow(wheeler et al 2007)

26 EMST Significant al 2009) PA scores in PD post 4 weeks (Pitts et RCT w/ PD EMST vs. sham exercise PA scores and hyolaryngeal fxn (Troche et al 2010) MMSE 24 Detraining Small loss of strength post 8 weeks but significantly above baseline levels (Baker et al 2005).

27 EMST(cont.) Integration and coordination of several related muscle areas neuroplastic changes (Sapienza & Wheeler 2006) Application of training principles: Overload, transference Kinematics: Hyolaryngeal, laryngeal closure Comprehensibility: easy-difficult BUT need device

28 Effortful Pitch Glide (EPG)

29 What is the Effortful Pitch Glide (EPG)? Background

30 What is the Effortful Pitch Glide New exercise Easy Recruits muscles used in swallowing Kinematic specificity (EPG)?

31 1. Falsetto What is the EPG? Pitch elevation Max F 0 and perceptual - significantly predicted PAS scores Lower max F 0 - significantly higher mean residue scores (Malandraki et al 2011)

32 What happens during pitch elevation? MRI Rising of hyoid and larynx, hyolaryngeal approximation(miller et al 2011)

33 What is the EPG (continued)? 2. Pharyngeal squeeze maneuver(psm) Evaluation of pharyngeal constrictors (Bastian 1993) PSM validated when compared with the pharyngeal constrictor ratio (Fuller et al 2009)

34 Pitch glide + PSM = EPG

35 Video of EPG

36 Aims #1: Describe the EPG #2: Test for swallowing specificity using two-planar dynamic MRI

37 Methods 11 healthy, young subjects mean 25.4 years (range yrs) 6 M, 5 F Used laryngoscopic exam to describe EPG (Aim #1) Instructions: 1. /i/ modal pitch - highest pitch 2. Forceful ee sound at highest pitch

38 Methods (continued) Used two-planar T1 weighted dynamic MRI at 8.3 frames per second alternating coronal and sagittal planes to measure kinematic variables to test specificity (Aim #2) 9 anatomical landmark measurements Image J software

39 Data Analysis Paired two-tailed t-test with Bonferroni Correction Inter-reliability

40 Effortful Pitch Glide Before EPG EPG -maximum

41 Aim 2: Does the EPG elicit similar kinematic movements as swallowing? 1. EPG>SW 2. EPG SW 3. EPG<SW Kinematic variables include: Hyoid Movement Hyolaryngeal Approximation Laryngeal Elevation (Superior hyoid & Posterior thyroid) Pharyngeal Shortening Pharyngeal Wall Medialization

42 Kinematic Variables of Interest Hyoid Movement Anterior

43 Kinematic Variables of Interest Hyoid Movement Superior

44 Kinematic Variables of Interest Hyolaryngeal Approximation

45 Kinematic Variables of Interest Laryngeal Elevation via Posterior Thyroid

46 Kinematic Variables of Interest Pharyngeal Shortening

47 Kinematic Variables of Interest Pharyngeal Wall Medialization

48 EPG compared with the swallow midsagittal Swallow at max EPG at max

49 EPG compared with the swallow Coronal plane of lateral pharyngeal walls Swallow at max EPG at max

51 Results EPG Rest to Max (cm) Mean ± SD (95% Confidence Intervals) Swallow Rest to Max (cm) Mean± SD (95% confidence intervals) p values Anterior Hyoid Movement 1.02±0.56 (0.69, 1.35) 1.02±0.34 (0.82, 1.22) 0.98 Anterior Hyoid CM EPG Swallow Ant Hy

52 Results EPG Rest to Max (cm) Mean ± SD (95% Confidence Intervals) Swallow Rest to Max (cm) Mean± SD (95% confidence intervals) p values Superior Hyoid Movement 0.49±0.68 (0.09, 0.89) 1.37±0.73 (0.94, 1.8) 0.00* Superior Hyoid CM 1 EPG Swallow Sup Hy

53 Results EPG Rest to Max (cm) Mean ± SD (95% Confidence Intervals) Swallow Rest to Max (cm) Mean± SD (95% confidence intervals) p values Hyolaryngeal Approximation 0.27±0.28 (0.11, 0.43) ±0.5 (-0.47, 0.13) 0.02 Hyolaryngeal Approximation EPG 0.1 CM Hyo Lar App Swallow

54 Results EPG Rest to Max (cm) Mean ± SD (95% Confidence Intervals) Swallow Rest to Max (cm) Mean± SD (95% confidence intervals) p values Laryngeal Elevation(by Posterior Thyroid) 1.4±0.65 (1.02, 1.78) 1.61±0.64 (1.23, 1.99) 0.3 Laryngeal Elevation via Post Thyroid 2.5 CM EPG Swallow Lar Elev via Post thy

55 Results EPG Rest to Max (cm) Mean ± SD (95% Confidence Intervals) Swallow Rest to Max (cm) Mean± SD (95% confidence intervals) p values Pharyngeal Shortening 1.3±0.69 (0.9, 1.7) 0.96±0.67 (0.56, 1.36) 0.2 Pharyngeal Shortening CM EPG Swallow Ph Short

56 Results EPG Rest to Max (cm) Mean ± SD (95% Confidence Intervals) Swallow Rest to Max (cm) Mean± SD (95% confidence intervals) p values Lateral Pharyngeal Wall Medilaization 1.81±0.68 (1.41, 2.21) 2.29±0.51 (1.99, 2.59) 0.16 Lateral Pharyngeal Wall CM EPG Swallow Lat Ph Wall Med

57 Kinematic Variables (EPG vs Swallow) ** EPG Cm 1 Swallow Inter-rater reliability r=

58 What does this tell us about muscle activity?

T2 Signal Profiles Muscle Intensity: Swallow vs. EPG All muscles except thyrohyoid and ant diagstric achieved sig. effect size changes All muscles except thyrohyoid achieved sig.

59 T2 Signal Profiles Muscle Intensity: Swallow vs. EPG All muscles except thyrohyoid and ant diagstric achieved sig. effect size changes All muscles except thyrohyoid achieved sig. effect size changes Muscle overload with EPG mylohyoid (hyoid elevation), palatopharyngeus and stylopharyngeus (posterior laryngeal elevation, pharyngeal shortening) (Pearson, W et al 2012)

60 How do we interpret this? EPG demonstrates kinematic specificity to swallowing: Anterior Hyoid Movement Hyolaryngeal Approximation Laryngeal Elevation Pharyngeal Shortening Pharyngeal Wall Medialization

61 How does the EPG compare to other therapies? Application of training principles: Overload, transference Kinematics: Anterior hyoid, hyolaryngeal approximation, laryngeal elevation, pharyngeal shortening and pharyngeal wall approximation Comprehensibility: Easy

62 Limitations MRI Can this exercise be detrimental? No acoustic or perceptual measurements Young, healthy subjects small sample

63 In Conclusion We have introduced the Effortful Pitch Glide (EPG), a non swallow exercise, that may effectively resemble certain swallowing kinematics including: Anterior Hyoid Movement Hyolaryngeal Approximation Laryngeal Elevation Pharyngeal Shortening Pharyngeal Wall Medialization

64 Thank you for your attention!

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Daniels SK & Huckabee ML (2008). Dysphagia Following Stroke. Muscles of Deglutition. Lateral & Mesial Premotor Area 6. Primary Sensory An Overview of Dysphagia in the Stroke Population Stephanie K. Daniels, PhD Michael E. DeBakey VA Medical Center PM & R, Baylor College of Medicine Communication Sciences and Disorders, University of Houston