Exploring the Efficacy of the Effortful Swallow Maneuver for Improving Swallowing in People With Parkinson Disease
Phase: NA
Conditions: Parkinson Disease, Dysphagia
Sponsor: University Health Network, Toronto

Steele. Effortful Swallow maneuver for Swallowing Impairment in Parkinson Disease 
  
Version date: Jan 14, 2022 
 
 
CAPCR-ID: 21-5814 
NCT NCT05319795 
 
STUDY PROTOCOL 
 
Exploring the Efficacy of the Effortful Swallow Maneuver for 
Improving Swallowing in People with Parkinson Disease 
 
PI: Catriona M. Steele, Ph.D. 1 
Co-I:  Connie Marras, MD, Ph.D. 2  
1 Toronto Rehabilitation Institute – University Health Network 
2 Edmond J Safra Program in Parkinson's Disease and Morton and Gloria 
Shulman Movement Disorders Clinic, Toronto Western Hospital, University 
of Toronto 
 

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Contents 
 
LIST OF ABBREVIATIONS .......................................................................................................... 3 
Background Information ................................................................................................................ 4 
Study Objectives and Hypotheses ................................................................................................ 4 
Outcome measures: .................................................................................................................. 4 
Hypotheses ............................................................................................................................... 5 
Study Design ................................................................................................................................. 5 
Selection of participants: ........................................................................................................... 5 
Inclusion Criteria ........................................................................................................................ 5 
Review of consent form: ............................................................................................................ 6 
Baseline study appointment procedures: .................................................................................. 6 
Study Intervention ......................................................................................................................... 9 
Risks ........................................................................................................................................... 10 
Benefits ....................................................................................................................................... 11 
Honorarium ................................................................................................................................. 11 
Data processing and analysis ..................................................................................................... 11 
Statistics ...................................................................................................................................... 11 
Conflicts of interest ..................................................................................................................... 11 
Direct Access, Handling and Record Keeping of Source Data ................................................... 12 
Quality Control and Quality Assurance Procedures .................................................................... 12 
References .................................................................................................................................. 12 
 
 
 

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LIST OF ABBREVIATIONS 
 
ASPEKT 
Analysis of Swallowing Physiology: Events, Kinematics and Timing 
ES 
 
Effortful swallow  
H&Y 
Hoehn & Yahr 
IOPI 
Iowa Oral Performance Instrument  
LVC 
 
Laryngeal Vestibule Closure  
mSv 
Millisieverts  
NIH 
National Institutes of Health  
PD 
 
Parkinson Disease 
PhAMPC 
Pharyngeal area at maximum constriction 
RES 
Regular effort swallow 
SRRL 
Swallowing Rehabilitation Research Laboratory 
TWH 
Toronto Western Hospital 
UHN 
University Health Network 
VFSS  
Videofluoroscopic Swallowing Study 
 
 
 

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Background Information 
 
Parkinson Disease (PD) is a common neurological disorder that is expected to affect 9 million 
people by 2030. Dysphagia (swallowing impairment) is highly prevalent in PD and can result in 
aspiration pneumonia, malnutrition, and dehydration. The most common intervention for 
dysphagia is the use of thickened liquids and modified food textures.  
However, due to dissatisfaction with their texture and taste, sensation of increased satiety and 
increased thirst with increasingly viscous fluids, this approach is reported by patients to 
negatively impact swallowing-related quality of life.  
The purpose of this study is to determine if an exercise-based approach called the Effortful 
Swallow maneuver is an effective intervention for dysphagia in PD that will enable people with 
PD and dysphagia to continue to consume regular foods and liquids.  
Research has found that while there are no optimal interventions, exercise-based interventions 
targeting improved swallowing efficiency and muscle strength hold promise (El Sharkawi et al., 
2002; Miles et al., 2017; Pitts et al., 2009; Athukorala et al., 2014; Troche et al., 2008). To select 
targeted exercise goals for dysphagia therapy, it is important to identify the physiological 
mechanisms contributing to swallowing impairment in PD. Studies identify two key mechanisms 
of swallowing impairment in PD: 1) prolonged time-to-laryngeal-vestibule-closure (time-to-
LVC)which is a risk for aspiration; and 2) reduced pharyngeal constriction, leading to pharyngeal 
residue after the swallow (Ellerston et al., 2016; Nascimento et al., 2020; Curtis et al., 2020; 
Gandhi et al., 2021). In other patients with dysphagia, the Effortful Swallow (ES) maneuver is 
commonly used to target faster airway protection and improved bolus clearance (Hind et al., 
2001; Fukuoka et al., 2013).  
Study Objectives and Hypotheses  
The objective of this project is to determine the immediate (compensatory effect) and long term 
efficacy (rehabilitative effect) of a 4-week program of the effortful swallow maneuver intervention 
on physiological swallowing parameters in Parkinson Disease. The Videofluoroscopic 
Swallowing Study (VFSS) recordings will be analyzed in duplicate according to a rigorous 
standard procedure known as the ASPEKT Method (Analysis of Swallowing Physiology: Events, 
Kinematics and Timing), from which the following outcomes will be measured. . 
Outcome measures: 
Primary Outcomes: 
 
Time-to-laryngeal vestibule-closure (i.e., the time interval between onset of the hyoid 
burst movement at the beginning of a swallow and achieving airway protection via 
closure of the laryngeal vestibule  
 
Swallowing safety and airway protection status as measured by the Penetration-
Aspiration Scale (Rosenbek et al., 1996) 
 
The degree of pharyngeal constriction during swallowing (“pharyngeal area at maximum 
constriction”)  
 
The amount of residue left behind in the pharynx after a swallow. 
 
Secondary Outcomes:  
 
The number of swallows per bolus 
 
Maximum value across 3 repetitions of a maximum tongue-palate press using the Iowa 
Oral Performance Instrument in an anterior position. 

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Hypotheses 
We expect that use and repeated practice of the ES will lead to show differences post-
interventionin swallowing function and physiology compared to baseline, as listed in the 
following table: 
 
 
Study Design 
Participants with Parkinson Disease will be recruited over 18-24 months to participate in a 
dysphagia intervention protocol. This protocol will be a single arm feasibility study to determine 
the impact of the ES maneuver intervention on swallowing physiology. Participants who display 
prolonged time-to-LVC, and/or poor pharyngeal constriction during their baseline 
videofluoroscopic x-ray of swallowing (VFSS) compared to healthy reference values will be 
enrolled in a 4-week intervention program, with two 30-minute sessions of ES practice daily, 5 
days per week. See Figure 1 for a summary of participant recruitment and study procedures. 
Selection of participants:  
Potential participants will be identified by staff at the Toronto Western Hospital’s Movement 
Disorders Clinic, who will make contact to introduce the research program and obtain verbal 
consent to provide the study team with the participant’s contact information (phone number 
and/or email, as preferred by the participant). The Movement Disorders Clinic staff will select 
potential participants based on the following criteria:  
Inclusion Criteria  
 
At least 18 years old 
 
English-speaking 
Parameter 
Prediction post-intervention of effortful swallow maneuver         
(vs baseline regular effort swallows) 
Primary outcomes: 
Time-to-Laryngeal-
Vestibule-Closure (time-
to-LVC) 
Earlier closure leading to shorter time to laryngeal vestibule 
closure 
Penetration-Aspiration 
Score (PAS) 
Lower frequency of airway invasion events due to earlier 
time-to-LVC 
Pharyngeal Area at 
Maximum Constriction 
(PhAMPC) 
Smaller pharyngeal area at maximum constriction (i.e. better 
constriction)                                       
Residue 
Reduced pharyngeal residue due to better constriction 
Secondary outcomes: 
# of swallows per bolus 
Lower number of swallows per bolus due to better bolus 
clearance 
Maximum anterior 
isometric pressure  
Increased tongue pressure 

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 
Able to follow study instructions 
 
Neurologist confirmed diagnosis of PD 
 
Hoehn and Yahr scale score of 2 or 3 
 
Self-report of one or more swallowing or related symptoms: 
 Difficulty with secretion management  
 Coughing at the meal time 
 Choking on food  
 Respiratory infection in the past 6 months (other than COVID) 
Exclusion Criteria  
 
History of head and neck cancer  
 
Radical neck dissection (e.g. anterior cervical spine surgery) or neck/ oropharyngeal 
surgery (not excluded – tonsillectomy, adenoidectomy)  
 
Past medical history of any neurological disease other than PD (e.g. multiple 
sclerosis, amyotrophic lateral sclerosis, traumatic brain injury, stroke)  
 
Cognitive or receptive communication difficulties that preclude the participant’s ability 
to follow study instructions provided in English. This will be determined by the 
participant’s physician prior to referring them to the study. 
The target sample size is 12 participants. We expect the ratio of males: females to be 1.5:1, 
reflecting the ratio of males to females in the PD population.  
Review of consent form:  
All participants that express interest in participating and have agreed to allow the Movement 
Disorders clinic to share their contact information with the study team will be contacted by study 
personnel of the Swallowing Rehabilitation Research Laboratory. Participants that show 
continued interest after a brief introduction will be provided with the study information and 
consent form ahead of a telephone or video-conference call (using MS Teams) to answer any 
questions. We will proceed to schedule a study appointment after the participant confirms they 
have understood all the information that is provided and after verifying they have no more 
questions and wish to proceed. The formal written consent will be obtained at the beginning of 
the baseline study appointment, and a copy of the consent form will be provided to the 
participant. If a participant does not wish to participate in the study, they will no longer be 
contacted by study personnel; a decision not to participate will have no impact on clinical 
services provided.  
Baseline study appointment procedures:  
 
1) Demographic and medical history information:  
Participants will be asked to complete a form capturing demographic, medical history 
and history of PD symptoms. The following data will be collected:  
i. Year of birth 
ii. Sex 
iii. Relevant medical history and ongoing treatments (e.g. presence/location 
of a deep brain stimulator).  
iv. Race/ethnicity  
v. Time post-onset of symptoms (initial and swallowing-specific); 
vi. Allergies to barium contrast, food thickeners or latex. 

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b. Participants will be requested to complete a 26 item validated questionnaire 
entitled the Munich Dysphagia Test – Parkinson’s Disease to understand the 
nature of swallowing difficulties experienced and associated burden. 
2) Tongue strength:  
Bulbar muscle strength will be measured using 3 repetitions of a maximum effort 
isometric tongue-to-palate press task using the Iowa Oral Performance Instrument 
(IOPI). A clean, single-use disposable tongue bulb will be used for each participant.  
 
3) VFSS: 
Stimulus preparation: Bracco E-Z-Paque® powdered barium will be prepared in 20% w/v 
concentration with water, and thickened to target consistency using Resource Thicken-
Up™ Clear (a xanthan gum thickener developed by Nestlé Health Science). Target 
consistency will be defined using the International Dysphagia Diet Standardisation 
Initiative definitions and Flow Test. All stimuli will be prepared no longer than 6 hours 
prior to scheduled use, according to a strict standard operating procedure.  
 
Procedure: Three cups of each stimulus will be prepared for the experiment, each 
containing 40 ml and organized in a muffin tray placed in front of the participant (please 
see table below for the order of the exams). The participant will be asked to take a 
comfortable sip from each cup. The cups will be weighed on a digital balance at the 
conclusion of the session to derive estimates of sip volume.  
 
Recording: The videofluoroscopic swallowing study will be captured in lateral projection 
using pulsed videofluoroscopy at a rate of 30 pulses per second, and recorded on a 
synchronized videocapture system at 30 frames per second. 
Timeline and location: A baseline VFSS will be conducted by speech-language 
pathologists at the Outpatient Swallowing Clinic at Toronto Western Hospital’s Gastric 
Suite. 
 
Order of stimuli:  
i. 
Saliva swallow (with no external barium bolus) to be used for land-marking  
ii. 
Up to 3 regular effort swallows of thin liquid 
iii. 
Up to 3 effortful swallows of thin liquid 
iv. 
Up to 3 regular effort swallows of mildly-thick liquid 
v. 
Up to 3 effortful swallows of mildly-thick liquid 
 
Intervention eligibility: Participants that display prolonged time-to-LVC measures and/or 
poor pharyngeal constriction measures compared to healthy reference values on the 
baseline VFSS with thin or mildly thick stimuli will be eligible for the intervention portion 
of this research study (described below). Once a participant has been deemed eligible, 
staff at the Toronto Western Hospital’s Movement Disorders Clinic will then provide the 
study personnel with an updated Hoehn & Yahr scale score and medication list prior to 
proceeding with the intervention. Participants who do not display impaired time-to-LVC 
and/or PhAMPC on the baseline VFSS will be withdrawn and will not continue to the 
intervention portion of the study. 
 

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Figure 1. Summary of participant recruitment and study procedures  
 
 
 
 
 
 
TWH Movement 
Disorders Clinic
•Identify eligible 
participants 
based on 
inclusion and 
exclusion list
TRI ‐ SRRL study 
personnel
•Detailed 
overview of the 
study with 
participant via 
phone/tele‐
conference
•If agreeable to 
participate, 
consent form to 
be signed at the 
start of the 
baseline study 
appointment
TWH Outpatient 
Swallowing Clinic 
•Baseline study 
appointment  
including 
demographic 
and medical 
history by study 
staff and a VFSS 
conducted by th 
TWH outpatient 
SLP team
•If prolonged 
time‐to‐LVC 
and/or poor 
pharyngeal 
constriction 
identified, 
participant is 
eligible for study
TWH Movement 
Disorders Clinic
•Once eligible, 
TWH movement 
disorders team 
to provide study 
staff with
•pt's medication 
list and
•PD history prior 
to enrollment
TGH ‐ SRRL study 
personnel
•Post‐
intervention 
VFSS conducted 
at TGH by study 
personnel
4-week ES 
intervention 
program 

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Study Intervention 
A 4-week intervention program with two 30-minute sessions of ES practice daily, 5 days per 
week will be offered to eligible participants based on confirmation of intervention candidacy in 
the  baseline VFSS.  
Practice will be supervised on a reducing schedule (week 1: 5 sessions; week 2: 4 sessions, 
etc.), via a secure videoconference using Microsoft Teams. Which days the intervention will be 
performed and supervised will be dependent on the availability of the participant and the study 
team member. This will be determined at the start of the protocol with each participant. There is 
no requirement to practice at the same time each day or to practice on the same days of the 
week each consecutive week. 
Intervention will involve biofeedback provided using the Iowa Oral Performance Instrument.  An 
IOPI device will be loaned to each participant for home use at the end of baseline 
videofluoroscopy, and a set of disposable pressure bulbs will be provided to cover the course of 
intervention. Participants will not be held responsible for lost or broken devices. Additionally, a 
supply of thickener will be provided to each participant for use in home practice sessions. 
Instruction in use of all supplies will be provided.  
Practice Sessions: Each session will include: 
 15 regular saliva swallows with the IOPI bulb in place. The mark on the connecting tube 
will be aligned with the upper incisors. A rest period of 20 seconds will be utilized 
between saliva swallow.  
 15 effortful saliva swallows with the IOPI bulb in place. The mark on the connecting tube 
will be aligned with the upper incisors. A rest period of 20 seconds will be utilized 
between saliva swallow. 
 15 effortful swallows of mildly thick liquid without the IOPI bulb in place, for 
generalization. A mandatory rest period of 20 seconds will be utilized between trials. 
Participants will be encouraged to use a stopwatch/timer to ensure at least one swallow/30 
seconds.  
A homework log will be provided to each participant to document the number of tongue presses 
practiced in each session. 
There will be two practice sessions per day.  On days when direct supervision is provided, this 
will replace one of the home practice sessions.  
 
Participants will be encouraged to contact the study team if they have any questions or need 
support. 
Study intervention withdrawal rules: 
Withdrawal rules for the intervention portion of the study are tied to participant absence from 
scheduled intervention sessions. A participant will be withdrawn from the study if they miss a 
total of 3 consecutive scheduled supervised intervention sessions, or develop a new health 
concern.

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Post-intervention VFSS appointment:  
Timeline and location: Participants that complete the intervention will be scheduled for a post-
intervention VFSS at the end of the 4-week intervention protocol. The post-intervention VFSS 
will be performed at the Toronto General Hospital’s Diagnostic Imaging Gastrics Suite by the 
SRRL study personnel. 
Order of stimuli:  
i. 
Saliva swallow (with no external barium bolus) to be used for land-marking  
ii. 
Up to 3 regular effort swallows of thin liquid 
iii. 
Up to 3 regular effort swallows of mildly-thick liquid 
VFSS stimulus preparation, procedure, and recording details are as described for the baseline 
VFSS described above.  
Risks 
During the consent discussion, the following risks will be disclosed to all participants who 
are considering taking part in the study:  
a) Participants may be experienced from continued practice of the Effortful Swallow 
maneuver, particularly during intervention sessions. Participants will be reminded at the 
beginning of each session to disclose any fatigue to the speech language pathologist 
(SLP) supervising the direct intervention session, and also that they are free to 
discontinue any session at any time or choose to leave the trial if they wish. 
b) Participants may dislike the taste of the stimuli presented for swallowing during the data 
collection sessions; they will be reminded that they are free to discontinue participation 
at any time.  
c) All x-rays, including the video x-ray in this study, involve low levels of radiation exposure. 
Radiation exposure always carries a risk of radiation effects (such as cancer). We 
manage these risks by following standard procedures and keeping radiation dose as low 
as possible. The following information should help to explain this risk: 
a. The risk of developing cancer changes based on sex and age. Lifetime cancer 
risks associated with a full clinical video swallowing x-ray are: 
i. for 60-year-old male: 4.9 per million 
ii. for a 60-year-old female: 7.2 per million   
d) The x-ray is expected to show whether or not the participant has swallowing impairment. 
We are looking for two specific types of swallowing problem: 
a. Food or liquid going into their airway (“aspiration”).  
b. Food or liquid getting stuck in their throat (which we call “residue”). 
If either of these problems occur during the study, the SLP will follow standard 
procedures to encourage the participant to expel the material and decide when study 
VFSS trials and/or exams need to be terminated early.   
 
Incidental Findings 
A swallowing x-ray captures information regarding the structures of the neck and how they 
move during swallowing. It is possible that the VFSS may contain evidence of other, unexpected 
findings that are noticed by the study speech-language pathologist (such as a diverticulum or a 
mass).  In such cases, the study licensed speech-language pathologist will follow routine clinical 

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procedures and ask the on-call radiologist to review the VFSS. If appropriate, the radiologist will 
generate a clinical report documenting the observation. The consent form includes a check box 
prior to the signature line, asking the participant to indicate whether or not they wish to be told 
about incidental findings  
Benefits 
There may or may not be benefits to taking part in the study. Benefits from participating in the 
study include potential amelioration of swallowing difficulties, and furthering knowledge 
regarding interventions for swallowing impairment in the Parkinson Disease population.  
Honorarium  
Once participants have completed all study steps, they will be given $100 in the form of an e-gift 
card for their time and effort. Participants that drop out early but have completed at least 2 
weeks of the intervention protocol, will be given $50 in the form of an e-gift card. Compensation 
will be provided upon return of loaned study equipment. 
Data processing and analysis  
All data processing and analysis will take place at SRRL – TRI. Prior to data analysis, each 
VFSS will be de-identified by study staff at TRI and the audio signal will be removed to limit the 
communication of any information that might bias the raters. The de-identified recordings will 
then segmented into bolus clips which will be randomized for rating. Blinded rating will be 
completed by trained raters (minimum of 30% to be completed in duplicate to ensure reliability). 
Raters will additionally be blinded to VFSS time-point (pre vs post-intervention), time post 
Parkinson Disease diagnosis and bolus consistency. The bolus clips will be analyzed by the 
Swallowing Rehabilitation Research Lab using the ASPEKT method.  
Statistics 
We will use Wilcoxon signed rank tests to show differences between baseline regular effort 
swallow (RES), baseline ES and post-intervention RES in the frequency and severity of 
impairment in time-to-LVC, pharyngeal constriction, airway protection and bolus clearance. 
Conflicts of interest  
Professor Steele, the principal investigator, holds current and prior research contracts with 
Bracco Canada and Nestlé Health Science, who are manufacturers of the barium products and 
thickening agents that will be used in this study. She has also served in an advisory capacity on 
expert panels for Nestlé Health Science. All products for use in the study will be purchased. 
Neither Bracco Canada nor Nestlé Health Science will have any role as sponsors of this study. 
Professor Steele will not receive any financial payment, either personally or to the lab, related to 
the use of Nestlé or Bracco products in this study.  Additionally, we will preparing liquids of 
different thicknesses (thin and mildly thick) in this study. The definitions of these thicknesses 
come from a recent framework developed by the International Dysphagia Diet Standardisation 
Initiative (www.iddsi.org).  Professor Steele is a member of the board of directors for IDDSI.  
Participants will be made aware of these relationships during the consent discussion.   

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Direct Access, Handling and Record Keeping of Source Data  
All participant data will be coded using an alphanumeric study code. The master key linking the 
study code to participant identity will be maintained by Professor Steele for the Toronto site, and 
by the lead investigators at Toronto Western Hospital.  
 
SRRL personnel involved in the study (recruitment, consent, and completing the intervention) 
will have direct access to the study related documents. VFSS studies will be de-identified and 
stored electronically on a secure, password-protected, encrypted research drive at Toronto 
Rehabilitation Institute. Any data collected on paper will be kept in a locked filing cabinet in 
addition to being entered into electronic documents and saved on the encrypted research drive.    
The research drive is backed up daily, which will protect against the loss of data.  
 
VFSS data and scanned copies of paper study forms from Toronto Western Hospital site will be 
transferred to the SRRL using UHN’s OneDrive and will then be stored in the same manner as 
the UHN records. 
 
As participant VFSS studies are considered personal health information and are protected 
under the Personal Health Information Protection Act (PHIPA), they will be archived at the end 
of the study and stored at SRRL under the custody of Professor Catriona Steele for a period of 
10 years after which they will be disposed of in a secure manner.  
 
Quality Control and Quality Assurance Procedures 
All VFSS ratings will be completed in accordance to Standard Operating Procedures (SOP) for 
parameters of swallowing physiology described. The individuals who will perform the ratings will 
all be SRRL trainees or employees. Duplication of ratings will be completed and interrater 
reliability will be calculated. 
A description of this clinical trial will be available on http://www.ClinicalTrials.gov, as required by 
U.S. Law  
References  
 
Athukorala, R. P., Jones, R. D., Sella, O., & Huckabee, M. L. (2014). Skill training for swallowing 
rehabilitation in patients with Parkinson's disease. Archives of Physical Medicine and 
Rehabilitation, 95(7), 1374-1382. 
Troche, M. S., Sapienza, C. M., & Rosenbek, J. C. (2008). Effects of bolus consistency on 
timing and safety of swallow in patients with Parkinson’s disease. Dysphagia, 23(1), 26-32. 
El Sharkawi, A., Ramig, L., Logemann, J. A., Pauloski, B. R., Rademaker, A. W., Smith, C. H., 
Pawlas, A., Baum, S., & Werner, C. (2002). Swallowing and voice effects of Lee Silverman 
Voice Treatment (LSVT®): a pilot study. Journal of Neurology, Neurosurgery & Psychiatry, 
72(1), 31-36 
Miles, A., Jardine, M., Johnston, F., de Lisle, M., Friary, P., & Allen, J. (2017). Effect of Lee 
Silverman Voice Treatment (LSVT LOUD®) on swallowing and cough in Parkinson Disease: A 
pilot study. Journal of the Neurological Sciences, 383, 180-187. 

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Pitts, T., Bolser, D., Rosenbek, J., Troche, M., Okun, M. S., & Sapienza, C. (2009). Impact of 
expiratory muscle strength training on voluntary cough and swallow function in Parkinson 
disease. Chest, 135(5), 1301-1308. 
Curtis, J.A., Molfenter, S.M. & Troche, M.S. (2020). Pharyngeal Area Changes in Parkinson 
Disease and Its Effect on Swallowing Safety, Efficiency, and Kinematics. Dysphagia 35, 389–
398 (2020). 
Ellerston, J. K., Heller, A. C., Houtz, D. R., & Kendall, K. A. (2016). Quantitative measures of 
629 swallowing deficits in patients with Parkinson Disease. Annals of Otology, Rhinology & 630 
Laryngology, 125(5), 385-392. 
Nascimento, W. V., Arreola, V. Sanz, P., Necati, E., Bolivar-Prados, M., Michou, E., …, Clave, 
691 P. (2020). Pathophysiology of Swallowing Dysfunction in Parkinson Disease and Lack of 
692 Dopaminergic Impact on the Swallow Function and on the Effect of Thickening Agents. 693 
Brain Sciences, 10, 609. 
Gandhi, P., Mancopes, R., Sutton, D., Plowman, E. K., & Steele, C. M. (2021). The Frequency 
of Atypical and Extreme Values for Pharyngeal Phase Swallowing Measures in Mild Parkinson 
Disease compared to Healthy Aging. Journal of Speech and Hearing Sciences  (in press). 
Hind, J. A., Nicosia, M. A., Roecker, E. B., Carnes, M. L., & Robbins, J. (2001). Comparison of 
effortful and noneffortful swallows in healthy middle-aged and older adults. Archives of physical 
medicine and rehabilitation, 82(12), 1661-1665. 
Fukuoka, T., Ono, T., Hori, K., Tamine, K. I., Nozaki, S., Shimada, K., & Domen, K. (2013). 
Effect of the effortful swallow and the Mendelsohn maneuver on tongue pressure production 
against the hard palate. Dysphagia, 28(4), 539-547.