Evidence-Based, Optimal Strength Exercise

Parameters: Practice Considerations for

Speech Therapists

Mark Richards, PT, MS, CEEAA

Vice President of Clinical Services
Accelerated Care Plus

markprichards@comcast.net
office phone: 763-208-7263
 Disclosures
I have relevant financial relationship(s) with the products or
services described in this presentation as I am an employee of
Accelerated Care Plus, Inc., Reno, NV.

ACP manufactures 2 products that are indirectly referenced in

my presentation: Omniband® (elastic bands) and Synchrony™
(a surface EMG assessment and exercise system).

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 Session Schedule
• THE PROBLEM OF WEAKNESS IN SPEECH THERAPY PATIENTS
• BRIEF REVIEW OF LITERATURE: S.T. STRENGTH EXERCISE
• S.T. STRENGTH EXERCISE NEEDS & RECOMMENDATIONS
• OPTIMAL STRENGTH EXERCISES & PARAMETERS
• DOCUMENTATION OF STRENGTH EXERCISE
• EXERCISE DEMONSTRATION
• EXERCISE LAB
• Q&A

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THE PROBLEM OF MUSCLE WEAKNESS
Speech Therapy Patients
 Weakness – ST Correlations
Reductions in 1. Neural activation and, 2. Muscle force output
are correlated to functional deficits commonly addressed by
speech therapists:

– Oral motor function:

• Dysarthria
• Bolus preparation
• Bolus management

– Pharyngeal phases of swallow

– Voice production and support

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 Average Loss of Strength
Across Lifespan
• Age 30 to 50 -  1/2 # mm per year
(Evans and Rosenberg, Biomarkers 1992)

• Age 50 -  1 # mm per year

(Nelson, et al, JAMA, 1994)
• Deposition of fat

• Losses of muscle strength

– 60’s and 70’s – 15% each decade
– 80’s and 90’s – 30% each decade
(Med Sci Sports Ex, 1998)

• Muscle atrophy AND neural decay

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 Sarcopenia
CT Scans: Mid-thigh
Donna

24 year old 64 year old

• Occurs throughout the body including oropharyngeal mm.

• Greater loss of Type II fibers (motor neurons and fiber size)

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 Muscle Fiber Types
• Type I
– Aerobic (oxidative system)
– Slow Twitch
– Weaker but fatigue resistant

• Type II (IIa, IIb, IIc)

– Anaerobic (alactic & creatine phosphate energy systems)
– Fast Twitch
– Stronger but fatigue more readily

• Percentage of fiber types in each muscle to varies by location

in the body (strength vs. endurance demands/ requirements)

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Weakness - Averages

Leg Strength
 Weakness: Oropharyngeal
Muscle weakness directly affects these functions:
• Oral Motor Function
• Oral Phases of Swallow
Dysphagia (MANY. MOST?)
• Pharyngeal Phases of Swallow

In older adults, swallows are typically characterized by a delay

between the time of bolus entry into the pharynx and hyoid
descent, allowing the bolus to be adjacent to an unprotected airway
for a precarious moment.”
(Kays S, Seminars in Speech and Language, 2006)

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Weakness: Posture & Function
Muscle weakness contributes to poorer posture and indirectly
affects these functions:
• Respiration

• Voice production

• TMJ position and function

• Swallowing (degree?)

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 Causes of Muscle Weakness
• Natural aging
– Hormonal decrements leading to:
– Neural decrements
– Histological decrements

• Inactivity
– Lifestyle
– Illness and chronic impairments

• Neuromuscular diseases

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 Neural Decrements
• Alpha motor neuron death (corticospinal) and loss of mm. fibers
(Larson and Ansved, Prog Neurobiol 1995)

  afferent input & motoneuron excitability (mm. tension, ROM,

etc.) and decreased ability to sense degree of effort
(Corden and Lippold, J Neurophysiol, 1996)
(Thelen, et al; J Gerontol Med Sci, 1998

• Decreased force-frequency response and firing rates; slower

and less coordination
(Narci, et al; J Appl Physiol, 1991)
(Laidlaw, Bilodeau, Enoka, Muscle Nerve, 2000)
(Erim, Journal of Neurophysiology, 1999)

• Increased coactivation of agonists/antagonists

(Macaluso, et al; Muscle Nerve, 2002)

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 Histological Decrements
• Fiber mass – motor fiber atrophy and death
– Largest contributor to strength loss
– Increased motor neuron span of control
(Larsson and Kaulsson, Acta Physiol Scand 1978)
(Newman, et al; JAGS, 2003)
– Adoption by slow twitch motor neurons

• Fiber ratios
(Bellew, Issues on Aging 1998)

• Decreased ability to produce force rapidly

(Izquierdo, et al; Acta Physiol Scand, 1999)

• Reduced muscle fiber specific tension

(Larson and Frontera, Am J Physiol, 1999)

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BRIEF REVIEW OF LITERATURE
Speech Therapy Strength Exercise
 ST Strength Research
Investigations have included the following
S.T. strength exercises:

• Oral motor, such as

– Lip closure
– Biting
– Tongue pressure

• Pharyngeal, such as
– Effortful swallow
– Mendelsohn maneuver
– Shaker (head lift)
– Chin tuck against resistance
– Resisted expiration

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Muscle Strengthening Benefits
Increasing muscle performance has been shown to:
• Increase lingual isometric strength and volume with
carryover into greater dynamic swallow pressures

• Decrease laryngeal vestibule penetration, tracheal

aspiration, and pharyngeal residue

• Improve hyoid range of motion including elevation, anterior

excursion, and upper esophageal sphincter opening

• Enhance bolus clearance, reduce aspiration and lead to

less restrictive diet

(Kays S, Seminars in Speech and Language, 2006)

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SPEECH THERAPY STRENGTH EXERCISE
Needs & Recommendations
 ST Strength Exercise Needs
“Presently, a gold standard does not exist for the most optimal
prescription for the majority of treatment options.”

Sapienza, Exercise Prescription for Dysphagia: Intensity and

Duration Manipulation, ASHA Perspectives

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 ST Strength Exercise Needs
“The principle of overload holds that in order to increase the force-
generating ability of a muscle, that muscle must be taxed beyond its
current capacity to respond. That is, it must be exposed to a load
greater than what it is typically exposed to on a daily basis.”

Wheeler-Hegland, Submental sEMG and Hyoid Movement during

Mendelsohn Maneuver, Effortful Swallow, and Expiratory Muscle
Strength Training, Journal of Speech, Language, and Hearing
Research, 2008

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 ST Strength Exercise Needs
A case control study of patients receiving swallow therapy
demonstrated that progressive resistive boluses may result in
superior clinical outcomes compared to using a bolus of the same/
constant resistance bolus

The methods included lower repetitions for the progressive

resistance bolus compared to high repetitions for the constant bolus

Carnaby-Mann, McNeill Dysphagia Therapy Program (MDTP): A

case control study. Archives Physical Medicine Rehabilitation, 2010

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 ST Strength Exercise Needs
Specific exercises recommended to improve voice production
include:
•Neck retractors

•Infrahyoid group

•Neck flexors

•Scapular retractors

Wilson Arboleda, Considerations for Maintenance of Postural

Alignment for Voice Production, J Voice, 2008

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 ST Strength Exercise Needs
• What lessons learned can we borrow from the thousands of
strength training RCTs involving healthy and morbid
subject populations?

• Further more, how may these lessons be applied in a

clinically practicable manner:
– Time-efficient
– Realistic modes of delivery
– Safely
– Good patient compliance/ willingness

• With the ultimate goal being enhanced therapy outcomes

delivered in less time

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 Strength Exercise Research
Summary Slide
• Hundreds of studies published in peer reviewed journals
STRONGLY demonstrate the effectiveness and safety of
strength exercise. This includes a preponderance of
studies with methods that included high intensity
protocols.

• There are no reports of any serious injuries or serious

exacerbations of medical conditions in response to
strength exercises. These findings include studies that
have investigated the impact on subjects with specific
diseases.

• The list of organizations that formally RECOMMEND

strength exercise as essential to health and function
is impressive

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Strength Exercise Advocates
• World Health Organization
• Centers for Disease Control & Prevention
• U.S. Department of Health and Human Services
• National Institutes of Health
• National Institute on Aging
• UK National Health Service
• American College of Sports Medicine
• American Geriatrics Society
• American Family Physicians
• American Medical Association
• The Cleveland Clinic
• Johns Hopkins
• Mayo Clinic
• and furthermore, disease-specific organizations

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Strength Exercise Advocates
• International Osteoporosis Foundation
• Osteoarthritis Research Society International
• Arthritis Foundation
• American Heart Association
• American Association of Cardiovascular and Pulmonary
Rehabilitation
• American Academy of Orthopedic Surgeons
• American Stroke Association
• National Multiple Sclerosis Society
• National Parkinson’s Foundation
• National Kidney Foundation
• American Diabetes Association

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Strength Exercise Physiologic Effects
• Recruitment and motor learning
(Fiatarone, JAMA 1990)

• Synchronization and motor control

(Patten, Topics Geriatr Rehab 2000)

• Swallow exercise, activation of/

increased reliance on supplemental

Strength
brain regions

• Fiber hypertrophy and  muscle

mass
(Lexell, Topics Geriatr Rehab, 2000)
1 2 3

• Enhanced agonist/antagonist co- Time (months)

activation and neuromuscular
coordination (i.e., timing)
(Gabriel, Sports Med, 2006)
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 Summary of the Evidence
• It is relatively easy to generate strength gains in weakened
patients of all ages

• Generally, weakened patients strengthen quickly

(Evans, 1999 - 10-15% gains per week for first 8 weeks)

• The weaker the individual, the more functionally meaningful

the strength gain

• The more disabled the individual, the more strength gains

positively impact quality of life

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 Absolute Contraindications
• Open and/or healing trachs (Shaker)
• Airway obstruction
• Recent fractures (unstable)
• Advanced CHF
• Cancer (tumors in target area)
• Recent, unstable MI
• Acute illness
• Acute inflammatory neurological disease

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Exercise Termination Criteria
• ONSET OR WORSENING OF THE FOLLOWING:
– Onset of angina
– Blood pressure changes as outlined
– Lightheadedness
– Confusion
– Ataxia
– Palor
– Cyanosis
– Cold and clammy skin
– Noticeable changes in heart rhythm

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OPTIMAL STRENGTH EXERCISES
& PARAMETERS
 Isometric
Isometric: Muscle contraction where joint angle and muscle
length do not change. Contractions held from a few to several
seconds.

Examples of Speech Therapy Isometric Exercises

• Lip press (closure)
• Lip protraction/ retraction
• Tongue pressure
• Bite
• Mendelsohn Maneuver
• Shaker (3, extended holds)
• Chin tuck against resistance (CTAR: ISO-SED, inflatable
rubber ball)

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 Isotonic (“Isokinetic”)
Isotonic: Muscle contractions that generate dynamic joint
movement and includes shortening and lengthening of the
muscle tissue. Muscle tension remains relatively constant.

Examples of Speech Therapy Isotonic Exercises

• Shaker (repeated head lifts)
• Mastication exercise
• Resisted tongue movements
• Jaw opening against resistance
• Effortful swallow
• Resisted expiration
• Cervical movements (flexion, extension)

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 Optimal Strength Exercise
Parameters
• Exercise Intensities
– High
– Moderate

• Repetitions, Sets & Frequency

• Progression and Documentation

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 Keys To Strength Exercise:
1. Intensity
• Classic Study: David Buchner
Topics In Geriatric Rehabilitation 1993

• Meta analysis: Effect sizes

(standardized difference between means)

• Why did aged subjects get stronger?:

- Frequency:  statistically significant
- Duration:  statistically significant
- Intensity: AHA! (p<0.001)

• The American College of Sports Medicine “Position Stands”

include similar intensity (and exercise) recommendations for
individuals of all ages
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Exercise Intensities

∞
Repetitions
 Exercise Intensities

Strength Exercise Aerobic Exercise

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∞

Possible, Unlikely for Most,

Inefficient
 High Exercise Intensity
WHY?
• Greatest strength gains
• Shortest period of time
• Longest lasting strength gains if/ when exercise is stopped

“Hard” “Somewhat hard”

8 12

80% of 70% of
maximum maximum
(likely) (likely)
 Moderate Exercise Intensity
WHY?
• Starting PRE’s, to gauge exercise response
• When exercising the cervical spine

“Somewhat hard” “Fairly light”

12 20

70% of 50% of
maximum maximum
(likely) (likely)
 Exercise Intensities: Subjective
• Determining subjective exercise intensities:

– No need to perform 1 Rep Max test

– Choose an amount of resistance you think:
• Your patient can complete the minimum rep target
number
• But not more than the maximum rep target

Example, 8 to 12 reps (high intensity or 70% to 80% of max): choose

an elastic band resistance (color) you think the patient is likely to
complete at least 8 good quality repetitions but not more than 12

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 Exercise Intensities: Subjective
• Determining subjective exercise intensities:

– Does your patient/ client have a look of

concentration?

– Borg Scale: AFTER 2nd REPETITION ASK,

• High: 8 – 12 reps: “somewhat hard” to
“hard”
• Moderate: 12 – 20 reps: “fairly light” to
“somewhat hard”

– Mild tremor

– Respiration increases slightly

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 Calculating % of Max. Effort
• Determining objective exercise intensities:

– Doable with any exercise for which objective performance

data or resistance can be objectively determined

– Surface EMG (percentage of muscle activity during

repetition test trials)

– Manometer (pressure measurement; e.g. expiratory lung

pressure, Iowa Oral Performance Instrument [IOPI],
Madison Oral Strengthening Therapeutic Device [MOST])

– Isotonic machines (e.g. Nautilus Cervical)

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REPETITIONS, SETS & FREQUENCY
 Repetition Performance
• Every repetition should be high quality: speed, ROM,
form, and breathing
• For our OT and PT colleagues, Therapeutic Exercise,
CPT code 97110, is a directly attended code requiring
a therapist’s undivided attention
• Observe every repetition and correct patient when
needed. Stop the set of exercise when the patient
cannot self-correct poor rep performance:
- Moves too quickly
- Incomplete ROM
- Poor form (substitution)
- Holds breath

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 Repetition Performance
• Do not tell patients how many reps to do

• As discussed, stop set when despite your cues

and instructions for the patient to improve
repetition performance, he/she cannot self-correct
and has to ‘cheat’ to continue

• Document the last, properly performed rep

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 Set Performance
• How many sets of multiple repetitions?

– Traditional - 3 Sets

– Research shows that excellent strength

gains are achieved by performing one set
of exercise

– Some studies show that two or three sets may generate

greater strength than one set but a single set should be
used when exercise time is an issue. Quality, not
quantity.

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Strength Exercise Frequency
Rest days are required for muscles to grow and are
increasingly important the longer the training period

• Therapy:

- At least 2 to 3 times per week

- Because average therapy LOS is 4 to 6 weeks, and this is

the neural adaptation time zone, daily?

- Spinal musculature: Perhaps one set to momentary

fatigue, 1x per week?

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 Endurance?
• Are high repetitions required to improve functional muscle
endurance? Perhaps not.

• In addition to Type II fibers, high intensity, low repetition

resistance exercise engages fatigue-resistant Type I fibers
and improves functional endurance:

- Time to exhaustion improved 47% for cycling and 12% for

running in healthy men in response to quad strengthening
(Hickson RC, et al, Med Sci Sports Exer, 1980)

- Walking endurance in aged subjects increased 38%

(Ades PA, et al, Ann Intern Med 1996)

- The initial goal of a training program to enhance muscular

endurance should be to increase maximum strength
(Naclerio, J Strength Cond, 2009)

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 Keys To Strength Exercise:
2. Progression
In order for a muscle to continue to strengthen, the resistance
applied must be increased as the muscle becomes stronger.
Therefore:

• Isometrics: A stronger muscle contracts more forcefully so

inherently, resistance is progressed if the exercise rating of
perceived exertion remains constant

• Isotonics: Switch to more resistive elastic band (different color) as

muscle strength increases

• Percentage of 1RM: A stronger muscle contracts harder so

inherently, resistance is progressed if the patient continues to
exercise at the same percentage of a 1 RM

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 Progression of Resistance
• As muscles strengthen, steady
increases in resistance are
REQUIRED for muscle strengthening
to continue

• When to increase isotonic exercise

resistance?

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 Progression of Resistance
• When patient can perform good quality repetitions equal to
the upper repetition target number for the desired intensity

• Normally, using the same resistance, the number of

repetitions a patient can perform increases during
subsequent treatment sessions

12 20

8 – 12 12 – 20
High Moderate to
High
 Progression? CTAR Exercises
• Issues:
– Shaker too difficult or uncomfortable
for some patients to perform

– Shaker: Once 3 repetitions of 60” hold

time accomplished, no longer a
progressive resistive exercise

– Exercise apparatus may also have

fixed, non-progressive resistance

• Solution?: Elastic bands?

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Isometrics: Recommendations
Optimal Isometric Exercise Parameters

• “Hard” intensity

• Six second hold, each repetition

• Ten repetitions

• Breathe (Mendelsohn Maneuver the exception)

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Isotonics: Recommendations
Optimal Isotonic Exercise Parameters
• Elastic resistance

• Identify appropriate resistance band (color) per as outlined

per desired exercise intensity

• Have patients exercise to momentary fatigue while moving

slowly, through the fullest available ROM, with good form
and technique without holding their breath

• Switch to next, more resistive band (color) as strength

increases

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DOCUMENTATION OF STRENGTH
EXERCISE
 Exercise Termination Criteria
• MUST track for each exercise:
– Exercise description
– Comments, special patient cues, important observations
– Date
– Resistance
– Repetitions

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 Document Progress
EXERCISE DATE 2/4 2/6 2/8 2/11 2/13 2/15 2/18 2/20 2/22 2/25

1.Chin Tuck Against Elastic Resistance RES

Y Y R R R G G G G B
Patient cued to sit up right, move slowly, and
touch chin to sternum for each rep.

17 21 14 19 22 13 18 19 23 15
REPS

2. RES

REPS

3. RES

REPS

4. RES

REPS

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 Progress Notes
Correlate strength gains to functional status citing objective measures.
Example:

“Patient has increased CTAR against elastic resistance 2 band colors

and is now able to perform 9 typical (normal) swallows with nectar thick,
10ml bolus before demonstrating double swallow vs. 3 reps 1 week ago.
See PRE flow sheet for exercise details”

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STRENGTH EXERCISE DEMONSTRATION
STRENGTH EXERCISE LAB
 Lab: Do One or Both
1. Chin Tuck Against Resistance
– Benefits: Increased hyolaryngeal motion and increased
UES opening
– Mode: Elastic resistance
– Intensity: Moderate
– Repetitions: To momentary fatigue
– Sets: 1

2. Scapular Retraction
– Benefits: Improves head-on-neck posture (kinetic chain)
to facilitate better voice production
– Mode: Elastic Resistance
– Intensity: High
– Repetitions: To momentary fatigue
– Sets: 1

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 Session Schedule
• THE PROBLEM OF WEAKNESS IN SPEECH THERAPY PATIENTS
• BRIEF REVIEW OF LITERATURE: S.T. STRENGTH EXERCISE
• S.T. STRENGTH EXERCISE NEEDS & RECOMMENDATIONS
• OPTIMAL STRENGTH EXERCISES & PARAMETERS
• DOCUMENTATION OF STRENGTH EXERCISE
• EXERCISE DEMONSTRATION
• EXERCISE LAB
• Q&A

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QUESTIONS & ANSWERS

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Copyright, Mark Richards 2014 Illustration courtesy of NovaCare, Inc.