Case study: application of isometric progressive resistance oropharyngeal therapy using the Madison Oral Strengthening Therapeutic device

Abstract

Purpose: Isometric progressive resistance oropharyngeal (I-PRO) therapy improves swallowing function; however, current devices utilize a single sensor that provides limited information or are prohibitively expensive. This single-subject study presents results of I-PRO therapy, detraining, and maintenance using the 5-sensor Madison Oral Strengthening Therapeutic (MOST) device combined with upper esophageal sphincter (UES) dilatation.

Methods: A 56-year-old female nurse who was 27 months post stroke and subsequent to traditional behavioral interventions and UES dilatations presented limited to gastrostomy tube intake only and expectorating all saliva. She completed 8 weeks of I-PRO therapy, 5 weeks of detraining, and 9 weeks of I-PRO maintenance (reduced frequency) followed by a third UES dilatation post intervention. Data included diet inventory, lingual pressures (MOST), lingual volume (magnetic resonance imaging), postswallow residue (videofluoroscopy), UES and pharyngeal pressures (high-resolution manometry), and quality of life (QOL).

Results: Findings after 8 weeks of I-PRO therapy were progression to general oral diet, 15 lb weight gain, increased isometric pressures (Δ ≯16 kPa) with transference to swallowing pressures, increased lingual volume (8.3%), reduced pharyngeal wall residue (P = .03), increased pharyngeal pressures (Δ ≯ 43 mm Hg) and increased UES opening (nadir) pressures (Δ ≯ 9 mm Hg) with improved temporopressure coordination across the pharynx, and improved QOL. After detraining, decreased isometric pressures and reduced UES opening were noted. After I-PRO maintenance, isometric anterior lingual pressures returned to levels noted after the 8 weeks of intervention.

Conclusion: I-PRO therapy, facilitated by the MOST device combined with instrumental UES dilatation, improved swallow safety, increased oropharyngeal intake, and facilitated UES opening while enriching QOL.

Keywords: deglutition; dysphagia; rehabilitation; strengthening; stroke.

Figures

Figure 1

Timeline of events, including multiple interventions for swallowing and dilatations of the upper esophageal sphincter (UES). Y-axis markers correspond to headings and subheadings in the swallowing history, methods, and detraining/maintenance sections.

Figure 2

High-resolution manometry plot of typical swallow pressure pattern for a 5 mL liquid bolus swallow. (A) Nasopharyngeal region; (B) tongue base and hypopharyngeal region; (C) upper esophageal sphincter region. Pharyngeal swallow is outlined with black box. Darker grey and black tones correspond to higher pressures.

Figure 3

Maximum isometric lingual pressures across intervention.

Figure 4

(A)Three trials of a whole tongue press, where the tongue presses against all sensors simultaneously, at baseline of I-PRO intervention. (B) Three trials of a whole tongue press at the end of I-PRO intervention.

Figure 5

Maximum oral pressures during swallowing tasks increased for bulbs #1 and #2 from baseline to week 8 and declined for bulb #3 from baseline to week 8. The 3 mL liquid and cup liquid swallow data are missing at baseline due to anterior loss of bolus out of the mouth. SS = semisolid.

Figure 6

Visual analysis of change in Penetration-Aspiration Scale scores across I-PRO intervention and maintenance periods. Detraining data are unavailable for analysis.

Figure 7

Visual analysis of change in durational measures across I-PRO intervention and maintenance periods. Lines represent mean values. Detraining period data are unavailable for analysis. A and B denote increases in oral transit and clearance durations, respectively, for 3 mL thin liquid and 3 mL semisolid boluses. C denotes a decrease in stage transition duration for the same boluses. D denotes a decrease between the beginning of laryngeal vestibule closure and the point when the bolus enters the pharynx for 3 mL thin liquid boluses.

Figure 8

Visual analysis of change in residue scores across I-PRO intervention and maintenance periods. Lines represent mean values. Detraining data are unavailable for analysis. In the 3 mL and 10 mL thin liquid rows, B denotes an overall decrease in residue along the posterior pharyngeal wall. In the 3 mL semisolid row, A, B, and C denote overall decreases in residue in the valleculae and along the posterior pharyngeal wall and an increase in cricopharyngeal residue, respectively.

Figure 9

Change in dysphagia-specific quality of life subscales pre to post I-PRO intervention.

Figure 10

Change in maximum isometric lingual pressures across intervention periods.

Figure 11

High-resolution manometry plot of a representative swallow pressure pattern from J.B. with a 5 mL liquid bolus swallow. (A) Nasopharyngeal region; (B) tongue base and hypopharyngeal region; (C) upper esophageal sphincter region. Pharyngeal swallow is outlined with a black box. Darker grey and black tones correspond to higher pressures.