INT J LANG COMMUN DISORD, XXXX 2019,

VOL. 00, NO. 00, 1–6

Research Report
Effect of effortful swallowing training on tongue strength and oropharyn-
geal swallowing function in stroke patients with dysphagia: a double-blind,
randomized controlled trial
Hee-Su Park†, Dong-Hwan Oh†, Taehyung Yoon‡§ and Ji-Su Park¶
†Department of Occupational Therapy, Kyungdong University, Wonju, South Korea
‡Department of Occupational Therapy, Dongseo University, Busan, South Korea
§Senior Care Research Center, Dongseo University, Busan, South Korea
¶Advanced Human Resource Development Project Group for Health Care in Aging Friendly Industry
(Received July 2018; accepted January 2019)

Abstract
Background: Effortful swallowing training (EST) is a remedial method for the training of swallowing-related
muscles in the oropharyngeal phase. However, clinical evidence of its effectiveness is insufficient.
Aims: To investigate the effects of EST on tongue strength and swallowing function in patients with stroke.
Methods & Procedures: Stroke patients with dysphagia were randomly assigned to one of two groups: an experimental
group (n = 12) and a control group (n = 12). The experimental group underwent EST, while the control group
performed saliva swallowing. Training was conducted 5 days per week for 4 weeks. Both groups underwent
conventional dysphagia treatment for 30 min/day, 5 days/week for 4 weeks.
Outcomes & Results: Tongue strength was assessed using the Iowa Oral Performance Instrument. The
Videofluoroscopic Dysphagia Scale (VDS), based on a videofluoroscopic swallowing study, was used to
analyze oropharyngeal swallowing function. The experimental group showed greater improvements in anterior
and posterior tongue strength compared with the control group (p = 0.046 and 0.042, respectively), and greater
improvement in the oral phases of the VDS (p = 0.017).
Conclusions & Implications: We recommend EST as a remedial strategy for improving tongue strength and oral
swallowing function in patients with stroke.

Keywords: randomized control trial, dysphagia, stroke, tongue, effortful swallowing.

What this paper adds

What is already known on the subject
EST is a remedial method of dysphagia and is mainly applied in clinical practice. However, the clinical evidence of the
effect is still unclear. Therefore, this study investigated the effect of EST on the tongue strength and oropharyngeal
swallowing of dysphagia patients after stroke.

What this paper adds to existing knowledge

This study conducted a randomized controlled trial to investigate the effect of EST. As a result, the experimental
group (effortful swallowing) showed more significant improvement not only in tongue strength but also in the oral
phase of swallowing than the placebo group.
What are the potential or actual clinical implications of this work?
EST was confirmed to have a positive effect on tongue muscle strength and oral swallowing function of dysphagia
patients after stroke. Therefore, we recommend EST as a remedial method to patients with dysphagia after stroke

Address correspondence to: Ji-Su Park, Advanced Human Resource Development Project Group for Health Care in Aging Friendly Industry,
47, Jurye-ro, Sasang-gu, Busan, South Korea; e-mail: [email protected]
International Journal of Language & Communication Disorders
ISSN 1368-2822 print/ISSN 1460-6984 online  C 2019 Royal College of Speech and Language Therapists

DOI: 10.1111/1460-6984.12453
2 Hee-Su Park et al.
Introduction Aims
We conducted a randomized control trial of the effects of
Effortful swallowing training (EST) increases the pos- EST on tongue strength and oropharyngeal swallowing
terior motion of the tongue base toward the poste- function in patients with stroke.
rior pharyngeal wall. In addition, videomanometric
studies have reported an increased effort during bo-
lus swallowing, a rapid increase in pressure on the Materials and methods
bolus and thus a decreased pharyngeal residue (Hind Patients
et al. 2001). As a result, a compensatory technique was The participants were recruited from the dysphagia
initially introduced for the purpose of improving the clinic at the rehabilitation department of Busan Paik
clearance of vallecular residues in the pharyngeal phase Hospital. The inclusion criteria were as follows: (1) di-
(Jang et al. 2015). agnosis of stroke based on computed tomography or
Recently, EST was reported as a remedial method for magnetic resonance imaging findings; (2) oropharyn-
the treatment of oropharyngeal dysphagia. It involves geal dysphagia after stroke confirmed by a videofluoro-
pushing the tongue firmly against the palate while swal- scopic swallowing study (VFSS); (3) inpatient at the Paik
lowing as forcefully as possible. EST is known to have Hospital; (4) no significant cognitive problems (Mini-
a positive effect in functioning at the oral and pharyn- Mental Status Examination score > 24); (4) ability to
geal phases. It involves the use of a variety of muscles perform EST; and (5) able to make tongue-to-palate
of the oropharyngeal phase to enable a strong swal- contact. The exclusion criteria were as follows: (1) sec-
low; thus, it activates the muscles involved such as the ondary stroke; (2) trigeminal neuropathy; (3) significant
tongue and suprahyoid muscles (Park and Kim 2016, malocclusion and facial asymmetry; (4) parafunctional
Hind et al. 2001). oral habits (clenching, bruxing or tongue thrusting);
Patients with dysphagia after stroke usually show de- (5) tongue strength could not be measured; (6) severe
creased strength of the oropharyngeal muscles such as communication difficulties associated with dementia or
the tongue and suprahyoid muscles. Reduced tongue aphasia; (7) neck pain or neck surgery; and (8) presence
strength leads to not only oral dysfunction but also as- of a tracheostomy tube. The Institutional Review Board
piration in the pharyngeal phase (Kim et al. 2017, Lee of Inje University approved the study, and all partic-
et al. 2016). In addition, weakening of the suprahyoid ipants provided written, informed consent before the
muscles directly affects hyolaryngeal movements caus- study.
ing pharyngeal dysphagia, which can lead to pharyngeal
residue and aspiration (Logemann et al. 1992, Jacob
et al. 1989). Sample size calculation
Several studies have reported that EST improves Sample size was calculated using G-power 3.1 software
tongue strength in the oral phase and induces activation (University of Dusseldorf, Dusseldorf, Germany). The
of the suprahyoid muscles (Park and Kim 2016, Huck- power and alpha levels were set at 0.60 and 0.05, respec-
abee et al. 2005), which are the main swallowing muscles tively, and the effective size was set at 0.8. According to
in the pharyngeal phase. Recently, Jang et al. (2015) re- a prior analysis, each group required at least 12 subjects.
ported the effects of EST on hyolaryngeal movement Therefore, this study assigned 15 subjects in the exper-
in healthy adults. EST proved to be more effective for imental group and 15 subjects in the control group in
the anterior–superior movements of the hyolaryngeal anticipation of dropout cases.
than for normal swallowing. It is clinically important
that EST affects the anterior–superior movements of the
hyolarynx. This is because reduced hyolaryngeal move- Procedures
ment is closely related to airway aspiration, pharyngeal This study was designed as a 4-week, double-blind,
residue and upper oesophageal sphincter opening (Park two-group, block randomized controlled trial. An oc-
et al. 2016). cupational therapist randomly assigned participants to
There were some limitations to the previous studies either the experimental group (n = 15) or the con-
that proved the effectiveness of EST. First, most of the trol group (n = 15) using a random allocation software
studies focused on healthy adults and elderly individuals. program; the allocation was performed under blinded
Second, few studies examined the effects of EST on the conditions.
oropharyngeal phase in patients with dysphagia after The experimental group performed EST. The EST
stroke, and no randomized controlled trials have been method was based on that described in a previous study
conducted; thus, clinical evidence of the effectiveness of (Park and Kim 2016). Patients were asked to push
EST is lacking. the tongue firmly onto the palate, while squeezing the
Effect of effortful swallowing 3
neck muscles, and swallow as forcefully as possible. oropharyngeal swallowing function in stroke survivors.
EST was performed 10 times per session, with three The 14 items of the scale represent the oral phase (lip
sessions per day, 5 days per week for 4 weeks with closure, bolus formation, mastication, apraxia, prema-
reference to a guideline for strength training by the ture bolus loss and oral transit time) and pharyngeal
American College of Sports Medicine Position Stand phase (pharyngeal triggering, vallecular residues, pyri-
(1990). Effortful swallowing was confirmed by the ther- form sinus residues, laryngeal elevation, pharyngeal wall
apist through visual observation and palpation dur- coating, pharyngeal transit time and aspiration). Scores
ing EST. We visually confirmed their expression and range from 0 to 100, with higher scores indicating
the strong contraction of the orofacial and suprahy- more severe dysphagia (Han et al. 2001). The VDS
oid muscles. Additionally, intermittent palpation of the performance was interpreted by an experienced physi-
suprahyoid muscles under the jaws confirmed effortful cian and an occupational therapist blinded to group
swallowing. allocation.
The control group was instructed to swallow nat-
urally without intentional force from the tongue and
neck muscles, according to the same schedule as that Statistical analysis
of the experimental group. All interventions were ad- All statistical analyses were performed with SPSS 15.0
ministered in the dysphagia clinic by an occupational software (SPSS Inc., Chicago, IL, USA). The descrip-
therapist with 7 years of clinical experience in treating tive statistics are presented as means with standard devia-
dysphagia. tions. To evaluate the effects of intervention, a Wilcoxon
We took some steps to support the training. First, signed-rank test was used to compare the pre- and
participants were supervised and given encouragement post-intervention measures in each group. The Mann–
during the training. Second, patients were given a small Whitney U-test was used to compare changes in out-
spray of water to induce swallowing if they found it come measures between the groups. The significant level
difficult to maintain swallowing. Third, in cases of fa- was set at p < 0.05.
tigue of the tongue or neck, rest was provided for several
seconds. Both groups received the same conventional
dysphagia therapy (e.g., compensatory techniques such Results
as the chin tuck and head tilting and rotation; therapeu-
In total, 24 participants completed this study. Three
tic techniques such as orofacial muscle exercises, thermal
participants dropped out before follow-up because they
tactile stimulation using ice sticks, expiratory training)
were transferred to another hospital. Three participants
from occupational therapists. The therapy was admin-
refused to continue because of fatigue or pain in the
istered for 30 min per day, consecutively for 5 days per
neck muscles, or general health problems (figure 1).
week for 4 weeks.
There were no significant differences between the groups
among any of the variables at baseline (p > 0.05). Table 1
Outcome measurement shows the characteristics of the participants.
In this study, the Iowa Oral Performance Instrument
(IOPI) (IOPI Medical LLC, Carnation, WA, USA) was Effects of tongue strength
used to measure tongue strength. This portable device
enables the measurement of the strength and endurance The experimental group showed significant increases
of the tongue. It consists of a 2.8 mL air-filled rubber in ATS and PTS (p = 0.009 and 0.002, respectively).
bulb, connecting tube and main body. The maximum The control group also showed significant increases in
value of tongue strength was determined as follows: the ATS and PTS (p = 0.005 and 0.031, respectively). Af-
bulb was placed between the tongue and palate, and ter the intervention, statistical analysis showed signifi-
pressure was applied to the bulb through elevation of the cant differences in ATS and PTS between the groups
tongue. Anterior tongue strength (ATS) was measured (p = 0.046 and 0.042, respectively) (table 2).
by positioning the bulb longitudinally along the hard
palate, posterior to the alveolar ridge. Posterior tongue
Effects oropharyngeal swallowing
strength (PTS) was measured by positioning the bulb
along the posterior border of the hard palate (Kim et al. The experimental group showed significant improve-
2017). ments in both the oral and pharyngeal phases of the
We conducted a VFSS to evaluate the oropharyngeal VDS (p = 0.003 and 0.004, respectively). The control
swallowing function. The Videofluoroscopic Dysphagia group also showed significant improvements in both
Scale (VDS) was evaluated based on the VFSS results. the oral and pharyngeal phases (p = 0.001 and 0.002,
The VDS is a functional evaluation scale that reflects respectively). After the intervention, statistical analysis
4 Hee-Su Park et al.

Figure 1. CONSORT diagram of participant recruitment. [Colour figure can be viewed at wileyonlinelibrary.com]

Table 1. Characteristics of participants

Characteristics Experimental group (n = 12) Control group (n = 12)

Age (year), mean ± SD (range) 66.5 ± 9.5 (51–81) 64.8 ± 11.2 (53–78)
Gender, male/female 6/6 5/7
Site of stroke lesion (number)
Middle cerebral artery 6 6
Midbrain 1 1
Frontal lobe 2 1
Internal capsule 2 2
Corona radiate 1 2
Time since onset of stroke, weeks, mean ± SD (range) 24.39 ± 8.65 (17–43) 25.74 ± 6.27 (18–42)
Note: SD, standard deviation.

showed significant differences in the oral phases between tongue is pushed firmly against the palate during swal-
groups (p = 0.017) (table 2). lowing. Park and Kim (2016) showed an increase in
tongue muscle strength of 8.1 kPa in elderly individ-
uals after 4 weeks of EST. Clark and Shelton (2014)
Discussion found that an average of 8.7 kPa increased strength in
This study involved a randomized control trial to inves- the anterior region of the tongue after 4 weeks of EST in
tigate the effects of EST on tongue strength and oropha- healthy adults. This is similar to the results of our study.
ryngeal swallowing function in patients with stroke. Af- We believe that the increase in tongue strength after
ter the intervention, the experimental group showed EST is the result of repetitive resistance training because
significant improvement in tongue strength compared during the effortful swallowing the tongue is strongly
with the control group. Therefore, this study demon- pushed against the palate. That is, the palate acts as a
strated that ETS is effective for increasing tongue resistor. The tongue comprises skeletal muscles, which
strength. undergo physiological changes in response to resistance
Normal swallowing pushes the tongue against the (Moritani and de Vries 1979). Further, resistance train-
palate to generate intraoral pressure, hence, it is im- ing effectively increases the strength of skeletal muscles,
portant to increase tongue strength for safe swallowing. such as those in the tongue, however, the increased in
EST may help to increase tongue strength because the strength can also be attributed to muscle hypertrophy.
Effect of effortful swallowing 5
Table 2. Changes in parameters before and after the treatment

Experimental group Control group

Before After p Before After p Between groups,
p-values

Tongue strength
ATS 20.83 ± 4.32 27.58 ± 4.27 0.009∗ 21.16 ± 5.78 23.08 ± 5.42 0.005∗ 0.046†
PTS 16.58 ± 5.00 23.17 ± 5.37 0.002∗ 16.75 ± 4.43 18.17 ± 4.46 0.031∗ 0.042†
VDS (oral phase) 17.83 ± 4.21 11.50 ± 4.32 0.003∗ 17.50 ± 3.38 14.33 ± 3.33 0.001∗∗ 0.017†
LC 1.21 ± 1.08 0.50 ± 0.90 0.096 1.00 ± 1.10 0.83 ± 1.03 0.180 0.397
BF 2.63 ± 1.30 2.17 ± 1.40 0.292 2.75 ± 0.87 2.33 ± 1.15 0.334 0.845
Mastication 3.67 ± 1.15 2.83 ± 2.44 0.194 3.33 ± 1.56 3.33 ± 1.30 1 0.347
Apraxia 0 0 1 0 0 1 1
TPC 4.58 ± 1.44 2.25 ± 2.49 0.020∗ 4.17 ± 1.95 3.29 ± 2.16 0.068 0.348
PBL 3.00 ± 1.82 2.38 ± 1.82 0.526 3.50 ± 1.80 2.13 ± 1.15 0.034 0.647
OTT 2.75 ± 2.01 1.38 ± 1.43 0.033∗ 2.58 ± 1.62 2.42 ± 1.16 0.593 0.104
VDS (pharyngeal phase) 43.96 ± 6.50 38.96 ± 5.37 0.004∗∗ 42.08 ± 7.2 38.8. ± 7.23 0.002∗∗ 0.728
TPS 4.17 ± 0.81 4.13 ± 1.30 0.655 4.38 ± 0.48 4.29 ± 0.50 0.589 0.801
VR 4.17 ± 1.8 3.54 ± 1.92 0.039∗ 4.42 ± 1.38 3.92 ± 1.31 0.063 0.677
LE 7.83 ± 2.66 7.00 ± 2.70 0.041∗ 6.42 ± 3.37 6.17 ± 2.72 0.564 0.375
PSR 6.92 ± 2.53 5.42 ± 2.97 0.024∗ 5.42 ± 2.69 4.83 ± 2.42 0.068 0.548
CPW 7.67 ± 2.77 7.25 ± 2.05 0.343 7.92 ± 2.75 7.38 ± 1.92 0.292 0.927
PTT 5.25 ± 1.36 4.92 ± 1.44 0.450 4.92 ± 1.88 4.79 ± 1.62 0.785 0.974
Aspiration 8.00 ± 2.95 6.67 ± 2.84 0.066 8.63 ± 3.01 7.46 ± 2.02 0.074 0.293
VDS (total score) 61.79 ± 9.12 50.46 ± 7.4 0.002∗∗ 59.58 ± 9.56 53.17 ± 9.56 0.002∗∗ 0.174
Notes: ATS, anterior tongue strength; PTS, posterior tongue strength; LC, lip closure; BF, bolus formation; TPC, tongue to palate contact; PBL, premature bolus loss; OTT, oral transit
time; TPS, triggering of pharyngeal swallow; VR, vallecular residue; LE, laryngeal elevation; PSR, pyriform sinus residue; CPW, coating on the pharyngeal wall; PTT, pharyngeal transit
time.
∗
p < 0.05 by Wilcoxon test, † p < 0.05 by Mann–Whitney U-test.

Recently, several studies have reported tongue resis- tongue has a direct effect on the oral phase; thus, it is
tance training (TRT). This is to increase the strength of important that the tongue has sufficient strength and
the tongue by pushing the tongue against the palate or movement because it plays an important functional role
pressure bulb. Kim et al. (2017) reported the results of in bolus mastication, manipulation and formation, and
TRT in patients with dysphagia after stroke that showed movement of its base (Oh et al. 2015). Previous stud-
an increase in tongue strength of about 9.2 kPa in the ies have reported that tongue strength in patients with
anterior region of the tongue, 11 kPa in the posterior re- dysphagia after stroke has a relationship with the oral
gion. Robbins et al. (2007) also reported improvements phase, particularly with regard to bolus formation, mas-
in tongue strength of 12 kPa after 4 weeks and 18 kPa tication, premature bolus loss, tongue to palate contact
after 8 weeks. These results are similar to the results and oral transit time (Lee et al. 2016, Oh et al. 2015).
of our study. The concept of EST is similar to that of In other words, increased tongue strength through EST
TRT because it requires strong pushing of the tongue has a positive effect on oral function, and consequently,
against the hard palate. The difference between the two it is effective in increasing oral pressure and improv-
is that EST requires the tongue to be pushed as strongly ing oral bolus clearance. In addition, the strength of
as possible against the palate during swallowing, while the tongue indirectly affects the pharyngeal phase, par-
the tongue is pushed firmly against the palate with- ticularly regarding the clearance of vallecular residue
out swallowing in TRT. Therefore, this study confirms and risk of aspiration (Kim et al. 2017, Robbins et al.
that, like TRT, EST can be applied to resistance train- 2007). Therefore, we believe that the increase in tongue
ing for the tongue and can effectively increase muscle strength resulting from EST has a positive effect on the
strength. oropharyngeal phase.
This study assessed VDS based on VFSS to evaluate This study demonstrated that EST has positive ef-
oropharyngeal swallowing function. The experimental fects on tongue strength and swallowing function. Nev-
group showed greater improvements in function during ertheless, after intervention, we still observed low tongue
both the oral and pharyngeal phases than did the con- muscle strength and incomplete swallowing function
trol group. Therefore, we demonstrated that EST ef- when compared with normal adult levels. This can be
fectively improved oropharyngeal swallowing function. caused by a variety of reasons. In particular, exercise
The results of this study can be explained as follows. to stimulate muscles and increase muscle strength and
Increased tongue strength may directly or indirectly restore function usually requires a minimum of 6–8
improve oropharyngeal swallowing. The strength of the weeks. Therefore, the 4-week training period of this
6 Hee-Su Park et al.
study may have been relatively short. Therefore, further on videofluoroscopic studies. Archives of Physical Medicine and
studies with longer training periods or more intense Rehabilitation, 82 (5), 677–682.
training are necessary. HIND, J. A., NICOSIA, M. A., ROECKER, E. B., CARNES, M. L. and
ROBBINS, J., 2001, Comparison of effortful and noneffortful
swallows in healthy middle-aged and older adults. Archives of
Limitations Physical Medicine and Rehabilitation, 82 (12), 1661–1665.
HUCKABEE, M. L., BUTLER, S. G., BARCLAY, M. and JIT, S., 2005,
This study has some limitations. First, the small sam- Submental surface electromyographic measurement and pha-
ple size may have influenced the results. Second, the ryngeal pressures during normal and effortful swallowing.
Archives of Physical Medicine and Rehabilitation, 86 (11),
absence of follow-up after the intervention did not al- 2144–2149.
low for determination of the durability of the effects. JACOB, P., KAHRILAS, P. J., LOGEMANN, J. A., SHAH, V. and HA, T.,
Third, the recovery pattern of stroke patients according 1989, Upper esophageal sphincter opening and modulation
to brain lesion was not observed. Fourth, we admin- during swallowing. Gastroenterology, 97 (6), 1469–1478.
istered conventional dysphagia therapy along with the JANG, H. J., LEIGH, J. H., SEO, H. G., HAN, T. R. and OH, B.
M., 2015, Effortful swallow enhances vertical hyolaryngeal
EST to the experimental group. Thus, the results of movement and prolongs duration after maximal excursion.
this study may not reflect the effects of pure EST. Fur- Journal of Oral Rehabilitation, 42 (10), 765–773.
ther studies with increased sample size and long-term KIM, H. D., CHOI, J. B., YOO, S. J., CHANG, M. Y., LEE, S. W. and
follow-up are needed to evaluate the long-term effects PARK, J. S., 2017, Tongue-to-palate resistance training im-
of EST. proves tongue strength and oropharyngeal swallowing func-
tion in subacute stroke survivors with dysphagia. Journal of
Oral Rehabilitation, 44 (1), 59–64.
Conclusions LEE, J. H., KIM, H. S., YUN, D. H., CHON, J., HAN, Y. J., YOO, S.
D., KIM, D. H., LEE, S. A., JOO, H. I., PARK, J. S., KIM, J. C.
This study demonstrated that EST is an effective method and SOH, Y., 2016, The relationship between tongue pressure
for improving tongue strength and oral swallowing func- and oral dysphagia in stroke patients. Annals of Rehabilitation
Medicine, 40 (4), 620–628.
tion in patients with stroke. Therefore, EST is recom- LOGEMANN, J. A., KAHRILAS, P. J., CHENG, J., PAULOSKI, B. R.,
mended as a remedial training procedure for dysphagia GIBBONS, P. J., RADEMAKER, A. W. and LIN, S., 1992, Closure
patients. mechanisms of laryngeal vestibule during swallow. American
Journal of Physiology, 262 (2 Pt 1), 338–344.
MORITANI, T. and DE VRIES, H. A., 1979, Neural factors versus hy-
Acknowledgements pertrophy in the time course of muscle strength gain. Ameri-
can Journal of Physical Medicine, 58 (3), 115–130.
This work was supported by BB21+ project in 2018. Declaration OH, J. C., 2015, Effects of tongue strength training and detraining
of interest: The authors report no conflicts of interest. The authors on tongue pressures in healthy adults. Dysphagia, 30 (3),
alone are responsible for the content and writing of the paper. 315–320.
PARK, T. and KIM, Y., 2016, Effects of tongue pressing effortful
swallow in older healthy individuals. Archives Gerontology and
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