Vocal Adduction Exercises for Swallowing Rehabilitation in Adults with Typical and Disordered Swallowing: A Scoping Review
Creators: name: Jain, Purvi
name: Tenchini, Beatrice
name: Kenny, Ciarán
Publisher: name: Open Science Framework
Year: 2022
Subjects: subject: Medicine and Health Sciences
subject: Scoping Review
subject: Swallowing Rehabilitation
subject: Vocal Adduction Exercises

description: Authors Purvi Jain1 Beatrice Tenchini1 Ciarán Kenny1 1. Trinity College Dublin, Ireland Abstract Objective: The objective of this scoping review is to understand the extent and type of evidence on different rehabilitative vocal adduction exercises and their effect on swallow physiology, in adults with typical or disordered swallowing. An account of the proposed principles of rehabilitation and outcome measures will be reported. Introduction: In healthy individuals, airway protection during swallowing involves closure of the larynx at multiple levels, including adduction of the true vocal folds and approximation of the false vocal folds (Vose &amp; Humbert, 2019). Different exercises to improve glottic closure during swallowing have been reported in dysphagia research. This review aims to map the evidence on vocal adduction exercises and their physiological effects in swallowing rehabilitation. Inclusion criteria: All published studies in adults (age&gt;=18years) with healthy swallowing and/or dysphagia investigating vocal adduction exercises and their effects on swallow physiology will be included in this review, with no restrictions on time, language or setting. Selected studies must instrumentally measure impact on swallow function, as this provides more valid and quantitative evidence of the physiological effects of the exercises. Methods: The Joanna Briggs Institute methods and PRISMA-ScR guidelines will be used to inform this review. Electronic databases (MEDLINE (PubMed), EMBASE (Ovid), CINAHL (EBSCO) and Web of Science) and grey literature will be searched from inception to March 2022 inclusive, to find studies on vocal adduction exercises and swallowing rehabilitation. Articles will be assessed by two independent reviewers, utilizing a three-step search strategy, to meet the following criteria: (1) exercises targeting vocal cord adduction (2) physiological outcomes measured instrumentally during swallowing, and (3) in typical healthy adults or persons with dysphagia. The resulting evidence map will be reported in tabular form along with a narrative summary. Introduction Vocal fold adduction is a crucial line of defense for airway protection during swallowing. The true and false vocal folds prevent aspiration by restricting entry of material into the lower airway and contribute to the forceful ejection of any material that has already penetrated the laryngeal vestibule (Voce &amp; Humbert, 2019). While compensatory strategies for laryngeal adduction during swallowing are well documented (Logemann, 1983), no comprehensive review has been conducted describing the use or efficacy of vocal adduction exercises in swallowing rehabilitation. Rehabilitative exercises, are intended to change and improve the swallowing physiology in force, speed or timing, with the goal of being able to produce a long-term effect, as compared to compensatory interventions used for a short-term effect (Langmore &amp; Pisenga, 2015). Based on the shared anatomical, physiological, and neurophysiological underpinnings of the voice and swallow mechanism, different rehabilitative exercises targeting glottic closure have been studied to find impact on swallowing function. The complex and heterogenous nature of these studies makes it imperative for a scoping review to map the existing evidence in dysphagia literature. No past or currently underway literature reviews on this topic were identified from our preliminary search. This exploratory project aims to assess the extent of the body of published literature and identify key concepts and knowledge gaps related to vocal adduction exercises for swallowing rehabilitation in healthy adults and, or persons with dysphagia, to apprise clinical practice and future research. Review question Primary questions: What exercises target vocal adduction for swallowing rehabilitation and what are their effects on swallowing physiology in adults with typical swallowing and, or dysphagia? Secondary questions: (1) What are the proposed principles of rehabilitation, and (2) what outcome measures have been reported, in the selected studies? Keywords Dysphagia; Exercise; Rehabilitation; Vocal Adduction; Larynx Eligibility criteria Participants Persons (age&gt;=18years) with healthy swallowing and/or dysphagia are included. Those with typical swallowing are included to examine proof of principle. Those with dysphagia help to generalise results across sampled populations. Paediatric populations will be excluded from the review due to structural and functional differences in body systems and rehabilitative practice. Concept Studies investigating rehabilitative exercises for vocal adduction, that instrumentally examine their effects on swallow function are included in this review. The earlier definition of rehabilitative exercise (Langmore &amp; Pisenga, 2015) is used to guide the review. Instrumental assessment is considered a more valid and reliable way of visualising and assessing movement patterns of swallowing-related structures to formulate inferences regarding the long-term effect of the rehabilitative exercise on physiologic function and integrity of deglutition, as compared to non-instrumental evaluations (e.g. clinical bedside swallow exam, patient reported outcome measures, quality of life, etc). Context Articles published from inception to March 2022, inclusive, will be selected. Randomised control trials (RCT), non-RCTs, cohort studies, case control studies and case series type of studies will be included. Literature reviews will be excluded from the study, but screened for original articles in their reference lists. No restrictions on culture, gender, ethnicity, language, time or setting will be applied to increase the reviews’ comprehensiveness. Gray literature will be manually searched to cover a wide and inclusive range of evidence and reduce publication bias. Types of Sources No restrictions are imposed on study design or quality (PRISMA-ScR; Tricco et al., 2018). This scoping review will consider both experimental and observational study designs, including individual case reports. In addition, systematic reviews that meet the inclusion criteria will also be screened for original articles in their reference lists. Gray literature consisting of text and opinion papers like letters to the editor will also be considered for inclusion in this scoping review to cover a wide and inclusive range of evidence and reduce publication bias. Methods The proposed scoping review will be conducted in accordance with the JBI methodology for scoping reviews (Peters et al., 2020). Search strategy An initial limited search of PubMed and Embase will be undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles will be used to develop a full search strategy for PubMed database, in an iterative process, and adapted for each included database and/or information source. The reference list of all included sources of evidence will be screened for additional studies. No limitations on publication date or language are applied. The databases to be searched include MEDLINE (PubMed); EMBASE (Ovid); CINAHL (EBSCO); Web of Science. All included sources of grey literature evidence like conference papers, letters to the editor, dissertations and theses will be included in the appendix. Study/Source of Evidence selection Following the search, all identified citations will be collated and uploaded into Covidence systematic review online software, Veritas Health Innovation, Melbourne, Australia, for deduplication. Following a pilot test on a sample of 25 titles and abstracts, search results will be screened by PJ and BT independently for assessment against the eligibility criteria for the review, once 75% agreement is achieved. Reasons for exclusion of sources of evidence will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers will be resolved through discussion with the third reviewer. The Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping review (PRISMA-ScR) flow diagram will guide the reporting of results of the search and the study inclusion process. Data Extraction A data extraction charting form will be developed by the primary reviewer in collaboration with the supervisor on Microsoft Excel, based on the research objectives, and examination of ten percent of the full texts identified as eligible for charting. The two reviewers will independently pilot the charting form on ten percent of the selected articles, discuss the results and continuously update the data-charting form in an iterative process. Disagreements will be resolved in collaboration with the research team through discussion. This is in an attempt to ensure the recommendations of data charting are met; that all relevant data is captured, keeping in mind the research aims and allow for the creation of a descriptive summary of results (Arksey &amp; O’Malley, 2005). If necessary, authors of papers will be contacted to request missing or additional data, where required. Critical appraisal will not be carried, because this study focuses on literature synthesis. The data extracted will include details about the participants, concept, context, study methods and key findings relevant to the review questions. The final charting form with clear definitions of each item will be attached. Any study information reviewers feel may be of relevance for interpreting outcomes will be included in a comment box and discussed between reviewers following conclusion of the data charting phase. Data items that are not considered as possibly useful towards answering the research questions before beginning the charting may be added if they present as reoccurring themes. Amendments to the data charting form will be reported. Data Analysis and Presentation A descriptive numerical analysis and qualitative thematic analysis will be done by the first author, presenting findings in a narrative format with tabular and visual representation, in relation to the primary and secondary review questions (Levac et al., 2010). Broadly, the results will be classified under main conceptual categories of rehabilitative vocal adduction exercises, patient populations, physiological effects on swallow function, principles/rationale for rehabilitation and outcome measures. Acknowledgements This literature review is being carried out as a part of the Master’s degree in Clinical Speech and Language Studies, dissertation project, at Trinity College Dublin, for the academic year 2021-2022, under the supervision of Dr. Ciarán Kenny. Funding The project received no professional or institutional funding as it is undertaken as part of the Master’s degree project at Trinity College Dublin. Conflicts of interest The authors report no conflicts of interest. References Arksey, H., &amp; O’Malley, L. (2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology: Theory and Practice, 8(1), 19–32. https://doi.org/10.1080/1364557032000119616 Ekberg O Closure of the laryngeal vestibule during deglutition. Acta Oto Laryngol. 1982;93:123–9. https://www.ncbi.nlm.nih.gov/pubmed/7064688 El Sharkawi, A., Ramig, L., Logemann, J. A., Pauloski, B. R., Rademaker, A. W., Smith, C. H., Pawlas, A., Baum, S., &amp; Werner, C. 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