Tongue Pressure Profile Training for Dysphagia Post Stroke
Condition: Dysphagia
MeSH terms: Deglutition Disorders
Study type: Interventional
Phase: Phase 2

Summary: 
      People with swallowing impairment experience particular difficulty swallowing thin liquids
      safely; the fast flow of liquids makes them difficult to control. The tongue plays a critical
      role in containing liquids in the mouth, channeling the direction of their flow towards the
      pharynx (throat) and controlling their flow along that channel. The investigators are engaged
      in a program of research to better understand tongue function in swallowing, particularly
      with respect to controlling the flow of liquids. In this study the investigators will compare
      two different tongue-pressure resistance training protocols, to determine whether a protocol
      that emphasizes strength-and-accuracy or one that emphasizes pressure timing work better for
      improving liquid flow control in swallowing.
    

Detailed description: 
      Drinking thin liquids is something that most of us take for granted; yet this task is one
      that many patients with dysphagia (swallowing impairment) cannot do safely. Instead, these
      individuals receive liquids in thickened form: thickened juice, thickened coffee… even
      thickened water. The literature tells us that patients dislike the taste and feel of
      thickened liquids and find that their thirst is not quenched. Patients on thickened liquids
      are prone to inadequate fluid intake and dehydration. Many patients are non- compliant and
      drink thin liquids, despite documented risk for aspiration (i.e., airway invasion) and its
      consequences. Given these limitations, it is important that dysphagia researchers continue to
      pursue treatments with the potential to restore safe and functional thin liquid swallowing in
      people with dysphagia.

      In the past decade, tongue pressure resistance training has emerged as an innovative
      treatment for dysphagia. Dr. JoAnne Robbins (University of Wisconsin - Madison)has shown that
      8-weeks of intensive tongue pressure resistance training improves tongue strength in healthy
      seniors and those with dysphagia following stroke. In our lab (the Swallowing Rehabilitation
      Research Laboratory at the Toronto Rehabilitation Institute), the investigators have studied
      a variation on Dr. Robbins' treatment called "Tongue Pressure Strength and Accuracy
      Training". This approach also improves tongue strength and improves aspiration. However, the
      investigators continue to be bothered by the fact that people with dysphagia post stroke
      often have difficulty controlling the flow of thin liquids, even after these strength-focused
      protocols of tongue-pressure training.

      The investigators have recently completed a study of tongue pressures profiles (strength and
      timing) in healthy people, which shows that tongue pressures are released more slowly with
      thin liquids than with thick liquids. This reveals active control of thin liquid flow, and
      suggests that both the strength and timing of tongue pressure play a role in flow-control.
      The investigators believe that treatment outcomes may be better if tongue pressure resistance
      training protocols take both strength and timing into consideration. To this end, the
      investigators have recently identified a subset of tongue pressure training tasks for which
      the strength and timing profile of tongue pressure onset and release is similar to that seen
      in liquid swallowing. The investigators propose that a treatment protocol will have better
      potential to yield favourable outcomes for thin liquid flow-control if it focuses on such
      tasks.

      In this study, the investigators want to determine whether tongue pressure profile training,
      which addresses both timing and amplitude issues in tongue pressure generation, yields better
      functional outcomes in swallowing than strength-and-accuracy focused treatment. The
      investigators will pursue this question in a small randomized prospective trial, building on
      our prior work in this area.

      The investigators will recruit 60 new patients with who demonstrate thin liquid flow-control
      difficulties secondary to stroke. These individuals will be randomized either to
      tongue-pressure strength-and-accuracy training (TPSAT) or to the novel intervention,
      tongue-pressure profile training (TPPT). The investigators will study their treatment
      outcomes after 12 weeks (24-sessions) of treatment.
    

Intervention name(s): Tongue Pressure Profile Training; Tongue-Pressure Strength-and-Accuracy Training
Intervention type(s): Behavioral; Behavioral
Intervention description(s): 60 tongue-pressure tasks per session, emphasizing control of the slope of tongue pressure release, informed by biofeedback. Pressures will be measured using a hand-held oral manometer (Iowa Oral Performance Instrument) with signals displayed on a computer.; 60 tongue-pressure tasks per session, emphasizing maximum effort strength tasks and accuracy targets within 20-95% of each patient's maximum, informed by biofeedback. Pressures will be measured using a hand-held oral manometer (Iowa Oral Performance Instrument) with amplitude output in kiloPascals displayed on an LCD screen.
Other intervention name(s): Iowa Oral Performance Instrument; Iowa Oral Performance Instrument
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Dysphagia; Viscosity; Tongue; Pressure