Effect of Tongue-to-Palate Resistance Training on Penetration-Aspiration Scale and Suprahyoid Muscle Electrical Activity in Geriatric Patients With Oropharyngeal Dysphagia
Phase: NA
Conditions: Oropharyngeal Dysphagia, Geriatric Patients
Sponsor: Dr Cipto Mangunkusumo General Hospital

Official Title : Effect of Tongue-to-Palate Resistance Training on Penetration-
Aspiration Scale and Suprahyoid Muscle Electrical Activity in Geriatric Patients 
with Oropharyngeal Dysphagia: A Randomized Control Trial 
 
Kuntjoro Harimurti1, Melinda Harini2, Bunga Saridewi Nurmansyah2, I Wayan Murna 
Yonathan3, Mohamad Yanuar Amal3, Steven Setiono2, Boya Nugraha4 
 
1 Department of Internal Medicine, Cipto Mangunkusumo Hospital, University of 
Indonesia, Jakarta, Indonesia 
2 Department of Physical Medicine and Rehabilitation, Cipto Mangunkusumo Hospital, 
University of Indonesia, Jakarta, Indonesia 
3 Department of Radiology, Cipto Mangunkusumo Hospital, University of Indonesia, 
Jakarta, Indonesia 
4 Department Rehabilitation Medicine, Hannover Medical School, Germany 
 
Running Title: TPRT and Swallowing Function in Geriatric Dysphagia 
 
Word counts: 2,927 words 
Number of tables: 5 
Number of figures: 1 
Abstract 
last updated : August, 1st 2025 

2 
 
Background: Oropharyngeal dysphagia is a prevalent geriatric syndrome associated 
with malnutrition, aspiration, and increased morbidity. Tongue-to-palate resistance 
training (TPRT) has emerged as a simple, home-based exercise to strengthen 
swallowing-related musculature, yet evidence in older adults remains limited. 
Objective: This study aimed to evaluate the effects of TPRT on suprahyoid muscle 
activity and swallowing safety, assessed by the Penetration-Aspiration Scale (PAS), in 
geriatric patients with oropharyngeal dysphagia. 
Methods: A single-blind randomized controlled trial was conducted at Cipto 
Mangunkusumo Hospital, Jakarta, from July 2022 to June 2024. Twenty patients aged 
>60 years with videofluoroscopic-confirmed dysphagia were randomized into TPRT 
and control groups. The intervention group performed TPRT (30 repetitions, five 
sessions per week, for eight weeks), while controls received individualized dysphagia 
therapy (neuromuscular electrical stimulation, CTAR, or biofeedback). Suprahyoid 
muscle activity was measured using surface electromyography (sEMG) at baseline, 
week 4, and week 8; swallowing function was evaluated using PAS and 
videofluoroscopic parameters. 
Results: Seventeen participants completed the study (intervention n=9, control n=8). 
Both groups demonstrated significant within-group increases in suprahyoid muscle 
activity over eight weeks (p<0.001), with larger effect sizes observed in the TPRT 
group, although between-group differences were not statistically significant. PAS scores 
improved in both groups [intervention: median 4→2; control: 4.5→2], without 
significant intergroup differences. Notably, anterior hyoid excursion significantly 
increased in the TPRT group (p=0.038). 

3 
 
Conclusion: TPRT enhanced suprahyoid muscle activity and anterior hyoid movement 
in older adults with oropharyngeal dysphagia, supporting its feasibility as a home-based 
intervention. Although no significant reduction in PAS was observed, TPRT shows 
promise as a safe, low-cost rehabilitation strategy warranting further investigation in 
larger, more homogenous cohorts. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

4 
 
Introduction 
Oropharyngeal dysphagia is highly prevalent among older adults, affecting 30–
40% of individuals over the age of 65 and over 60% of those in long-term care 
facilities.1,2 This condition, characterized by impaired bolus formation and transit from 
the oral cavity to the esophagus, may lead to aspiration and choking3,4, and has been 
classified as one of the geriatric giants by the European Union Geriatric Medicine 
Society (EUGMS) and the European Society for Swallowing Disorders (ESSD) due to 
its impact on nutritional status, functional decline, morbidity, and mortality.4–6 
Age-related physiological changes, including reduced tongue strength, 
diminished laryngeal elevation, and weakened suprahyoid muscle activity, contribute to 
impaired swallowing efficiency.7,8 Tongue strength is essential for effective bolus 
propulsion and generating adequate intraoral pressure, directly influencing the 
pharyngeal phase of swallowing.9,10 Rehabilitation strategies, such as Shaker or CTAR 
(Chin Tuck Against Resistance) exercises and neuromuscular electrical stimulation 
(NMES), are frequently employed but may be unsuitable for frail elderly patients due to 
physical limitations or low adherence.7,11  
Tongue-to-palate resistance training (TPRT), performed by pressing the tongue 
against the palate, offers a simple and feasible alternative that can be implemented as a 
home-based program.11–13 TPRT has been shown to enhance both anterior and posterior 
tongue strength,11 increase hyoid bone excursion,11 and improve upper esophageal 
sphincter opening by activating the suprahyoid muscles.11,14,15  
Several studies also report a correlation between tongue movement and 
suprahyoid muscle activation, with surface electromyography (sEMG) confirming 
greater suprahyoid activity during TPRT compared to Shaker exercises.14,16–18  

5 
 
The effects of tongue and suprahyoid muscle strengthening exercises are also 
supported by findings of increased geniohyoid muscle thickness from 2.3 to 2.6 cm² 
after eight weeks of training,7 as well as increased thickness of the mylohyoid and 
digastric muscles following tongue-to-palate pressing exercises performed over six 
weeks.9,19 A TPRT program consisting of 30 repetitions, five times per week for four 
weeks, also reduced PAS scores from 6 to 3.56 (p < 0.000).20  
A preliminary study conducted at the Department of Physical Medicine and 
Rehabilitation, Cipto Mangunkusumo Hospital, showed an increase in suprahyoid 
muscle electrical activity from 8.56 ± 3.456 µV before TPRT to 15.26 ± 3.19 µV after 
one week of training, and further increased to 17.44 ± 3.922 µV after two weeks.13 Since 
the strength of both the tongue and suprahyoid muscles can improve solely through 
tongue-strengthening exercises, TPRT has the potential to enhance swallowing function 
in both the oral and pharyngeal phases in patients with dysphagia, and may be suitable 
as a home-based training program. This study aims to evaluate the effect of tongue-to-
palate resistance training in geriatric patients with oropharyngeal dysphagia over a 
longer observation period than typical hospital-based rehabilitation. The outcomes 
assessed include suprahyoid muscle electrical activity and the Penetration-Aspiration 
Scale (PAS) to determine the effectiveness of the training and the risk of aspiration. 
 
 
 
 
 
 

6 
 
Methods 
Design, population, and setting 
 
This study was an interventional, single-blind, randomized controlled trial 
(RCT) conducted at the Department of Medical Rehabilitation, Radiology Unit, and 
Integrated Geriatric Clinic of Dr. Cipto Mangunkusumo General Hospital, Jakarta, 
between July 2022 and June 2024. 
 
Eligible participants were geriatric patients aged >60 years diagnosed with 
oropharyngeal dysphagia confirmed through videofluoroscopic swallowing study 
(VFSS). Inclusion criteria required that participants had not received swallowing 
training in the preceding two weeks, were cooperative, and had a caregiver available to 
support adherence to the intervention protocol. Baseline suprahyoid muscle electrical 
activity, measured by surface electromyography (sEMG), had to be ≤37.1 μV RMS. 
Exclusion criteria included significant cognitive impairment based on the MoCA-Ina 
test, history of radical neck dissection, malignancy of the oral cavity, recent head and 
neck chemoradiotherapy within three months, complete inability to move the tongue, 
baseline EMG = 0 μV, presence of a pacemaker, or known allergies to contrast agents 
or training materials. 
 
All participants provided written informed consent prior to enrollment. Ethical 
approval was obtained from the Research Ethics Committee of the Faculty of Medicine, 
Universitas 
Indonesia/Dr. 
Cipto 
Mangunkusumo 
Hospital 
(No. 
KET-
1415/UN2.F1/ETIK/PPM.00.02/2022) 
 
Sample Size 

7 
 
The sample size was determined using a paired-mean difference calculation. For 
suprahyoid muscle electrical activity, the standard deviation of the mean difference was 
estimated at 3.68 with an expected mean difference of 4.0. Using a significance level of 
α = 0.05 (Zα = 1.96) and power of 80% (Zβ = 0.84), the required minimum sample size 
was seven subjects. 
For the Penetration-Aspiration Scale (PAS), the standard deviation of the mean 
difference was estimated at 1.03 with an expected mean difference of 1.0, yielding a 
minimum sample size of eight subjects under the same statistical assumptions. To 
ensure adequate power, the larger estimate of eight participants per group was selected. 
Accounting for an anticipated 20% dropout or loss to follow-up, the final target sample 
size was set at 20 participants, with 10 allocated to each group. 
 
Baseline measurement, randomization and intervention 
Following consent and initial assessments, participants underwent baseline VFSS and 
suprahyoid sEMG evaluations. Block-permuted randomization with a block size of four 
was used to allocate subjects into intervention and control groups.  
The intervention group received TPRT home exercises consisting of 30 repetitions per 
session, five sessions per week, over eight weeks with video guidance and support from 
caregiver. Participants were monitored via logbooks and follow-up calls.  
 
The control group received individualized dysphagia therapy, which may have 
included neuromuscular electrical stimulation (NMES), biofeedback swallowing 
therapy, and home-based chin tuck against resistance (CTAR) exercises. NMES 

8 
 
involved placing electrodes in the submental region. Both groups received education on 
safe swallowing techniques, posture, and bolus modification. 
 
Follow-up and outcomes measurement 
Suprahyoid sEMG was reassessed at weeks 4 and 8. VFSS parameters (PAS score, 
pharyngeal transit time, hyoid movement) were evaluated again at week 8. sEMG was 
recorded using surface electrodes placed in the submental area after skin preparation. 
Electrode placement was confirmed by asking participants to press their tongue against 
the palate and perform a dry swallow. Each test was performed three times, with at least 
10 seconds of rest between trials to prevent fatigue. 
The outcomes measured were suprahyoid muscle electrical activity and the Penetration-
Aspiration Scale (PAS). 
 
Blinding 
Outcome assessors were blinded to group allocation. Suprahyoid muscle electrical 
activity (sEMG) was evaluated before and after the intervention by a rehabilitation 
medicine physician, while videofluoroscopic swallowing studies (VFSS) were 
conducted by a radiologist and a rehabilitation medicine specialist. All assessors were 
unaware of participants’ treatment assignment. 
 

9 
 
To ensure comparability across groups, both the intervention and control groups also 
received standard education on posture adjustment, swallowing maneuvers, and bolus 
modification for safe swallowing. 
Harms 
Adverse events were systematically monitored throughout the study. Participants and 
caregivers were instructed to report any kejadian tidak diharapkan (adverse events) via 
telephone during scheduled follow-up logbook checks. This approach ensured 
continuous surveillance during both the home-based exercise program and the hospital-
based assessments. No adverse events were reported in either the intervention or control 
groups, whether during the training sessions or during outcome evaluations such as 
suprahyoid 
sEMG 
recordings 
and 
videofluoroscopic 
swallowing 
studies 
(VFSS)Statistical analysis 
Data were presented using narrative summaries and tabular formats. Statistical analysis 
was conducted using both descriptive and inferential approaches. The normality of 
EMG data was tested using the Shapiro–Wilk test. If data were not normally distributed, 
a log transformation was applied. Repeated measures ANOVA (General Linear Model 
approach) was used to assess time-related effects, with Mauchly’s test of sphericity 
applied to test variance assumptions. If sphericity was violated, corrections 
(Greenhouse–Geisser or Huynh–Feldt) were applied. For other outcomes, paired t-tests 
or Wilcoxon signed-rank tests (for within-group comparisons) and independent t-tests 
or Mann–Whitney U tests (for between-group comparisons) were used based on data 
distribution. A p-value < 0.05 was considered statistically significant. 
 

10 
 
Results 
Recruitment and randomization 
A total of 36 patients were screened for eligibility. Sixteen were excluded for the 
following reasons: suprahyoid EMG activity >37.1 μV RMS (n = 3), cognitive 
impairment (n = 5), history of radical neck dissection (n = 3), pacemaker implantation 
(n = 2), absence of a consistent caregiver (n = 1), and refusal to participate (n = 2). 
Twenty eligible participants were randomized using block-permuted randomization 
with a block size of four, resulting in 10 participants allocated to the intervention group 
and 10 to the control group. This sample met the minimum number required based on 
the a priori sample size calculation. 
All participants completed the first four weeks of training and underwent the week-4 
suprahyoid sEMG assessment. By week 8, three participants withdrew: one from the 
intervention group due to hospitalization for vascular stenting, and two from the control 
group (one lost to follow-up and one relocated). In total, 17 participants (intervention n 
= 9, control n = 8) completed the study and were included in the final analysis. The 
participant flow and reasons for exclusion and withdrawal are summarized in Figure 1 
(CONSORT flow diagram). The recruitment period spanned from July 2022 to June 
2024. 
No adverse events were reported during training sessions or during outcome 
evaluations, including suprahyoid sEMG and VFSS assessments. 
 

11 
 
 
Figure 1. CONSORT 2010 flow diagram of participant recruitment, randomization, 
follow-up, and analysis in the TPRT trial 
Intervention and comparator delivery 
 
All participants in the intervention group adhered to the tongue-to-palate 
resistance training (TPRT) protocol, consisting of 30 repetitions per session, five 
sessions per week, performed at home with caregiver support, video guidance, and 
logbook monitoring. In the control group, participants received the standard hospital-
based protocol of neuromuscular electrical stimulation (NMES) or biofeedback twice 
weekly, followed by unsupervised home-based chin-tuck against resistance (CTAR) 

12 
 
exercises. Both groups were able to complete their assigned interventions as scheduled 
during the study period. 
 
Concomitant care 
 
Both groups additionally received standardized education on posture adjustment, 
swallowing maneuvers, and bolus modification to ensure safe swallowing. 
 
Patients’ characteristics 

13 
 
 
A total of 17 participants completed the full 8-week protocol, including 
suprahyoid surface electromyography (sEMG) and videofluoroscopic swallowing study 
(VFSS) assessments. Due to non-normal distribution of sEMG data, natural log 
transformation was applied, and repeated measures ANOVA (GLM approach) was used 
for analysis. Baseline characteristics are summarized in Table 1. The mean age of all 
subjects was 70.18 ± 6.24 years, with no significant age difference between the 
intervention group (69.67 ± 4.67 years) and the control group (70.75 ± 7.97 years). Male 
participants accounted for 58.8% of the sample, with a slightly higher proportion in the 
control group (62.5%) than in the intervention group. 
 
Body mass index (BMI) was non-normally distributed and showed no 
significant difference between groups, with a median of 22.14 (19.22–30.41) kg/m² in 
the intervention group and 21.14 (16.9–29.4) kg/m² in the control group. The Charlson 
Comorbidity Index (CCI) was slightly higher in the intervention group [median 6 (3–8)] 
compared to the control group [median 5 (3–8)]. The proportion of frailty was 
marginally higher in the control group (62.5%) than in the intervention group (55.6%). 
 
The most common etiology of dysphagia was stroke (47.1%), followed by 
laryngopharyngeal reflux (LPR, 41.2%) and nasopharyngeal malignancy (11.8%). The 
baseline PAS score was 4 (2–8) in the intervention group and 4.5 (2–8) in the control 
group. Penetration (70.6%) was more prevalent than aspiration (29.4%) across both 
groups. 
 
Table 1 Patients’ characteristics 

14 
 
Characteristics 
Total 
Group 
Intervention 
(n=9) 
Control 
(n=8) 
Age (years)  
70,18 ±6,24  
69,67 ±4,67  
 
70,75 ±7,97  
 
60-69 
10 (58,8%) 
6 (66,7%) 
 
4 (50%) 
 
70-79 
6 (35,3%) 
3 (33,3%) 
 
3 (37,5) 
 
>80 
1 (5,9%) 
0 (0%) 
 
1 (12,5%) 
 
Gender 
 
 
 
 
 
Male 
10 (58,8%) 
5 (55,6%) 
 
5 (62,5%) 
 
Female 
7 (41,2%) 
4 (244,4%) 
 
3 (37,5%) 
 
BMI (kg/m2) 
21,6(16,9-30,41)  
22,14(19,22-
30,41)  
 
21,14(16,9-
29,4)  
 
CCI 
5(3-8) 
6(3-8) 
 
5(3-8) 
 
Mild  
0 (0%) 
0 (0%) 
 
0 (0%) 
 
Moderate  
6 (35,3%) 
3 (33,3%) 
 
3 (37,5%) 
 
Severe  
11 (64,7%) 
6 (66,6%) 
 
5 (62,5%) 
 
Frailty 
 
 
 
 
 
Yes 
10 (58,8%) 
5 (55,6%) 
 
5 (62,5%) 
 
No 
7 (41,2%) 
4 (44,4%) 
 
3 (37,5%) 
 
Etiology 
 
 
 
 
 
Stroke  
8 (47,1%) 
4 (44,4%) 
 
4 (50%) 
 
Laryngopharyngeal 
Reflux (LPR) 
6 (35,3%) 
4 (44,4%) 
 
2 (25%) 
 
Nasopharyngeal 
3 (17,6%) 
1 (11,1%) 
 
2 (25%) 
 

15 
 
cancer 
Dysphagia severity 
(PAS) 
5(2-8) 
4(2-8) 
 
4,5(2-8) 
 
Penetration 
12 (70,6%) 
7 (77,8%) 
 
5 (62,5%) 
 
Aspiration 
5 (29,4%) 
2 (22,2%) 
 
3 (37,5%) 
 
 
Suprahyoid Muscle Electrical Activity 
 
Baseline measurements showed comparable activity between the intervention 
and control groups in both tongue-pressed and dry swallowing conditions. At week 4 
and week 8, the intervention group showed an increase in median electrical activity 
during tongue-pressed movements from 34.54 (24.32–36.91) µV RMS to 49.12 (31.28–
58.42) µV and 60.87 (28.84–95.79) µV respectively. The control group exhibited a 
smaller increase from 32.26 (23.42–34.89) µV to 33.13 (30.13–54.38) µV and 42.99 
(25.55–89.04) µV. During dry swallowing, the intervention group improved from 35.38 
(25.95–36.99) µV RMS at baseline to 50.06 (29.75–69.85) µV at week 4 and 63.91 
(27.32–91.99) µVat week 8. The control group increased from 33 (21.43–35.80) µV to 
32.14 (24.7–59.15) µV and 54.04 (31.13–85.37) µV. Table 2 describes the increase in 
suprahyoid muscle electrical activity in both the intervention and control groups during 
tongue-pressed and dry swallowing movements. Both groups had similar baseline 
values in tongue-pressed movement as well as in dry swallowing. 
 

16 
 
Table 2. Suprahyoid Muscle Activity Before and After Training in the Intervention and 
Control Groups 
Suprahyoid muscle 
electrical activity 
Baseline 
Week 4 
Week 8 
Tongue pressed (μVRMS) 
Intervention 
34,54(24,32-36,91) 
49,12(31,28-58,42) 
60,87(28,84-95,79) 
Control 
32,26(23,42-34,89) 
33,13(30,13-54,38) 
42,99(25,55-89,04) 
Dry swallowing (μVRMS) 
Intervention 
35,38(25,95-36,99) 
50,06(29,75-69,85) 
63,91(27,32-91,99) 
Control 
33(21,43-35,80) 
32,14(24,7-59,15) 
54,04(31,13-85,37) 
 
 
Repeated Measures ANOVA (GLM approach) was performed after log 
transformation of non-normally distributed data. Mauchly’s test of sphericity indicated 
violation of the assumption (p < 0.05), requiring Greenhouse-Geisser correction. The 
results indicated a significant time effect for both tongue-pressed (p = 0.000, η² = 0.693) 
and dry swallowing (p = 0.000, η² = 0.669), while time*group interaction was not 
significant, indicating similar patterns of change in both groups. Between-group effects 
analysis did not yield statistically significant results (p > 0.05), though effect sizes were 
moderate to large (η² = 0.164 for tongue pressed, η² = 0.123 for dry swallow), 
suggesting a potential clinical impact. Figure 1 illustrates the trend of mean log-
transformed suprahyoid muscle activity during tongue-pressed and dry swallowing tasks 
across baseline, week 4, and week 8, showing a consistent increase in both the 
intervention and control groups, with greater improvement observed in the intervention 
group. 

17 
 
 
Figure 1. General Linear Model of Suprahyoid Muscle Electrical Activity 
 
Penetration-Aspiration Scale (PAS) 
 
VFSS evaluation prior to the intervention showed similar PAS scores between 
groups: median (min–max) PAS was 4 (2–8) in the intervention group and 4.5 (2–8) in 
the control group, with no statistically significant difference (p > 0.05). After 
completing the training protocol, both groups demonstrated a reduction in PAS at week 
8: 2 (1–8) in the intervention group and 2 (1–8) in the control group. However, the 
difference between groups remained statistically non-significant (p > 0.05). Table 3 
presents the comparison of Penetration-Aspiration Scale (PAS) scores between the 
intervention and control groups at baseline and after 8 weeks of training. While both 
groups showed a reduction in median PAS scores following the intervention period, no 
statistically significant differences were observed either within or between groups. 
Table 3. Comparison of Parameters Before and After Training in the Intervention and 
Control Groups 

18 
 
Parameter 
Group 
Baseline 
Week 8 
p-value 
Anterior hyoid 
mo
ve
me
nt 
(%
C2
–
C4
) 
Intervention 
15.75 (3.21–24.43) 
28.26 (3.5–45.18) 
0.038ʷ 
 
Control 
14.09 (0.96–17.54) 
14.48 (1.07–23.69) 
0.161ʷ 
 
p-value between groups 
0.178ᵐ 
0.021ᵐ 
 
Superior hyoid 
mo
ve
me
nt 
(%
C2
–
C4
) 
Intervention 
14.52 (5.54–38.85) 
22.07 (4.83–38.33) 
0.086ʷ 
 
Control 
16.56 (10.68–34.62) 
19.50 (1.77–48.93) 
0.327ʷ 
 
p-value between groups 
0.441ᵐ 
0.564ᵐ 
 

19 
 
PTT (seconds) 
Intervention 
0.63 (0.1–1) 
0.73 (0.23–0.83) 
0.859ʷ 
 
Control 
0.68 (0.5–1) 
0.74 (0.33–5.6) 
0.327ʷ 
 
p-value between groups 
0.923ᵐ 
0.310ᵐ 
 
PAS 
Intervention 
4 (2–8) 
2 (1–8) 
0.232ʷ 
 
Control 
4.5 (2–8) 
2 (1–8) 
0.753ʷ 
 
p-value between groups 
1.000ᵐ 
0.797ᵐ 
 
 
Pharyngeal transit time (PTT) 
 
Other parameters assessed using VFSS in this study included Pharyngeal Transit 
Time (PTT) and anterior and superior hyoid movement. As shown in Table 3, PTT 
evaluation revealed no significant differences within or between the intervention and 
control groups before and after training (p > 0.05). 
Effects of TPRT to hyoid movement 
Hyoid movement in the anterior and superior directions was expressed as a 
percentage of the C2–C4 distance, normalized by dividing each measurement by the 
length of a straight line connecting the inferior borders of C2 and C4 on the y-axis. 
Table 3 displays the changes in anterior and superior hyoid excursion. No significant 
differences were observed between groups at baseline for either direction (p > 0.05). 
However, in the intervention group, a statistically significant increase was found in 
anterior hyoid movement between baseline and week 8 (p = 0.038). Additionally, an 
intergroup comparison at week 8 showed a significant difference in anterior hyoid 
movement (p = 0.021) 
 

20 
 
Discussion 
 
This study aimed to evaluate changes in swallowing function in geriatric patients 
with oropharyngeal dysphagia by analyzing suprahyoid muscle activity and the 
Penetration-Aspiration Scale (PAS). Participants were assigned to either a home-based 
TPRT group using video guidance and logbook monitoring or a control group receiving 
standard care, including NMES or biofeedback sessions and unsupervised CTAR 
exercises. 
 
Findings showed that both groups experienced significant increases in 
suprahyoid muscle activity from baseline to weeks 4 and 8 during tongue-pressed and 
dry swallowing tasks. While between-group differences were not statistically 
significant, the large effect sizes observed in the intervention group suggest potential 
clinical relevance. These results align with previous studies showing improved tongue 
strength after TPRT or similar resistance training protocols. A more recent study by 
Kim et al. demonstrated that home-based tongue-to-palate training in stroke patients 
was as effective as hospital-based programs, with both groups showing significant 
improvement in tongue muscle strength and volume without differences between the 
two delivery modes.41 
 
Previous studies by Kim et al. reported that the positive effects of TPRT could 
be observed as early as after 4 weeks of training in tongue muscle strength.10 Similarly, 
Plaza et al. found a statistically significant increase in suprahyoid muscle sEMG values 
by the 4th week of combined tongue-to-palate pressing and strengthening exercises 
using IOPI, reaching 57.3±13.6 %MVC by the 8th week with tongue-to-palate pressing 
alone.21 Resistance training improves muscle performance through neural mechanisms 
such as increased motor unit recruitment and hypertrophy mediated by muscle IGF and 

21 
 
myogenic factors.22–24 Robbins et al. further emphasize post-stroke swallowing recovery 
may involve neuroplasticity.25–27 
 
TPRT targets oral and pharyngeal phases of swallowing by strengthening 
muscles responsible for bolus formation and palatal contact.15,28,29 The activation of 
genioglossus and hyoglossus muscles indirectly enhances geniohyoid and suprahyoid 
activity.9,17,28,29 Although sEMG reference values vary due to age and normalization 
methods, a consistent upward trend in sEMG across this study indicates positive 
training effects. 30–32 
 
The PAS decreased in both groups by week 8, but without significant between-
group differences. Similar findings have been reported in older adults receiving tongue 
resistance training.20,33,34 One possible explanation is the "floor effect" in participants 
with initially low PAS scores, limiting the ability to detect statistical improvements. 
Additionally, PAS is affected by multiple physiological factors such as pharyngeal 
timing and hyoid displacement.35–37 Bingjie et al. identified increased pharyngeal delay 
time, prolonged pharyngeal transit time, and reduced maximal vertical displacement of 
the larynx and hyoid bone as independent predictors of aspiration in older adults.42 
Similarly, Zhang et al. demonstrated in a large cohort that anterior hyoid displacement 
was the most reliable predictor of penetration–aspiration risk, highlighting the critical 
biomechanical role of hyoid excursion in swallowing safety.43 
 
Furthermore, no significant change in PTT was observed, possibly due to 
participant heterogeneity and age-related physiological changes.38 In contrast, Namiki et 
al. reported shortened PTT post-TPRT in a healthier cohort.11 This study observed 
statistically significant improvements in anterior hyoid movement among intervention 
participants. Anterior hyoid displacement is essential for upper esophageal sphincter 

22 
 
(UES) opening and airway protection. Increased anterior hyoid movement suggests 
neuromuscular adaptations from TPRT, even though PAS scores remained unchanged. 
These results indicate potential for improving biomechanical aspects of swallowing.39,40 
 
In summary, TPRT may enhance suprahyoid muscle activity and anterior hyoid 
excursion in older adults with oropharyngeal dysphagia. Though PAS and PTT changes 
were not statistically significant, the observed physiological improvements highlight 
TPRT as a feasible and promising home-based intervention. 
 
Strengths and limitations 
 
This is the first randomized controlled trial in Indonesia to evaluate tongue-to-
palate resistance training (TPRT) in geriatric patients with oropharyngeal dysphagia. Its 
simple, equipment-free protocol supports feasibility for home-based use. However, the 
heterogeneous sample, small sample size, and high data variability may have limited 
statistical significance despite moderate-to-large effect sizes. A floor effect in PAS 
scores and use of only thin-liquid consistency for VFSS may also limit generalizability. 
 
Conclusion 
 
Tongue-to-palate resistance training (TPRT) has the potential to enhance 
suprahyoid muscle electrical activity in geriatric patients with oropharyngeal phase 
dysphagia. However, this intervention did not result in a statistically significant 
reduction in Penetration-Aspiration Scale (PAS) scores in the studied population. This 
study supports the feasibility of implementing home-based TPRT as a clinical 
intervention for geriatric patients with oropharyngeal dysphagia. The training protocol 
may serve as a reference for rehabilitation programs targeting swallowing function in 

23 
 
this population. Future studies should involve larger and more homogenous sample 
populations to increase statistical power and generalizability. Additionally, longer 
training durations or combined exercise protocols are recommended to further explore 
the potential therapeutic effects of TPRT in this patient group. 
 
Sources of Funding 
The author did not receive any source of funding. 
 
Conflict of Interest 
The author declares no conflict of interest. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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[Internet]. 2020;35(1):66–72. Available from: https://doi.org/10.1007/s00455-019-
10000-5 
 

Table 3. Comparison of Parameters Before and After Training in the Intervention and Control Groups 
Parameter 
Group 
Baseline 
Week 8 
p-value 
Anterior hyoid movement (%C2–C4) 
Intervention 
15.75 (3.21–24.43) 
28.26 (3.5–45.18) 
0.038ʷ 
 
Control 
14.09 (0.96–17.54) 
14.48 (1.07–23.69) 
0.161ʷ 
 
p-value between groups 
0.178ᵐ 
0.021ᵐ 
 
Superior hyoid movement (%C2–C4) 
Intervention 
14.52 (5.54–38.85) 
22.07 (4.83–38.33) 
0.086ʷ 
 
 
Control 
16.56 (10.68–34.62) 
19.50 (1.77–48.93) 
0.327ʷ 
 
p-value between groups 
0.441ᵐ 
0.564ᵐ 
 
PTT (seconds) 
Intervention 
0.63 (0.1–1) 
0.73 (0.23–0.83) 
0.859ʷ 
 
Control 
0.68 (0.5–1) 
0.74 (0.33–5.6) 
0.327ʷ 
 
p-value between groups 
0.923ᵐ 
0.310ᵐ 
 
PAS 
Intervention 
4 (2–8) 
2 (1–8) 
0.232ʷ 
 
Control 
4.5 (2–8) 
2 (1–8) 
0.753ʷ 
 
p-value between groups 
1.000ᵐ 
0.797ᵐ 
 
 
m) 
Mann-Whitney 
Test; 
w) 
Wilcoxon 
Test