Scribd Logo
Upload

Welcome to Scribd!

  • Dose in Exercise-Based Dysphagia Therapies - A Scoping Review - Enhanced Reader

    Uploaded by

    Luis Cortes
    62 views32 pages

    Original Title

    Dose in Exercise-Based Dysphagia Therapies_ A Scoping Review _ Enhanced Reader

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    Download as pdf
    62 views32 pages

    Dose in Exercise-Based Dysphagia Therapies - A Scoping Review - Enhanced Reader

    Uploaded by

    Luis Cortes

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    Download as pdf
    of 32
    Dysphagia (2021) 36:1-32 httpd org/10.1007/500455-020-10104-3, REVIEW ® Dose in Exercise-Based Dysphagia Therapies: A Scoping Review Brittany N. Krekeler’?© - Linda M. Rowe’? Nadine P. Connor!? Received: 11 October 2019 / Accepted: 25 February 2020 / Published online: 5 March 2020, © Springer Science Business Medi, LC, part of Springer Nature 2020 Abstract Background Optimal exercise doses for exercise-based approaches to dysphagia treatment are unclear. To address this gap in knowledge, we performed a scoping review to provide a record of doses reported in the literature. A larger goal of this ‘work was to promote detailed consideration of dosing parameters in dysphagia exercise treatments in intervention planning and outcome reporting. Methods We searched PubMed, Scopus[Embase], CINAHL, and Cochrane databases from inception to July 2019, with search terms relating to dysphagia and exercises to treat swallowing impairments, Of the eligible 1906 peer-reviewed articles, 72 met inclusionary criteria by reporting, at minimum, both the frequency and duration of their exercise-based treatments. Results. Study interventions included tongue exercise (n = 16), Shakerfhead lift (n= 13), respiratory muscle strength training (n= 6), combination exercise programs (n = 20), mandibular movement exercises (n = 7), lip muscle training (n = 5), and other programs that did not fit into the categories described above (n = 5). Frequency recommendations varied greatly by exercise type, Duration recommendations ranged from 4 weeks to 1 year. In articles reporting repetitions (n = 66), the range was 1 to 120 reps/day. In articles reporting intensity (n = 59), descriptions included values for force, movement duration, or descriptive verbal cues, such as “as hard as possible.” Outcome measures were highly varied across and within specific exercise types. Conclusions We recommend inclusion of atleast the frequency, duration, repetition, and intensity components of exercise dose to improve reproducibility, interpretation, and comparison across studies. Further research is required to determine ‘optimal dose ranges for the wide variety of exercise-based dysphagia interventions. Keywords Scoping review - Dysphagia treatment - Dose - Evidence-based practice Introduction Exercise-based approaches have been used in dysphagia treatment for over three decades. The overall aim of these treatments isto increase the strength and endurance of mus- cle groups involved in deglutition and airway protection, 5 Britany N. Krekeler brittany krekeler@northwesten.edu Department of Communication Sciences and Disorders, University of Wisconsia-Madison, Goodnight Hall, 1300 University Ave, Madison, WI53706, USA. Department of Surgery-Otolaryngology, Clinical Science Center, University of Wisconsin-Madison, 600 Highland ‘Avenue, Madison, WI 53792-7378, USA Department of Communication Sciences and Disorders, Northwestern University, Swallowing Cross-Systems Collaborative, 2240 Campus Drive, Evanston, IL 60208, USA ‘These exercise approaches target specific muscles or rroups of muscles active in deglutition including the oral ‘musculature (maximum isometric pressure of tongue, lips, jaw), pharyngeal constrictors (effortful swallow, Masako), hyolaryngeal complex (Mendelsohn, Shaker Head Lift), and respiratory muscle complex (inspiratory and expiratory mus- cle strength training) [1]. Itis intuitive that exercise dose is an essential component of any exercise-based therapy, and understanding the relationship between dose and treatment efficacy is critical to maximizing patient benefit. As such, importance of dose in resistance exercise has been well established in the limb literature [2-6]. However, definitive {guidelines for optimal dosing in swallowing rehabilitation programs have yet to be established [7,8]. Because of critical differences that exist between skeletal muscles of the head and neck and the limb in terms of muscle structure, biology, and physiology [8I, itis important to develop exercise dose recommendations specific to deglutatory musculature and D Springer 2 B.N.Krekeler tal: Dos in Exercise-Based Dysphagia Therapies: Scoping Review not rely on prescriptions developed for limb muscles. Ree- ognizing this gap in knowledge, we reviewed the literature to explore the range of exercise doses reported in research ‘on exercise-based interventions to treat dysphagia. Scoping Review To gain perspective on reporting of exercise dose informa- tion in the dysphagia literature, we performed a scoping review, which is defined as: “{a] preliminary assessment of the potential size and scope of available research literature. It aims to identify the nature and extent of research evidence’ (p. 101) [9]. A scoping review does not require the in-depth critique of research quality typically performed in a system- review [10] and is useful for examining a particularly heterogeneous literature base. In contrast to a systematic review, a scoping review can provide a more inclusive refer- ence guide of research evidence available regarding exercise dosing. The purpose of this scoping review was twofold: 1) To provide researchers and clinicians with a record of currently reported exercise dosing in the adult and geriat- ric dysphagia therapy literature base; 2) To call attention to important components of exercise dosing that should be con- sidered in every exercise-based study and should be reported in dysphagia treatment methodology both in clinical practice and peer-reviewed manuscripts. Relationship Between Exercise Dose and Muscular Conditioning Both endurance exercise and resistance exercise have been studied in skeletal muscle and cardiorespiratory systems [11]. Endurance exercise (aerobic) can last from minutes to hours, and makes use of high-repetition actions at low resistance to maximize changes in skeletal muscle o. tive capacity [12]. Resistance exercise (anaerobic) involves high resistance training with the goal of increasing muscular ‘mass and power [12]. Endurance exercise increases signaling for mitochondrial biogenesis in muscles of the limbs with chronic exercise effects resulting in increased mitochondrial content and function leading to improved muscular capacity and fatigue resistance [13-17]. The primary goal of resist- ance exercise is to increase muscle strength by increasing muscle fiber cross-sectional area (CSA), also known as muscular hypertrophy. These increases in size occur both in young and elderly individuals with resistance exercise training [2, 18]. Depending on the goals of an exercise-based treatment program, there can be a focus on resistance training, endur- ance training, or can involve a combination of both (concur- rent training). Dysphagia exercise programs have generally focused on increasing strength, using fewer repetitions at increasing resistance; however, some exercises do involve a D Springer component of endurance (e.g. head sustained head lift exer cise) [19]. Since a majority of dysphagia exercise programs include some component of strength training, we will focus, this introductory discussion on effects of strength training, ‘on muscle biology. Muscular hypertrophy is achieved when a muscle or group of muscles contracts to resist against increasingly higher loads, above what is normally required of that par- ticular muscular system {20-22}. Increasing load challenges the muscle(s), requiring higher-threshold motor units to be activated [20-22] and promotes protein signaling to induce ‘muscular hypertrophy [23-25]. Gains in muscular strength observed after resistance exercise are due, in part, to muscu- Jar protein synthesis inereasing fiber size (hypertrophy) and number as well as other shifts in muscle fiber composition and metabolism towards a more powerful, fatigue resistant profile [26-29]. At the cellular level, among other related processes, resistance exercise can increase fiber number by inducing quiescent satellite cells to enter the mitotic eyele and differentiate to promote new myofiber development [30, 31h Mechanisms involved in muscular hypertrophy and con- ditioning with exercise are known to increase in a dose- dependent manner [6], making consideration of dose in exercise particularly important. The relationship between resistance exercise dose and muscular hypertrophy have been explored and debated in the limb literature with the goal of optimizing dose prescription to maximize strength- related outcomes [5, 6]. Relationships between training intensity and frequency have been well studied, and these findings have contributed to the American College of Sports, Medicine (ACSM) Guidelines for Exercise Testing and Prescription (9th edition) [32]. With increasing intensity of resistance exercise there is a corresponding increase in the synthesis of myofibrillar proteins [33]. Similarly, increasing resistance exercise-training frequency (number of training sets/week) is related to increasing muscular hypertrophy in a graded, dose-responsive manner [34] Other important considerations in determining dose pre- scription are training status and the risk of over-prescription. “Meta-analyses in the exercise science literature have sup- ported differences in optimal dose considerations for trained ‘ys untrained individuals (outlined below), which will impact how exercise is prescribed [5]. More importantly, incorrect dose prescription could result in over-prescription of exer- cise, which can have negative or “diminishing” effects [5, 6]. ‘These are critical factors to consider when designing a train- ing program: improper and over-training can lead to reduc~ tions in strength and can increase risk of injury [6]. As such, exercise scientists who study effects of dose-response in the limb have made the following recommendations regarding, training doses for individuals wishing to prevent age-related changes in muscle and induce muscle hypertrophy [5, 6, 32]: B.N. Krekeler tal: Dose in Exercise-Based Dysphagia Therapies: A Scoping Review 3 For untrained individuals: 60% of 1 Rep-Maximum (RM); 4 sets (I set = 8-12 repetitions); 3 days/week ‘© For trained individuals: 80% IRM; 4 sets; 2 days/week ‘© Fortrained athletes: 85% IRM; 8 sets; 2 days/week ‘These doses have been well studied and explored in mus- cles ofthe limbs and trunk, dose-response recommendations for muscles of the head and neck have not been definitively determined (1, 7]. While the work of the limb and exercise science literature can provide a starting point for developing dosing for exercise-based dysphagia therapies, structural and physiological differences between the limb vs cranial mus- culature [8] require us to explore effects of exercise dose in ‘our muscles of interest, specifically. ‘Components of Exercise Dose in Dysphagia Therapy When considering dose-related effects in exercise therapy, there are several components of dose that must be consid- cred. Depending on the type of exercise, and the muscle systems targeted imb, trunk, cranial), different terminology ight be used to describe similar components. The ACSM’s Guidelines for Exercise Testing and Prescription (9" Bai tion) lists 9 components of exercise: frequency, intensity, time (duration), type, repetitions, sets, patter (rest inter vals), and progression. We combined items on this list into four components of exercise dose that are relevant and nee- essary in a dysphagia treatment prescription (represented in Fig. | and described below): Frequency (frequency, sets), Repetitions, Intensity, Duration [32]. Repetitions are defined as the number of actions per- formed in one set ofa specific exercise maneuver. For exam- ple, 10 lingual presses or 40 effortul swallows constitutes the number of repetitions of an action. Frequency defines how many of “sets” of exercise are performed in one day or session, and how many days of exercise per week are prescribed. One “set” of exer- cise is defined by the number of repetitions in the set. Determinants of Dose Intensity Repetitions Frequency 6 Max Length of hold sets / day ys / week Duration coq Pram Fig.1| Determinants of dose in dysphapia specific exercse-based interventions For example, exercise prescription could include perfor- ‘mance of 3 sets of 10 lingual presses per day for 3 days per week. This translates into the patient performing 30 lingual presses per day (in each of 3 sessions) and thus 90 presses total per week. The amount of rest between individual repetitions has not been well defined, nor has the optimal number of total sets recommended for perfor- ‘mance in one day. In the exercise science literature, sets per day are used to break up the number of repetitions of an action performed to allow for periods of rest. The ACSM recommends between 2-3 min for rest between sets (32]. However, other than the Shaker exercise, there are no current guidelines regarding proper rest between sets of other exercises to treat dysphagia [1]. Given the limited research and reporting on this topic, we did not include rest as a dosing component in this review. How- ever, it should be considered in future studies of dysphagia exercise. Intensity reflects the amount of effort or force exerted during a single repetition of an exercise. This can be meas- ured by percentage of a maximum amount of effort, if, using a device-facilitated approach, or a more descriptive criterion, such as “press has hard as you can” or “using ‘maximum amount of effort.” For an isometric exercise, length of hold can serve as a definition of intensity. While having a device-facilitated program will most accurately capture intensity, providing participants with a qualitative description of level of intensity is an acceptable way of ensuring successful execution of a specific strengthening Duration of the exercise program is the total length of the exercise program, and can be defined by a number of sessions, weeks, months, or other similar metric. The dura- tion also represents the final endpoint at which patients can be expected to see measurable, clinical improvement in function. The exercise science literature recommends between 8-12 weeks for progressive resistance training programs [2]. However, the optimal duration for exercise treatments for dysphagia have not been determined. With- out defining a specific program duration, clinicians and researchers are unable (o compare program outcomes or define an end point for expected clinical improvement. ‘We considered these components as basic dosing parameters during our scoping review for ensuring repro- ducibility of exercise conditions. In this review, we aimed to highlight study parameters of frequency, repetition, intensity, and duration of clinically relevant exercises to allow comparison across articles. While interpreting the specific effects of swallowing exercises was beyond the scale of the current study, we reported the primary out- comes and statistical findings to summarize the existing evidence of treatment effects on swallow-related outcomes for each individual study. D Springer 4 B.N.Krekeler tal: Dos in Exercise-Based Dysphagia Therapies: Scoping Review Methods for Sco) 9 Review ‘This scoping review was performed with the assistance of ‘wo librarians (SJ, MC). We searched 4 databases (PubMed, ‘Scopus[Embase], CINAHL, Cochrane, Fig. 2) with search terms customized for each database, and included variations of Dysphagia, Deglutition disorders, Swallowing disorder, Shaker exercise, Mendelsohn maneuver, Masako exercise, ‘Tongue hold, Effortful swallow, Protective airway maneu- ver, Tongue pressure resistance, and Iowa Oral Performance Instrument, among others (please see “Appendix” for full listing of MeSH terms). The literature search in this study was limited to peer-reviewed publications in the broad area of exercise treatment of adults with dysphagia that were published on or prior 7/2019, No other study design criteria ‘were employed for the literature search, in accordance with generally accepted scoping review methodology [9]. ‘All 1906 citations were reviewed by both the first and sec- ond author (BNK, LMR). Criteria for inclusion inthe review were broad and focused on any exercise-based intervention used to treat adult dysphagia from any primary etiology. We also included articles trialing exercise therapies in healthy adults without dysphagia. To meet final inclusion criteria for dosing specifications, articles had to report at least the ‘Srequency and the duration of exercise. Articles that reported detailed information on all four components of dose were considered to be “gold standard” articles and are noted in the tables (see “Results"). Full text articles not available to us were excluded from review. Articles were not included if the resistance exercise treatment was supplemented with aan additional stimulation treatment (e.g., neuromuscular Pobiied ‘Scopus Nat Cocvane (339) (646) (160) (on) Duplcatons| Removed (656) Graton Retrieved (3906) Final studies Tecuded 3) Fig.2. Flow chart demonstrating abstract search and review D Springer stimulation, thermal or gustatory stimulation techniques) because stimulation involves a different dosing mechanism than exercise alone. However, for articles that compared the effects of neuromuscular stimulation to @ non-stimulated exercise condition, data from the exercise-only group were included in our final results. Articles were excluded from review if they reported exercise interventions lasting less than 4 weeks, did not involve a resistance exercise com- ponent (¢.g., range of motion or passive manipulation), reported on single case studies only, or small case series (n< 10). Optimal durations for exercise treatment programs have not been well defined in limb or cranial muscles [1, 32], and thus we chose a 4-week minimum treatment duration to allow inclusion of respiratory muscle training programs, which are usually 4 weeks in length [35]. Data abstraction was performed for all included articles by both the first and second author (BNK, LMR). Data regarding dosing recommendations (frequency, intensity, repetitions, duration), populations studied, and exercise- ‘based treatment effects on primary outcome(s) with reported statistical findings (p values) were recorded and are repre- sented in Tables 1, 2, 3, 4,5, 6, and 7. Throughout abstract review and data abstraction, if there was disagreement, the first and second author reached a consensus. Exercise Type and Study Population Articles were grouped into tables based on the type of exer- cise program: (Table 1) 20 articles reporting combination exercise pro- ‘grams (2 or more specific exercise approaches) (36-55] (Table 2) 16 articles reporting tongue exercise [5671] (Table 3) 13 articles reporting head lift (Shaker) exercise [72-84] (Table 4) 6 articles reporting respiratory muscle strength training (RMST) [85-90] (Table 5) 7 articles reporting mandible exercises [91-97] (Table 6) 5 articles reporting lip muscle training [98-102] (Table 7) 5 articles reporting other programs (e.g., Phar- yngocise) [103-107] ‘Components of dose reported were variable within an inter- vention type, especially for combination exercise programs, Of all 72 articles that met inclusion criteria, 79% met “gold standard” criteria by including all four components of dose. ‘The majority of articles included healthy participants (24%), B.N. Krekeler tal: Dose in Exercise-Based Dysphagia Therapies: A Scoping Review Buyer dooscuonyoopia, (sia) aye9g eos, Yang 1o90>4 upg per wo3se15 sooo=d roma siro=d reuonoung soo=d rwoonary ZOO 4 — youssass8 ID ‘aavaw) ‘Aaoquaeu eeudsig uospuy GW {1a 259e sqtou zy word ssn qi Od aumwado Twosd ——adudaeydooty word wr opera Hou Suump 33006 oy eon, avout No LLo'seo'Le0=4 “ 0L0'sz00"1L00=4 seq anzu01 soo 21098 2098 9g0=4 wonedse wonensuag “kdoasoaonyoopt wos} sowo2IN9) -aronnsod suo ¢ 18 19M0] sem 2009 owesuas sngoiD, sou 400 pul PEOH, sso yo0u PUP PESH sso yoo pur PED tied (S000) dewey oa (002) ww99i0 (al sym g Suunp sy28 9a oud sy20% 1 sod sinuous ¢ sa (3002) WeHED. RID e1 0H sam Z 1 in ‘ (ont20}0 Saunp) uous f=¢-1 x x fosnnodss pe ours) 0¢ = yeUS og = someus, Xx = wyosPpUELY 1 = noneas rguou = prow anu0y, panyssep ¢ Sms 4 X= soos eases X= Pus panysiep ¢ Seppx 6 (9ewoaino Kew otpms (sQuonendog “equine won (raf) sown ay open suognoday Kouonbaig (4) $9. ‘suresSoud asosox9 wonewiquoD 1 >/geL D Springer B.N.Krekeler tal: Dos in Exercise-Based Dysphagia Therapies: Scoping Review 8 motes sare, 240 ee 039, 8 zo0=¢ swohed jo afeivaaie sro=d oped SeoqTong ywsunean sod guow swaned sou YOU pur PEE, sou yoo pe peor {sel (110 ue, (eel (102) wosmanoyy sunuow ¢ 190d sino0Kr 11a coy sod y95m yoaTury SE = myos}>puayy f= PTUs of = soul anuoy, of = wars nod on, "= Bny-2-3n a1 od 2200 = wyosapuoyy "ur umop dors a0 da [ee] sqpuow z+ ow — ez g=npe-RMI OL = NUON seoo=d — das)a8unyprorc, sours yo0u pur peo Eta) HEN, swan Sung ‘Sor = Sun, ‘01 = 20805 . ‘morTens + wonessye Hos eeu (wonEA3)2 snducy + moyen mp20y) z dno jo asitana pauisse tel 8 ora jo dno yanystep { coro=d Sere (e100) #19 samy ruoys) tno sndsuonnadsugr epee exqun wonE (yentes.d —_(Semosino Smug parpms s)uoMeINdog —_UPaA) JomME I owen Sasuonay suonnadey! ouonbarg_ () $9, (onus) 1 rae b S a B.N. Krekeler tal: Dose in Exercise-Based Dysphagia Therapies: A Scoping Review wo guais ou = d soo>d 6 1 7 (8002 1819 Bung), 19S $SIA MON, axons (e102) 30 sow z x Looo=d —asoud praucreug stot erosd —-aedun oseyd jg, feos Kianas lot] sod stpuout ¢ ssuonduosop 6TO=4 — swoamnowseydsiqy sooue yooupuE pe — (L107) SuSSPY PUP. YD SuNG] 30 891 TR 295 . 1a ARID Wod siqUOW Ey deonpuy wisoyds (el suonduosep of = 0m «eoo=4 o> spoue) PON ue pea (8102) rweusUE spon g 39} 89) TnY 295 QT = 204m . oro=d eatauns seo6-z Prey anye suwow 9 04 sis 8 €-2 = myOsiapUON -oueip Woy 1aEON (sel sod sqiuou ¢ panyscup 1 Od _uruny) sso] 143!9 JOUR YSOU PUR Pra (LIOR) ZoqHY pur LY Sung, pz 20) 2peiq 8 surese ‘anuoy ysnd = aout sal onfuoy, SI ploy pur ayqissod st ay oy = 2nduo, 102s ofeas ls] se puoixe = worlow 49} osasaxa aoursisoq Ee0=d uorwadse wontenousg —so0uro yoou pue peor (6102) 3a som jookury X= sesi0109 WOH . Appx £00 Jog “SMOITENS 09 peat 2109s apeas sed—zonead So0>d wonweadse wonenaweg wiBeydshp omadaanaN sm x tes paras, sequin wore (Santer d —_(SJamosino Krew porpms (sjuoneindog ——_(weaA) Jouine ST uwoneana Susu suopnadsy _Kouanbaiy (4) 89. (onus) 1 rae D Springer B.N.Krekeler tal: Dos in Exercise-Based Dysphagia Therapies: Scoping Review E00 =a peBuKsHJ0 2 9 sor9=d -towgns 5024 uossiox9 yodu cero=d —jouosayop puosss EIV0=4 un uorsnox9 joy, wso=d ovary] 28H ened AL0= 4 Ksonendsar TunorTES trl seni wos (02) 80044 p08 Zt asanatop 5 sco uosurya sypan § Senne fe seanyssep 9 100.0> 4 pours yeu pue pea (6102) aOWFUE] sean zt fom “aun won b (omnes dons mag ppm (Snonmdog —_ Gms) aT cones ssa swoonaiog Sooty (89 (pannus) Large — Gil B.N. Krekeler tal: Dose in Exercise-Based Dysphagia Therapies: A Scoping Review ‘opus snoauninaiad ped “SudnsfoKuona9pe soqjins Qn Sd uopeIpEL LF “dex woREIPeIOMDyD 279 sayy woneIpES Py ‘SIAN XL, 9909 SOU PUY PLAY INH "PEPER POF SD) sox Jo uonnoox9 so} suonoansuySusuaut 3o/pus sodA estuox9 aytdods sy 10 psp 2]ENUE EYL STEDIPUE X (Siow trl ayes aye 0 (e100) rroonuny 385m) syens fa spon es Sage Surworens to¥1 oo0> 4 jowwoussasse wR, —soANIS dN loz) FSU, spam 9 otc 0—dsinsaid onda ueoyy oydshp son OL-LV@D OL sua snptpUL isi poms ¢ soyo=d oor mous fuyjomp Kumutue 102) WsEsEgeREN, squow ¢ wessol —alersounssoy ADE aqua won (anes d_(awosino Amuag_poypns sHNoNEINdag ("a4 OMNES open Aysuo suopnadoy _foumnbard (4) $9 (onus) 1 rae D Springer B.N.Krekeler tal: Dos in Exercise-Based Dysphagia Therapies: Scoping Review 0 vous ou = uso=4 iseo=d (nai useing poe cyan) m0 A2eaeS pus peateckydoig, nos3 angen —(eondnaip wr0=49 swo=dia wr0=4:y oso=d9 Uxe0= dq “poaMsV) Asoo i — Ooo =4:y Roum ypoupue peor s2oueD HOU PUR eH ———FLOZ)STUEAT ANY sod sepIRYST aK, worsEA KOT MEIKS sas 25 o100=4 —voyendse wong zoo=d sna 1o00=4 sansoupun zo0=d aimed anny Z100=d —-s.ow prosy sousdag aad (orl eons Tep9=4 rou prosq ors wiimadigsg ——GIODIEN PANY ie ee soo>d tooe eos sore womoo} sod sdo19—souoiod poe ol ovonme = qane SOP 2 soord ayes amoeges (100 wo SR Sunouost a ae Tegan wore (Soajead —_(Sawormo Seuua —poxpas @uoperndog —_GEBK)soUNE ST —_—_uonENE yun suondoy —ovonbaus (4)89 ssjunes anu, 2aIgeL L & al B.N. Krekeler tal: Dose in Exercise-Based Dysphagia Therapies: A Scoping Review wo=4:a to0=4'5 sro=da 100=4:¥ xd SUNOS o'rcopeme nape suns (ox wat 1000=4:91H —_p>paW) sOMnssaNd bs} 30-408 L-7 9 2000= 4 spHAdsenoUON 3d eau (002) e601 SHRM SATION: T REAR —_ Bo a OF * owas uous yo apmuaue suro=d sd ponyewion, se unsaid Iss} 204 [ap 0a yoaop ¢ 1o90=4 ——anuor MPH —sIRPY ePID AUIEAH, (102) Wd yIMy SURE] YSN, watsEM OL EKE urn uo0=4 ssn 18 ‘vans zoo=d —onfun souanog cobs uioons bs} “ane aut ono aeoupsoy ¢ owo=d niu ouoIy yong G1o2)¥d SOY worsassedxor AEs eoO=d omseiip jossouPML les} Xo¢ = a101081 Le00=4 prosyoliw jo sonny spe Sano AepEOHL (to) ¥ea Spa xe = omnawos], : 08 aos 1ur0=4 —vondse wong (Goussod stoo=dq sa sououe y) ams 6000 = 4:y -saxd vor wHMETEN co ‘yeoducseyd ig 30 = dig -0)2Mos VEUESKD od pur sowie eoyshop ¢ = 1:9 sxdoosongooptA ayens oun spony Xx soyuos od xO BENT ada Say ¢ pn susan woo> di 05) sas wmag 5 OF S00> tea is} jo sas wna 10> 4:0 sxdoanosonyoopia avons (sto2) a Wat 08 “Swontda 1 40s ¢ . (ana d join Kreutd orem ‘suo Souonbang () $9 (pannus) zaraeL D Springer B.N.Krekeler tal: Dos in Exercise-Based Dysphagia Therapies: Scoping Review wo=d ood ovo=d eco-sr0=4 s000= 4:4 sooo= 4: word wo=d9, 1wo= da wordy worda e0=49, ro00= 4:8 esosdv oda tov0> dey uvoyiuts ou = d ssn, ‘ssoulerp ewownoug np (esl (102) eana-sn#0x, owendse-uonenuag rues qu wo: "HT ‘a Inpuoy “TH ¢:¥) ‘nprsa eaudseyoug us Tg awl OM WHE sl exons (400) suigann, “a1o3s 209 uodendse uowwaauad) seuoo sano axdoosoxongoopta, worse 18d x 06 . soyasod we) x OF . (onqea d orem sso oy fount 80 B (panenv0) zag Gl D Springer oro cd RL BOOT 'ES0E'S 30s Fz OME sua wang ans soud unowost wnat tel vueoyiults oud xeuruiseouasayia supe Supra AuHEOHL (6102) uomIs wap UTA syoo8 g . (oq90= 4) sovrsod—aanssaud poseaiout sdnar8 qo osrvos! unUATEYY (0000 = 4) dosT 1011 sousywe—asnssaid sl ada § am J yor 80d < dnex3 1ousjuy — >UPWIOS| NUR —sINPR SUDPIa KUNAL (B1OZ) UoEIG W9P EEA —-—=SPOMB—_UaDMG UE ISAS OF nssaud ooo=4 — Sumorens iypsON 1op0=d —amssad aseq onduoy tooo=d —amssaid da anuoy, -Buyuenap syaar gz J sowO2IND amssaud coo0=4 — Sumonens rapsou (o90=4 —amsaid ang anu (unueu og =d — amsaud da anfu0 so npn A358) coro= aL Dales 08 yeanyston ¢ ssyeom g esouooMG —syMpe Bonok ka yea §—pun'1 399805 509 x ADK eeoo= pee ecoo=a siuou gary soo =d pur ez00=4 sows Z ry soma zen szo0=d pee 10. 0=4 ‘uous Fay Felecia! We 100=d pur ezvO=d Suu Jo von2ydwo; i ee ‘unsaid Buon ouawsod pur ouany —syspe Bunox Kye yea § IL JO 091 OAL wotsas od 0¢ : (ana join Kreud owen. ‘suo suonnaday _Souonbaid (4) $9, B.N. Krekeler tal: Dose in Exercise-Based Dysphagia Therapies: A Scoping Review (pannus) zaraeL B.N.Krekeler tal: Dos in Exercise-Based Dysphagia Therapies: Scoping Review value(s) Population(s) studied Primary outeome(s) Ist author (year) Citation number Tensity ration Repetitions Table2 (continued) GS) Frequency 1s ‘3 q participants with dysphagia resulting from stroke (25%), or participants with head and neck cancer (25%). ‘As shown in Table 1, combination exercise programs were the largest group (28%), and included a wide range of tasks such a5 tongue exercise (tongue press, tongue resistance, tongue elevation, tongue hold, tongue mobility), head lift exercise (Shaker), effortful swallows, supraglttic swallows, Jaw exercise, and pharyngeal exercise. Most programs defined the exercises in their regimens (85%), while the others (15%) used! more general terminology such as “swallow exercise,” or “therapeutic intervention for swallowing,” but did not list actual exercise procedures, For specific exercise categories, respiratory muscle strength training, mandible exercises, and lip muscle training groups had the most consistent dose reporting, with all articles in these categories reporting all four components of dose. Most articles reporting tongue exercise and head lift met “gold standard” criteria as wel, with the exception of two articles in the tongue exercise category [60, 68] and one article reporting, head lft [80]. The “other programs” category included articles, that did not fit into the diserete or combination exercise cat- egories found in Tables 1, 2, 3 4 Sand 6 (see Table 7), with all but two articles (106, 107] meeting “gold standard” criteria. ot significant (005 ein 03 p-<0.001 > » > > io scale pyriform sinus, UES upper esoph: n-aspiration ratio sale (hin, pressure Tiguids) Penetrat sale score [Normalized residue nectar) ‘Stage duration (thin posterior tongue Maximum isometric sd residue metic pressure, RM = 1 repeated maximum contraction, Stroke ‘Components of Exercise Dose Exercise dose components were grouped and are discussed here by exercise type (represented in Tables 1, 2,3, 4.5, 6, ?. Frequency was described by all exercise programs in this review, per final inclusion requirements. For combina- tion exercise programs, frequency varied from as much as, 7 xiday for 7 days/week to as little as 3 x/day for 3 days/ week. Head lift exercises and tongue exercise had the most, consistent recommendations for frequency across all treat- ‘ment types. For head lift, 3 x/day for 7 days/week was used ‘most often (54%). For tongue exercise, 3 x/day for 3 days/ week was used most often (31%). All articles that incorpo- rated respiratory muscle strength training (RMST) used a frequency of 5 xiday for either 5 or 6 days a week (100%). Mandible exercises were performed 2-3 x/day for 7 days! week in 5/7 articles. Lip muscle training occurred 3 x/day for 7 days/week forall 5 articles (100%). “Other” category of exercise programs varied greatly, ranging from 1 x/day for 1 day/week to as many as 4 x/day for 7 days/week, depend- {ng on the program. Repetitions were described in 85% of combination pro- grams, 94% of tongue exercise, 92% of head lift, and all respiratory muscle strength training articles (100%). Rep- ctitions were described in all mandible, lip muscle training, and the “other” exercises category (100%), For combina- tion exercise programs, the most commonly reported set of repetitions was 10, but other repetition counts included 15 ‘Stesle (2016) [s3) pressure strength and accuracy training, MIP maximum SENG surfece electromyography, SWAL-QoL swallowing quality of life, MASA Mann assessment of swallowing ability, NRRSp normali ageal sphincter, PAS Penetration Aspiration Seale] RM 1 rep maximum, kPa kilopascals, EMG surface elecwomyography di (24 sessions 8-12 weeks g 4 i 7 £ a based an protocol Saliva natural, or font Max Isometric specific exercise types and/or intensityinstructions for execution of exercise ivafbolus tasks for rength andor aceu- racy. Each exercise 5-20 reps (Tivo prococols: TPPT. tesa research stay that repors all 4 components of dose ("Gold Standard” or GS) Lxiday 2-3 xlweck GS gold standard, TPPT tongue-pressure profile tang, TPSAT tongu indicates that article didnot B.N. Krekeler tal: Dose in Exercise-Based Dysphagia Therapies: A Scoping Review merosd Tauado naw aydoso odd 8800°0= 4 osinaxs proxy souDIUY ws Yes omauost 0) ¢ 10904 worsnoxs prosy ouadag ——SMPE9PIO PAH (IGE) HUTA YOK ENEWS Jo} UR | pIOHL 188 nau 30 sda OF - onvo9 pur Jy 84 AVI OS soo>d — worssandop Sune-yos wo=d Corr ag Te tes > uonedse uonena soo a opsanpanaaos (rsa 998 9) 080} oe uyip od aud 7095 00> —voneadse wones24%4 pouyp S04) (490m 999 #) tou :ainnxa anidvoy, 40 5031 96 AVL spyoys oda 37098 91 roy un 110 Snauryost 00>d — oneadse uomenaueg —— omar gaa (LIOR) OUD SRM —_ARVID PUEUTT PEOH . ‘uouasou youre, SO 4 -aysodeson mma uoysinoxs (eats soo>d soo umes S00 > proxy ouSWE uMMEE, (eydsép-u0.) bl spanssep £ sawioomo sowueyseiorg SdoososongooptA —SuNPR 32910 KH, p28 9 ‘uu plon ost 45 suonnadas og KE (Some d —_—_(@awost0 Keung —_porpmis )uonejndog (4294) soyaMe S| oR Aysuonu suonodoy, Kouanbalg () $9) Sos UH POH E/E D Springer B.N.Krekeler tal: Dos in Exercise-Based Dysphagia Therapies: Scoping Review 16 Soo>d ——amssaud snogeney sapump san rune] seu wossnoX> eotutsy soyadns xt ‘suorsinxe pros 10% _}ueogRUSIs ow =d_—-a]ue puv soudns xe S010 > ow puon20s-ss01 gn, uyuado soo>d soo>d oun unaee wo>d tueoynudis ou = soo>d tovo>d soo>d tov a> 4 Lico=d'1990>4 spuons oenaus, Z6s0=d —jerduy dnass-aose0q, coo=d Swo=4'eus0=d — spmydu yeod Opa stages tou = d ortanp MOTTAS smpe s9p(0 =H (os -ojop ad) uy -uado san eauooge t891 ‘wim swaned pay-anL (2002) EHS 91 supe uno Spe (5102) ENE (ened —_@awos.no Krew patpais(yuonendog (124). onna Aasuonoy suonodoy, Kovanbaty (4) $9. (ponunuos) ¢ Iga b S a B.N. Krekeler tal: Dose in Exercise-Based Dysphagia Therapies: A Scoping Review 0 sr0=dioweys 9900=d veoo=d 160 4"1000> 4:8 ereo=a 700 = diy LiGO=4 _trpuoy Zounp wore 9100 =4 -5w2[osam protyesdng Summoqens rmpaoyo Batnp woe tweounudis ou =d _-noe aosnu prosyesding SSA nou por SINON VHSV 1 S200 imogrulis ou =d yp du uooIbe 00> ye) as ssa won soo>d SWON VHSY i990=4's pro0=4"1 ro0= 4's r000= 4°71 soneury 2390 TE oj agus ou = ‘pros soudns pero = sdnout-asoaont 6E00= 4:5 — Gousdas sons wordy s000= 4s sovo= av woprooe sosesougn9o pre ‘taoues You pue POH saunpe Bun eH axons ayo sompe Sunk aH ul ooo) eda sya98.9 syomg teal (6102) wy wa sye9K.9 ual (L100) ¥g_ HIRE to (+100) 00m ssoqeas aqgeuo;u05 290g popuanxs Sean peogy uu YON, ‘dso, xfeydsiq yeuon wanton, D Springer syoanystep z foe sean ¢ x ‘0 pours you Koo, oanystep ¢ Sop t syoanystep Kopp ¢ 7 dn019 pais 1 Seppe tt dno (ened —_@awos.no Krew patpas(Soneindog onna Aasuonoy Kovanbaty (4) $9. (ponunuos) ¢ Iga suonodoy, B.N.Krekeler tal: Dos in Exercise-Based Dysphagia Therapies: Scoping Review 8 Pas "soumss01 wureBE 9M UN VL) “PION pauTEsNs uso ‘spouad sau 0 Suypjoq oy PSU “kyso}BA TURSUOD Eye SI Peay axpnassue> = SADUTyOS! Uap “PARPURIS POS suas Jo uonna9x9 30} Suonsnssuyusus.u 20/pue Sadi asfu9¥9 2y!99d8 5 10U PIP a Ww SN!PUL vwonranoe prosyuadns ‘Aigo 30 peawsut sooaop og 18 320 ura wo pa sojourn oe foul Papuan prog ui shoud weoyniis w= d poweronssad onduoy, -mpinpurJunOC SNH, (GIOZINO. SHAKY suo ‘OES ES * yoann ss s000=¢ soma 30 ssouyOKUL, year WO=d — oumap jo sou, 0004 — somempue dn an8u0y unsaid cooo=d — Fuwonens rou unsaid sroo=d ——Suumoytens eaL0N, tov0=d —amssaud aseq ano, p1g0=d ——_amssaud dn anu, notes (ores rnoye Bump uones s+ PEE ZH, BONS Z zovo= 4 _-povayosNU prokyEdns ‘paona) suonadas 9 Amp (Senmexd —_(awos!o Kreua_patpms (S)uoneindoa Asana suonnaday —__ Souanbaid (4) $9 (ponunuos) ¢ Iga b S a B.N. Krekeler tal: Dose in Exercise-Based Dysphagia Therapies: A Scoping Review 19 Tabled Respiratory muscle strength training BO Ropeey Rains ewy unin IneaiorGgen) Poplin) Pinay pie) Graton sumer sted” Gomes) 7 Exlig Seno Gtitmminnl Syn age 16) Soke Cake fm We Sugneck Srepetion expatry om eden) “cy ay prewar (updated once Total MBSImP — p< .001 ae ‘pharyngeal irae) Spats = sek pen ‘ton pr Indvital—p MBS com- ponerse : 1steofmmimal vests ite Pukinon Rose pe- cary (2008) iene ton apa pres Cv tm tensor baseline) : ‘Stctmaninel Ayes Test 01) Patinwm Renee p cary oh ica aon pres Cv tensor tone st eee swaL-Ool—p Ometotbos p spr UES opening p Us-widet—p UBS costs Laryngeal Sire Maxinum aye p= 0081 ea coe Lanes open ine : ‘steofmmimal Sveks Hushoon ——Healandneck DIGEST captor (018) cme pre Cv tr cae baseline) ees MDADL p= Mpsine p> 00s : Strath porss, OK maxi! Aesks Pai @QO17) Hoy sey Bacsimtor—_p-< 05 Seer "exponen tm novo mae peste, Oticrisors 2p <00s" Tn ain a parca st ora sy 20 B.N.Krekeler tal: Dos in Exercise-Based Dysphagia Therapies: Scoping Review Tabled (comtinved) Citation number studied ‘outcome(s) jap mar ee swallowing test” and expiratory) pressure s increased by ‘Swallowing. 15% resistance ‘Capacity = Er ae, — am sv, GS gold standard, SWAL-Qol. swallowing quality of life questionnaire, UES upper esophageal sphincter, MDADI MD Anderson dysphagia index, DIGEST dynamic grade of swallowing toxicity, FIVC head and neck cancer, Tx therapy, PAS penetration aspiration seale *MBSimP (Modified Barium Swallow Impairment Profile) pharyngeal components: initiation of pharyngeal swallow, soft palate elevation, laryngeal clevation, anteriohyoid excursion, epiglotic movement laryngeal vestibule closure, pharyngeal stripping wave, pharyngoesophageal segment opening, tongue base retraction, pharyngeal residue No prior studies regarding respiratory muscle strength training in Huntingtons disease; unable to contol for the sizeof type Il error. Outcomes are reported as standardized effect sizes (Hedges’g) and 5. For head lift exercise, 30 lifts were recommended for isokinetic exercise (lift and lower) and 3 sustained lifts ‘were recommended for isometric exercise (hold); when head. lift exercises were incorporated into a combination exercise program, these dosing specifications for repetitions were consistently used. Tongue exercise repetitions ranged from 5 times to as many at 120 reps in a single session, but most consistently included 30 repetitions per day (38%). RMST consistently recommended 5 repetitions (100%). For iso- toniclisokinetic mandible exercises, over half studied effects of 30 repetitions (57%) with more varied for isometric (hold) exercises. Lip muscle training described 3 repetitions per session most frequently (80%). The “Other” exercise pro- gram category had highly variable repetition numbers, with all 5 articles reporting different numbers. Intensity was described in over half (55%) of the com- bination exercise programs, all but one tongue exercise and head lift (94% for both), all RMST (100%), all mandi ble (100%), all lip (100%), and more than half of “Other” programs (60%). When a device was not used to provide objective information on resistance (c.g., IOPI, RMST, or other device), intensity was described as the duration of a sustained hold (e.g. for tongue press or Mendelsohn maneu- ver), Other articles used more qualitative descriptors, such as “as hard as possible” or “maximum effort”. Duration was included in all exercise programs in this review per inclusion requirements and had the widest spread across any category. For combination exercise programs, the longest duration was 11 months post chemoradiation D Springer therapy. Head lift exercise duration ranged from 4-8 weeks. ‘Tongue exercise duration ranged from 4-12 weeks. RMST duration was between 4-8 weeks. Mandible exercise dura- tion was between 4 weeks up to 1-year post chemoradiation therapy. Lip exercise duration was between 4 weeks and 6 months. “Other” exercise programs reported durations that ranged from 4 weeks to 6 months. Outcomes Primary outcomes of each study were expressed as treatment effects with statistical comparisons of either a control group, another treatment group, or change in outcome from pre- to post-exercise within one group. Of all the articles in this review, 41 used comparison to control/sham or other exer- cise group, 29 used a pre-post analysis of the exercise group, and 2 articles used a unique statistical analysis (41, 72] Primary outcomes measured in the articles contained in this scoping review were highly variable. Methods used for deriving outcomes were also broad (please refer to Tables 1, 2, 3, 4, 5, 6, “Primary Outcome(s)” column to sce a com- plete list), Combination Exercise Articles ‘The most commonly reported outcomes in the combination exercise articles included grade of oral intake (36, 37, 41, 55], and measurements of change on videofluoroscopy using either the penetration aspiration scale (37, 44, 45, 108] or 0s wnop passaidito> 309 ‘apy = ot reas yuo ‘Aysuoiu 40 vonduasap 20} rnb pauses sour, los} pe 2ouets Pa CO=P jas sya PEN PUE PAK (L10z) eBuafeErY SPINE UI YPM UND ao | ayo passed “ps 64 ases30, rwonborgng xor soured xeusog pre (1s 9248) moynitis we=d _Kdoosei0ngoopiA npavouekp wo omens IO g070= 4 —aujor sty aseg poze sm fans spur Syston ams ¢ x's 0930} 3551 sno ousted as 0 ‘on possa Sooper sICO=F —puesouY ee nfvans fs sooo=d ——Suriado we solgns (ss con porsad eg so’ wafuans yom} uy somos Seon (SIOZ) eBoy SIN —_AAVOE FVII wortwvig + aye up sauuoaino sam ls} mat endn P weep WB 2000= 4 somo URE WEI —PoUPEEPRAKT (FOZ) UNO LUD Buna, 40} vonwoygnd 995, 40} woneoqand 298, onaweuy Truonusnu0> Sep) OF + cai) lcs} Xog=smoe, —yeansieps ——_aomstsor soo>d syons (e100) Ra ae Wop puwse~M Ug Powpms—_soquanu wont (one d (Suoneindog —Uea4) sown st von yuan suonnodat Sovonba1g unsSoud jo auen () $9 B.N. Krekeler tal: Dose in Exercise-Based Dysphagia Therapies: A Scoping Review 2.qpuEE a FULTON SONIA. ga1gEL D Springer B.N.Krekeler tal: Dos in Exercise-Based Dysphagia Therapies: Scoping Review *desoq wonepesouroy> 79 ‘2e08 doneatdse uonenUad SK ‘2b aye peo euoHNY STO eadeydoso soda ¢:77‘sounstsar wureBe Buwado el yYor “somEssas uNEBe YoM UD AVL “PHEPURIS pIOB So) exeydsgp eon “pen ut of, + xoe= 00 an aHo}sT son loal $0120) unop xe=pm yeausiep s —_arsansury 00> 4 —sios pee sya arong (IODA INE = sHNBWIOS| YP suEWOS, fepac MLM pOUIPOW eognaisiou = d_anpisaswasuceyg so0>d Bese WKH yy SED s0o> 4 Sumiedo San -eqdonaanddn jo (sa pur} wn bs asia so0>d —wonwioy pros BuSdopammpEy CIO) EPE «AMY “Huo eTusdg, —suotsuana HOt ¢ susie mer Woo=d'e -punn psu <4 pray pany ay POPE suovluts se woamg ouaiow ———_eieylstyn us so, Sumado net eenstep a Zo0=4 —protipmendn soup poMIG (GIoz) MERSIN YUM pg “ipxz ——‘fuualo mer Cawoowe | porpms sequin woe (anna Amaug (Someday GeaH ogMe sT_—_—_woNEM ec Souonbaigumifond you (.) $9 (onus) § age Springer as B.N. Krekeler tal: Dose in Exercise-Based Dysphagia Therapies: A Scoping Review repanis pro8 so) svo>d word sswoqad asaqo—_,umoqens pasa Ur poonpey,” ~psnu pur yzn03, uwon2uny s0r0> 4 sonou wasuzeqdency (osrre “aun panoyreas ben Jo nour) 1op0>d Aaeded SuwoHENS 1o90> 4 (ergissod se Arun sv 20M 900, Ut 1o90>¢ 1op0>d +6) smpe Xap KHAN (BIO2) HOMER, soos anyoy wadydos eel (e102) worm ‘1 ayons sor tel yong (102) 38eH {061 axons (goo) Fen, spam sauou 9 smoour ¢ samuour ¢ Spang not ord ere sor-s20y ang (sro ane s0o1s25) noIsaspx € eomystep 1 ‘ep € uu amnsop dr aun 3 nognumounau (e101 Buus asst dry 22901 Sfuaqen osm dry 0001 Sfuuyen ost dry (onyead —Gjawooino Karu porpms()uonmndog wortangt Kovonbasy tuvsdoud jo uN (4) SD ‘Fuqua apse dry 9argeL D Springer B.N.Krekeler tal: Dos in Exercise-Based Dysphagia Therapies: Scoping Review ‘uBeur soueuosos onauseun py ‘pEpURIS POS SD ssp Jo uogns2x9 29) suononssuy suai soypue sods 2stxo¥9 ays sou pp 2] 1H SOH|PUL X sada 99g sealed 295 Lc0>4 snssoyfosty L00>4 Pros Too>4 —_snsso(Fou2p PN, ian, Ag pup to pad 328 aS “deoxy por -asyoq anno jo (4paa saNpo Ke 0) yaaw pep | Bum poupue pray (102) camo 08) Appx 1 (ao Sut ave Baynes seams & “amp wow) sy9am 9 X plo suonnaday ‘Keprx@—psooduKinyd, eos ays lst 01-820) row Wwo>d poo euonoung exons (602) wetog estudiy] pouresng sg KaKo uonnadas [ —yaa4y tosjpuay, resfow aqnsentos reoducioyd aan snap m 2580.50) 1D ee use Radusse owe pur sousdng By ww o¢-0¢ Bodo sou span reoBeudo [yet ‘souess21 3 jpomystop , sousd asp1 Too>4 —seddnwmemveyy sommes Kpveayy (grog) eae spam gu gg SBA Z-0 Rep SOURS NOTES ‘ysuonat .AouaroygnsuL 9208 Susea.out Gansop ‘uowinoud —ainsoj ore, 2ansop It seams, yeuoj8) powour soded20g sy suonezqeudson — yuemstuaneg, siquou 9 oj poseaisuy wou; dn Buun0>) Kopp «SSID NDA (Seuto2ine paypais (Songer Sieg (uonyindog. open Asuotuy sonny ovonbaig —umifoxd jo amen (4) $0 ‘smesBoud apisow9 somo) 4 21geL Springer as B.N. Krekeler tal: Dose in Exercise-Based Dysphagia Therapies: A Scoping Review 2% another rating method [39, 42, 48, 49, 51, 52}. Other out- comes included percutaneous endoscopic gastrostomy (PEG) tube dependence [36, 37], lingual pressure measure- ments (40, 53], or rating scales (ie., MD Anderson Dys- phagia Inventory) [38, 39, 42, 47, 48, 53, 54]. All but three articles (42, 46, 53] reported at least 1 significant finding in the outcome(s) measured following the combination exercise program, However, as shown in Table 1, it was not apparent that improvements in various outcome measures following combination exercise programs were attributable to use of particular treatment doses. Tongue Exercises ‘The primary goal of tongue exercise is to increase peak lingual pressure generation (109]. However, the effects of tongue exercise on tongue pressure during swallowing, pen- etration, aspiration of material into the airway, and amount of residue in the oropharynx were also studied [109]. All 16 tongue exercise articles reported on changes in lingual pressure generation anteriorly, posteriorly, or both. All ar cles except one [58] found significantly increased tongue pressure after tongue exercise (p < 0.05), regardless of dif- ferences in exercise repetitions, frequencies, and treatment durations. One study compared various tongue exercise intensities, but did not find a difference among training lev- els at 60%, 80% or 100% of a I repetition maximum (RM) over 8 weeks [70]. Airway invasion, as measured using the penetration aspiration scale [108] on videofluoroscopy, was an outcome in 5 articles [57, 64-66, 71]. Only one study [57] found any significant improvement in airway invasion after 4 weeks of tongue exercise. This study used 5 tongue presses per session and was not facilitated by a device. Further, this study used fewer presses per session than many of other tongue exercise articles, which typically reported at least 30, presses per session (see Table 2). The other 4 articles did not find any significant impact on airway invasion after tongue exercise at any dose. Five articles examined residue, using variety of techniques to quantify location and amount [57, 64-66, 71]. OF these, 2 articles [57, 65] found significant decreases in residue after a course of tongue exercise. Nei- ther of these articles included a control or sham condition. Accordingly, it is unclear whether these findings resulted from tongue exercise alone or another factor. Head Lift Exercises The purpose of the head lift exercise (Table 3) is to improve opening of the upper esophageal sphincter by increasing ‘movement of the hyolaryngeal complex upward and for- ward {110}. Given the goals of this exercise, the three most common outcome measures used in 13 articles targeted were changes in hyoid bone movement [72, 74, 76, 77, 79], suprahyoid muscular activation [78, 81, 84], and UES open- ing [72, 74, 76, 77]. For changes in hyoid excursion, three out of five found significantly increased hyoid movement (anteriorly) (72, 74, 79], but two articles did not (76, 77] Most of these articles used the same or a similar protocol for head lift exercise [72, 74, 76, 77]. Suprahyoid activation was significantly increased after exercise in two out of three arti- cles, with no significant treatment effects in the study with the least frequently prescribed exercise frequency (I x/day; 2 days/week) [84]. Anterior-posterior opening of the UES ‘was significantly greater in 3 out of 4 articles [72, 76, 77]. Respiratory Muscle Strength Training {In dysphagia treatment, the goals of RMST are to improve swallow function by increasing respiratory muscle strength, because respiration and swallowing actions are highly eoor- dinated [35]. Swallowing outcomes in the RMST articles, included in this review were particularly broad. The most ‘common measure was the penetration aspiration scale (PAS) {108}, reported in over half of the articles [85-88], with only three ofthe four reporting a significant improvement in PAS score [85-87]. Other outcomes were Modified Barium Swal- low Impairment Profile [111] (MBSImP) components [85, 8], UES opening and closure [87], and the SWAL-Qol [87, 90] with mixed findings across articles. As shown in Table 4, all articles that reported an exercise frequency of 5 x/day for 5 days/week found that at east 1 or more swallowing, outcome improved with treatment. However, an inerease in frequency did not yield greater improvements in swallowing, outcomes, as indicated by the lack of significant changes, reported in a study using a 5 x/day for 6 days/week [90] regi- ‘men. This result could be due to the unique study population (Huntington’s Disease), or aspects of its methodology [90] ‘This was the only study that included both inspiratory and expiratory training, and intensity was set to 30% of maxi- ‘mum at baseline, with increases of 15% every month [90] Intensities in all other articles ranged from 60%—75% of ‘maximum expiratory capacity. Mandible Exercises ‘These exercises included jaw opening, jaw closing, and chin tuck against resistance (CTAR). Four out of 7 of articles that examined mandibular exercises were published within the last four years. One study [93] measured chin tuck strength, jaw opening strength, tongue strength, muscle volume, and changes in videofluoroscopy and found significant changes, in all but the videofluoroscopy parameters. Another article reported significant weight gain after | year of CTAR and ‘TheraBite therapy 3 x/day at 7 days/week [92]. Two arti- cles [95, 96] examined effects of jaw opening exercise on hyoid movement and reported significant increases in hyoid D Springer 26 B.N.Krekeler tal: Dos in Exercise-Based Dysphagia Therapies: Scoping Review elevation (p < 0,05). Other articles in this category looked at penetration aspiration scale (PAS) [108] ratings [94, 97), laryngeal elevation and epiglottic closure {91}. Articles in this category had a wide range of methodologies in treat- ‘ment administration and outcome measurement, making it difficult to make comparisons regarding exercise dosing and statistical findings. Lip Muscle Training Lip muscle training is used in rehabilitating oral function after stroke, and has also been used to facilitate improve- ments in swallowing outcomes [99]. The principles behind 1Qoro® lip muscle training are based on neuroplastcity, which is different from many of the muscle strength based. approaches in these other dysphagia treatments {99101}. The two articles using the IQoro® training method with stroke patients focused on outcomes related to facial activ- ity testing and swallowing function [99, 100], both showing, significant improvements in “swallowing capacity” (amount of water swallowed, mL/s) and “oropharyngeal motor fune- tion” (not specified), respectively. Dose methods in these articles were very similar, with the largest variation being, in duration of treatment, ranging from 4 weeks to 6 months. Articles reporting shorter treatment durations of 4-8 weeks 98, 102] found significant changes in lip force and “eating behavior,” which may indicate that changes from this treat- ‘ment may occur within shorter periods of time. Other Exercise Articles Outcomes for the “other” category included tracking hos- pitalizations for pneumonia [103], anatomical landmark changes with swallowing (ic., UES opening, laryngeal excursion) [104], functional oral intake scale (FOIS) [112] scores [105], and measurement of muscle size and composi tion using MRI techniques [106]. All five articles reported positive and significant changes in these individual swallow ing outcomes following their interventions. Because of the different exercises and outcomes reported in these articles, comparisons related to dosing and outcomes are not possible across treatments Discussion The purpose of this scoping review was to: (1) examine the dysphagia literature to provide the range of resistance-based dysphagia exercise doses reported in peer-reviewed publica- tions, and (2) demonstrate the importance of dose considera- tion in our exercise-based dysphagia treatments. Our broad search resulted in inclusion of 72 articles, While this review involved a complete literature search of four databases, it D Springer was not a systematic review because article inclusion was not limited by aspects of research design, such as evidence level achieved, number of participants included, and other considerations operationally defined ina rigorous systematic review [10]. Given the wide variability in treatment meth- ods reported across articles, and the variety of outcomes reported, it was not possible to determine the “best” or “most effective dose” of resistance exercise for the treatment of dysphagia, ‘To achieve the first aim of this review, we provided an overview of the articles that reported at least the frequency and duration of exercise in their methods to create a record of exercise doses found in the research literature, We found that there are a wide range of doses and outcome meas- ures reported in the dysphagia exercise literature. Within individual treatment categories, some components are more homogenous than others. For example, inthe tongue exet- cise category, most articles reported 3 x/day for 7 days! week for exercise frequency with 30 repetitions. For res- piratory muscle strength training, articles often reported doses of 5 x/day for 5 days/week, 5 sets of 5 repetitions, and 60-75% maximal expiratory capacity. However, across categories, duration and intensity were varied overall. This record clearly demonstrates the lack of agreement in dose prescription across interventions in our field. In relation to our second aim, findings suggest that a broad discussion of methodological considerations in dys- phagia treatment research is necessary to allow for discov- ery of the most effective exercise doses for different treat- ‘ments and patient groups, as well as adequate comparison of study outcomes. Controlled studies that test and clearly report exercise doses are needed to allow development of guidelines that improve reproducibility in dysphagia research. This is an important consideration in delivery and reimbursement of speech-language pathology services. For example, through Medicaid, speech-language pathology treatments must be “reasonable [and have the} appropriate amount, frequency, and duration of treatment in accordance with standards of practice” [113]. The findings ofthis review demonstrate clear need to better define these characteristics of exereise dosing to allow demonstration of treatments that are medically necessary and that will provide patients with adequate benefits to ensure best practice. Findings from this review demonstrated a large breadth in reported dosing methodology in dysphagia research as 4 whole. While some interventions, such as the head lift maneuver, had more consistently reported dosing com- ponents, the majority of treatments had a wide range of reported frequencies, repetitions, intensities, and dura- tions. For combination studies, the range of exercises and doses was very widespread. With so many combinations of exercises and various doses reported, it is likely dificult for the dysphagia clinician to identify an optimal dose for B.N. Krekeler tal: Dose in Exercise-Based Dysphagia Therapies: A Scoping Review 2 use witha particular patient. Although we did not perform formal quality appraisal asa part ofthis scoping review, wwe did require atleast exercise frequency and duration to be reported, at @ minimum, for inclusion. While many of the included articles reported all four components of dose (79%), there is concern regarding the reproducibility of the remaining articles, either for research or clinical use. Omis- sion of even one parameter integral to reproducing the exer- cise condition, ofa lack of detail in description of exercise methodology and outcomes measured could prevent study replication, Without ths information explicitly reported, it is difficult to compare and interpret the relative effective- ness of treatment regimens between articles. Therefore, we ‘must ensure that we sustain a high evel of scientific igor in reporting of study methodology by providing detailed infor- mation about all four components of dose, and specifics on how an exercise intervention was carried out. These descrip- tions should also include measures of patient performance or adherence, which are critical factors to ensuring reproduc ibility and validity of comparisons across future articles ‘Another area that emerged as a concern in quality and reproducibility was outcome selection. As we reported in the results, there are a wide range of outcome measures selected and reported for various articles within the same treatment type (See “Primary Outcomes” in Tables 1, 2, 3, 4, 5, 6, 2). This lack of uniformity in outcome selection prevents us from performing any meta-analyses or true com- parisons between different dose prescriptions. Even in the case where PAS scores are reported across multiple art- cles, there ae various methods that can be used to evaluate Videofluoroscopic swallow studies to obtain these ratings. ‘This makes direct comparison of findings even among these articles using PAS ratings more difficult, especially if vide- fluoroscopic protocols are not well described (.c., bolus type, order administration, size) or the method of generating ratings differs between articles (e.g, average of PAS score across swallows, vs “worst” PAS score across swallows). Some articles developed their own outcome measurements (G.c., swallowing capacity or “Water Swallowing Test") that are not used broadly in dysphagia literature. The problem of outcomerassessment selection was apparent in this study, and should be considered when interpreting these dose- related findings for clinical practice or future research. tations in the Literature In evaluating the research literature examining exercise- based dysphagia interventions, we noted that many articles did not provide a detailed account of the exercise method- ology used in their studies, When designing and reporting human subjects research studies, researchers should provide sufficient detail to allow replication and thus must report, at a minimum, basic information such as details of participant selection, interventions used, outcomes assessments and a rationale for their selection, sample size and statistical meth- ‘ods, and if appropriate, blinding and randomization [114] ‘These guidelines have been clearly articulated in the Con- solidated Standards of Reporting Trials (CONSORT), which can be adapted to any number of research designs [114]. We encourage researchers in our field to use these guidelines not only during manuscript preparation to guide methods report- ing, but early in study development to ensure scientific rigor. Conclusion Exercise approaches available to the dysphagia clinician ‘might include resistance exercise, neuromotor exercise, oF flexibility exercise (stretching). The ACSM recommends dose prescription for these exercise categories that are out- lined in’Table 8. While the ACSM guidelines provide a start ing point toward development of dosing criteria in dyspha- sia treatment, these recommendations may not be entirely applicable to dysphagia treatment, given anatomical and functional differences between spinal motor systems and the upper aerodigestve tract [115]. More systematic, high qual- ity studies of varying exercises doses across exercise-based dysphagia treatments are required to improve our evidence base regarding dose recommendations. A consensus among dysphagia clinicians and researchers can then be reached to standardize dosage parameters for exercise treatments across care settings. In general, it is unlikely that there is a singular optimal exercise dose for each specific exercise protocol. Its more probable that optimal dosing for a spe- cific exercise will difer depending on the patient's age, sex, comorbidities, primary etiology, physical fitness, and other factors [116]. The continued exploration of how different components of dysphagia exercise dose can be altered to ‘maximize benefit for different individuals with dysphagia is required to improve clinical protocols forthe wide range of people who are treated for dysphagia. The development of exercise-training programs that can be readily modified or tailored to target specific population(s) will be required to ‘maximize outcomes [116]. In future work on dysphagia exercise dose, we encourage researchers to consider these components of exercise dose (frequency, repetitions, intensity, duration) when designing and reporting on exercise-based treatment methods. For cli- nicians seeking to engage in evidence-based practice for dys- phagia therapy, the tables provided that summarize the cur rent evidence can serve asa reference point when developing patient-specific treatment plans. Regardless of the challenges that exist related to differentiating dose recommendations in these resistance-based exercise programs, continued work in this area is critical for continued refinement of current D Springer B.N.Krekeler tal: Dos in Exercise-Based Dysphagia Therapies: Scoping Review Gxsov) seu mpayy suods Jo 28509 wrouaMrY aq) wy PaIdePR TER, payiseds oN -[2)) woos 18H se youu neu part [sks ssoiowont —qjoS-o¢ sotod stoxdur oy sempraspals3pI0, sauspin? 959 01 wel ‘upi0ove pours {Hog > :ouempus seas 29038 OL, “1p Saanayap WOT 20S-OW TEMPE APIO swoaq your sey Sururen—paououadh sor AT Jo 208 = paouausds JO wow om9d¢——_ INL J0 9504-09 ‘aeIpautaya 01 29180N, “sumpe25p10 aanay sour yeamstep ez “Agppamug¢-02 2NoAUN Ep SOSIDKT_ eHENSLD o}oMADN wornu weeudsip a ted 30 2g eur > Jo yomasoxda 105 92- paBe-qppm 30} C1 seamysieop x eZ pe au39400 KOPP HZ ANORUT EN SostoIOKG—_astoox9 sOUESTSOY wotangr ‘ausu>iuy suonndoy eventing wonmysd saxo yoadKL ‘omnos sau pue supa SHOU 0 A¥5]}0D WHAM a4) WN) PardEPY SuOnEPERUINO.AL aI BOIgEL Springer as B.N. Krekeler tal: Dose in Exercise-Based Dysphagia Therapies: A Scoping Review » practices to provide our patients with the highest level of evidence-based care, Acknowledgements This work was supported by NIH Grants 1F31AG059351-01, 732-DC009401, ROIDCO1S071, ROIDCOO8 149, ROLDCO14358, R37CA225608. This manuscript was submitted in pare tial fulfillment of the requirements forthe doctoral dissertation of the first author, BNK. She would lik to thank and recognize er disserts- tion commitee members for their valuable contributions to her traning and feedback on this manuscript: Drs. Nicole Rogus-Pulia, Michelle Ciucei, Gary Diffee, Catriona Stele, and Timothy McCulloch, Compliance with Ethical Standards Conc ofinterest ‘The authors have no confit of interes to declare. Appendix PubMed (((C(Ctongueltw] AND (pressure*[tw] OR resistanceftw] OR hold*[tw] OR lift*{tw] OR strength*[tw))))) OR (effortful swallow*[tw] OR shaker exercise*[tw] OR men- delsohn maneuver*[tw] OR supraglottic swallow*{tw] OR exercise*[tw)))) AND (((deglutition disorders{mh] NOT gastroesophageal reflux[mh]) OR (deglutition disorder{tw] OR dysphagialtw] OR swallowing disorder*[tw] OR swal- lowing diffcult*{tw))))). Scopus[Embase] (((TITLE-ABS-KEY (tongue) AND TITLE-ABS-KEY ( pressure* OR resistance OR hold* OR lift* OR strength")) OR ( TITLE-ABS-KEY ( “effortul swallow*” OR "shaker exercise” OR "mendelsohn man*" OR “supraglotic swal- low*” OR exercise*))) AND (TITLE-ABS-KEY ( “degluti- tion disorder*™ OR dysphagia OR "swallowing disorder*” OR “swallowing dificul*"))) AND (INDEX (embase)) CINAHL (Ctongue AND (pressure* OR resistance OR hold* OR lift OR strength*)) OR ( ("effortul swallow*" OR "shaker exercise" OR "mendelsohn man*" OR “supraglottic swal- low*” OR exercise*))) AND ((“deglutition disorder*” OR dysphagia OR “swallowing disorder*” OR "swallowing diffieuk*"). Cochrane CENTRAL (Ctongue AND (pressure* OR resistance OR hold* OR lift* OR strength*)) OR ( ("effortful swallow*" OR "shaker exercise” OR "mendelsohn man*” OR “supraglotic swal- Jow*” OR exereise*))) AND ( “deglutition disorder*” OR dysphagia OR "swallowing disorder*” OR "swallowing dif- ficult*")) in Title, Abstract, Keywords in Trials’ References 1. Burkhead LM, Sapienza CM, Rosenbel JC. Strength-raining ‘exercise in dysphagia rehabilitation: principles, procedure, and directions for future research. Dysphagia. 2007;22(3):251-6. 2, Latham NK, etal. Systematic review of progressive resist= ance strength training in older adults, J Gerontol A. 2004:59(1):M48-M61 3. Obkawara K, etal. A dose-response relation between aerobic ‘exercise and visceral fat reduction: systematic review of clinical vials Int ¥ Obes, 2007:31(12):1786 4. Radaeli R, etal. Dose-response of 1,3, and 5 ses of resistance ‘exercise on strength, local muscular endurance, and hypertrophy. TStrength Cond Res. 2015;29(5)1349-8. 5, Peterson MD, Rhea MR, Alvar BA. Applications ofthe dose- response for muscular strength development review of meta- analytic efficacy and reliability for designing trtning presrip- tion, J Strength Cond Res. 2005:19(4):950-8 6. Rhea MR, et al. A meta-analysis to determine the dose response for strength development. Med Sei Sports Exerc. 2003:35(3):456-64. 7. Langmore SE, Pisogna JM. Eficacy of exercises to rchabiltte dysphagia: aeritique of the literature. InJ Speech Lang Pathol 2015:17):222-9, 8, Sciote JJ etal. Specialized cranial muscles: how different are 3 muscles? Cells Tissues Organs. 9, Asksey H, O'Malley L. Scoping studies: towards a methodotogt- «al framework, It I Soe Res Method. 2005;8(1):19-32 10, Wright RW, etal. How to write a systematic review. Clin Orthop Relat Res, 2007:455:23-9. 11, Hollman W, eal. Physical activity and the elderly. Bur Car

    You might also like