Outcomes of tongue-pressure strength and accuracy training for dysphagia following acquired brain injury

Figures & data

Table I. Participant demographics and baseline videofluoroscopy impairment profiles.

Participant	Gender	Age	Description of injury	Time post-injury at start of protocol	Diet at start of protocol
1	F	45	Intracranial haemorrhage. Fractures: C5–C6.	6 months	Gastrostomy feeding, nil by mouth.
2	M	32	Intraventricular haemorrhage, diffuse axonal injury, frontal lobe white matter density changes. Partial left lung lobectomy following major aspiration event 24 months prior to enrolment.	42 months	Gastrostomy feeding, nil by mouth.
3	M	47	Closed head injury, epidural haematoma.	6 months	Oral minced diet with honey-thick liquids, no fibrous textures.
4	M	54	Closed head injury, subarachnoid haemorrhage. Fractures: ribs, C6–7, T1–3.	18 months	Gastrostomy feeding. Therapeutic trials of water, soft solids.
5	M	32	Closed head injury and multiple musculoskeletal injuries (not specified).	24 months	Oral minced diet with nectar-thick liquids.
6	F	44	Diffuse axonal injury, bilateral frontal lobe contusions, subarachnoid and left occipital horn haemorrhage. Left flail chest, pneumo-mediastinum, pneumothorax. Fractures: ribs, L1, L2, L5, pelvis. Lacerated liver. GCS 7.	5 months	Gastrostomy feeding, nil by mouth.

Table II. Baseline swallowing status from pre-treatment videofluoroscopy.

Participant	Baseline swallowing status (videofluoroscopy)
	Stimulus	Penetration–aspiration scale scorea	Vallecular residue scoreb	Pyriform sinus residue scoreb
1	Thin	8	2	2
	Spoon-Thick	8	2	2
2	Thin	8	0	2
	Spoon-Thick	5	0	2
3	Thin	8	1	0
	Spoon-Thick	5	2	1
4	Thin	7	2	1
	Spoon-Thick	1	2	2
5	Thin	8	1	0
	Spoon-Thick	1	1	0
6	Thin	8	2	1
	Spoon-Thick	8	3	1

aPenetration–aspiration was rated using the 8-point Penetration Aspiration Scale (Rosenbek et al., 1996) in which a score of 1 reflects normal swallowing safety, a score of 2 indicates high penetration of the supraglottic space with subsequent ejection, scores of 3–5 indicate laryngeal penetration, and 6–8 indicate aspiration of material below the true vocal folds.

bResidues in the valleculae and pyriform sinuses were rated using a 4-point ordinal scale described by Eisenhuber et al. (2002) in which 0 = no residue, 1 = thin coating, 2 = 25–50% full, and 3 ≥ 50% full.

Figure 1. Flow-chart of a tongue-pressure strength and accuracy training session.

Figure 2. Control charts showing progress in anterior maximum isometric tongue–palate pressures over the course of therapy. Dashed horizontal lines indicate a moderate effect size band around baseline performance, used as a threshold to determine whether there was evidence of change in the form of at least three consecutive data points exceeding the effect size band.

Table III. Baseline measures of tongue strength (means and standard deviations) calculated over the first three treatment sessions, with 12 repetitions of each task per session.

Participant	Baseline MIP (KPa)
		Anterior	Posterior
1	Mean	28.4	26.6
	SD	2.7	3.6
2	Mean	43.5	26.8
	SD	7.5	5.2
3	Mean	23.7	17.2
	SD	5.7	5.1
4	Mean	41.9	21.4
	SD	3.8	2.6
5	Mean	28.4	23.3
	SD	9.2	7.6
6	Mean	32.4	20.3
	SD	8.6	9.1

Figure 3. Control charts showing progress in posterior maximum isometric tongue–palate pressures over the course of therapy. Dashed horizontal lines indicate a moderate effect size band around baseline performance, used as a threshold to determine whether there was evidence of change in the form of at least three consecutive data points exceeding the effect size band.

Figure 4. Control charts showing progress in saliva swallowing pressures over the course of therapy. Dashed horizontal lines indicate a moderate effect size band around baseline performance, used as a threshold to determine whether there was evidence of change in the form of at least three consecutive data points exceeding the effect size band.

Table IV. Post-treatment swallowing outcomes from videofluoroscopy, by participant.

Participant	Stimulus	Penetration–aspiration scale scorea	Vallecular residue scoreb	Pyriform sinus residue scoreb
1	Thin	5 (improved)	2 (unchanged)	3 (worse)
	Spoon-Thick	5 (improved)	3 (worse)	3 (worse)
2	Thin	1 (improved)	2 (worse)	1 (improved)
	Spoon-Thick	1 (improved)	2 (worse)	2 (unchanged)
3	Thin	8 (unchanged)	2 (worse)	0 (unchanged)
	Spoon-Thick	3 (improved)	2 (unchanged)	0 (improved)
4	Thin	2 (improved)	2 (unchanged)	2 (worse)
	Spoon-Thick	2 (worse)	3 (worse)	3 (worse)
5	Thin	4 (improved)	2 (worse)	1 (worse)
	Spoon-Thick	8 (worse)	2 (worse)	0 (unchanged)
6	Thin	4 (improved)	2 (unchanged)	1 (unchanged)
	Spoon-Thick	1 (improved)	3 (unchanged)	0 (improved)

Roman text in the table reflect a functional swallowing improvement in comparison to the pre-treatment videofluoroscopy, while italics reflect no noticeable change and underlined text indicates deterioration in function for that bolus/parameter combination, relative to the baseline evaluation.

aPenetration–aspiration was rated using the 8-point Penetration Aspiration Scale (Rosenbek et al., 1996) in which a score of 1 reflects normal swallowing safety, a score of 2 indicates high penetration of the supraglottic space with subsequent ejection, scores of 3–5 indicate laryngeal penetration, and 6–8 indicate aspiration of material below the true vocal folds.

bResidues in the valleculae and pyriform sinuses were rated using a 4-point ordinal scale described by Eisenhuber et al. (2002) in which 0 = no residue, 1 = thin coating, 2 = 25–50% full, and 3 ≥ 50% full.

Rosenbek, J. C., Robbins, J. A., Roecker, E. B., Coyle, J. L., & Wood, J. L. (1996). A penetration-aspiration scale. Dysphagia, 11, 93–98.

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Eisenhuber, E., Schima, W., Schober, E., Pokieser, P., Stadler, A., & Scharitzer, M. (2002). Videofluoroscopic assessment of patients with dysphagia: Pharyngeal retention is a predictive factor for aspiration. American Journal of Roentgenology, 178, 393–398.

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