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The effects of tongue pressure strength and accuracy training
on tongue pressure strength, swallowing function, and quality
of life in subacute stroke patients with dysphagia:
a preliminary randomized clinical trial
Jong-Hoon Moon
a,
*, Suk-Chan Hahm
c,
*, Young Sik Won
d,†
and Hwi-Young Cho
b,†
Tongue pressure strength and accuracy training (TPSAT)
has been proposed as an intervention to improve dysphagia.
However, the effects of TPSAT on dysphagia in subacute
stroke patients remain unclear. The aim of this study was to
investigate the effects of TPSAT on tongue pressure
strength, swallowing function, and quality of life in subacute
stroke patients with dysphagia. Sixteen subacute stroke
patients were assigned randomly to two groups: the TPSAT
group (n=8) or the control group (n=8). In the former, both
TPSAT and traditional dysphagia therapies were performed
for 30 min each per day; in the latter, only traditional
dysphagia therapy was performed for 30 min twice a day.
Both groups performed each daily intervention five times
per week for 8 weeks. To assess the tongue pressure
strength, maximum isometric tongue pressures (MIPs) of
the anterior and posterior tongue using the Iowa Oral
Performance Instrument were measured before and after
the intervention. Mann Assessment of Swallowing Ability
(MASA) and Swallowing-Quality of Life (SWAL-QOL) were
also used to assess the swallowing function and quality of
life, respectively. TPSAT with traditional dysphagia therapy
significantly improved MASA, SWAL-QOL, and MIPs both
anteriorly and posteriorly, and traditional dysphagia therapy
significantly increased MASA, SWAL-QOL, and MIPs
anteriorly (P<0.05). The TPSAT group showed a significant
improvement in anterior and posterior MIPs and tongue
movement score in MASA compared with the control group
(P<0.05). Our findings suggest that TPSAT may
significantly improve dysphagia management in subacute
stroke patients. International Journal of Rehabilitation
Research 00:000–000 Copyright © 2018 Wolters Kluwer
Health, Inc. All rights reserved.
International Journal of Rehabilitation Research 2018, 00:000–000
Keywords: dysphagia, quality of life, stroke, tongue
Departments of
a
Occupational Therapy, Graduate School,
b
Physical Therapy,
Gachon University, Incheon,
c
Graduate School of Integrative Medicine, CHA
University, Seongnam and
d
Department of Occupational Therapy, Shinsung
University, Dangjin, Republic of Korea
Correspondence to Hwi-Young Cho, PhD, PT, Department of Physical Therapy,
College of Health Science, Gachon University, 191 Hambangmoe-ro, Yeonsu-gu,
Incheon 21936, Republic of Korea
Tel: + 82 328 20 4 5 60; fax: + 82 328 20 4 420; e-mail: hwiyoung@gachon.ac.kr
*Jong-Hoon Moon and Suk-Chan Hahm contributed equally to the writing of this
article.
†
Young Sik Won and Hwi-Young Cho contributed equally to the writing of this
article.
Received 11 October 2017 Accepted 10 March 2018
Introduction
Dysphagia is a condition characterized by difficulty in swal-
lowing. It is known to occur in 37–78% of patients with stroke
(Martino et al., 2005). More than 50% of stroke patients have
oropharyngeal dysphagia associated with inappropriate control
of mastication, increased oral and pharyngeal residue, as well
as upper esophageal sphincter opening dysfunction (Hamdy
et al., 1997). Oropharyngeal dysphagia results in undesirable
complications, such as malnutrition, dehydration, and
aspiration pneumonia, which may ultimately lead to death
(Kuhlemeier, 1994). Furthermore, dysphagia negatively
affects the quality of life as an unrecognized handicap
(Gustafsson and Tibbling, 1991).
The tongue and its pressure generate intraoral cavity
pressure that transports the bolus from the oral cavity to
the pharynx, affecting the oral transit time during the
swallowing process (Clark et al., 2003; Steele et al., 2013).
According to previous research, an increase in the tongue–
palate pressure during swallowing enhances the generation
of pharyngeal pressures (Huckabee and Steele, 2006).
Considering these aspects, the generation of tongue–palate
pressure may play an important role in the establishment of
the overall swallowing strength.
Patients with neurogenic injury, especially stroke patients
with dysphagia, are often accompanied by weakness of
tongue strength (Konaka et al., 2010). Decreased tongue
pressure strength and swallowing function because of
dysphagia may hinder bolus movement from the mouth to
the pharynx. Dysphagia is characterized by increased phar-
yngeal transit time, residue in valleculae, and aspiration
(Youmans et al., 2009). Stroke patients with dysphagia suffer
oral and pharyngeal phase problems, such as disorders of
mastication, bolus formation, oral residue, and premature
spillage into the pharynx (Seo et al., 2011). Robbins et al.
Original article 1
0342-5282 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/MR R.0000000000000282
Copyright r2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
(2005) have reported that healthy elderly individuals
undergoing intensive tongue pressure resistance training
showed significantly improved tongue strength and volume,
whereas stroke patients with dysphagia showed improved
tongue strength, volume and pressure, as well as airway
protection (Robbins et al., 2007). Considering these studies,
tongue strength seems to be important for oropharyngeal
swallowing and oral-phase swallowing.
Tongue strength training has been shown to be more
effective when it is accompanied by accuracy training
compared with tongue strength training alone (Yeates
et al., 2008; Steele et al., 2013). Tongue pressure strength
and accuracy training (TPSAT) improves not only the
tongue strength but also bolus control within the mouth
(Yeates et al., 2008). Despite these effects of TPSAT on
dysphagia, to date, only three or six patients have parti-
cipated in previous studies showing the efficacy of
TPSAT on dysphagia (Yeates et al., 2008; Steele et al.,
2013); moreover, a randomized-controlled trial study was
only conducted in stroke patients with dysphagia (Steele
et al., 2016). To the best of our knowledge, there has
been no study investigating the effects of TPSAT on
dysphagia in subacute stroke patients. Thus, the aim of
this study was to evaluate the effects of TPSAT on
tongue pressure, swallowing function, and quality of life
in subacute stroke patients with dysphagia.
Patients and methods
Patients
A total of 118 stroke patients with dysphagia, who were
hospitalized at I Hospital located in Incheon between April
2015 and March 2016, were recruited. This study was
approved by the Institutional Review Board of Gachon
University, Seongnam, South Korea. The selection criteria
were as follows: (i) aspiration or penetration, oropharyngeal
residue confirmed by videofluoroscopic swallowing evalua-
tion (VFSE) (Robbins et al., 2007), (ii) initial VFSE per-
formed during the subacute stage between 3 and 12 weeks
aftertheonsetofstroke(Seoet al., 2011), (iii) patients who
could follow the instructions provided (a score of at least 21
on the Mini-Mental State Examination), and (iv) decreased
lingual pressures with either the anterior or posterior tongue
as 40 kPa (Robbins et al., 2007; Steele et al., 2016). This
study excluded any nonstroke patients with dysphagia as
well as those with pain during tongue movement. Patients
with tongue cuts were also excluded because they were not
eligible for tongue training. All participants provided written
informed consent before participation.
Study design
This study was designed as a single-blinded, preliminary
randomized-controlled trial. Before conducting the test,
participants were assessed to determine whether they
fulfilled the inclusion or exclusion criteria (Fig. 1). Of the
118 individuals, 19 were included and allocated randomly
to either the TPSAT group or the control group using a
random allocation software (http://randomization.com/).
After the preassessment, random allocation was per-
formed by an independent staff member. For allocation
concealment, sealed envelopes sequentially numbered
and opaque were used. The envelopes were kept in a
location distinct from the assessment place and were not
available to the assessor or the data analyst. The envel-
ope was signed, dated, and opened by the allocation
examiner immediately before the intervention, and only
in the absence of the assessor and the data analyst.
Experimental procedures
The TPSAT group underwent TPSAT for 30 min in the
morning and traditional dysphagia therapy for 30 min in
the afternoon five times per week for 8 weeks. The
control group underwent traditional therapy for 30 min in
the morning and 30 min in the afternoon, five times per
week for 8 weeks. Dysphagia therapy was performed by
an occupational therapist with 6 years of experience with
dysphagia management. In both groups, standardized
physical and occupational therapies were included.
Tongue pressure strength and accuracy training
TPSAT with traditional dysphagia treatment was per-
formed in the TPSAT group. TPSAT consisted of an anterior
and posterior isometric tongue strength exercise and an
isometric tongue accuracy exercise (Yeates et al., 2008). For
the anterior isometric tongue strength exercise, participants
were instructed to use the tongue tip to press on the air-filled
bulb of the posterior portion of the alveolar arch of the tongue;
for the posterior isometric tongue strength exercise, partici-
pants were instructed to use the middle portion of the tongue
to press on the air-filled bulb of the middle portion of the hard
palate. The protocol involved five sets of tongue-to-palate
presses, with six repetitions per set for each session. As for the
isometric tongue accuracy exercise, amplitudes were set at 50,
75, and 100% of the maximum pressure measured during the
first isometric strength exercise in the session for each bulb
location by the occupational therapist. Participants were
instructed to generate precise pressures within 10 kPa error
for each amplitude. The traditional dysphagia therapy
consisted of thermal tactile stimulation, the Mendelsohn
maneuver, effortful swallow, and diet modification.
Outcome measures
To assess the MIPs of the anterior and posterior tongue, the
Iowa Oral Performance Instrument (IOPI; IOPI Medical
LLC, Redmond, Washington, USA) was used. The bulb
for anterior tongue elevation was placed between the hard
palate and the alveolar ridge and the bulb for the posterior
tongue elevation was placed between the hard palate and
the soft palate. The measurement of MIPs using IOPI has
an excellent test–retest reliability (0.76–0.99) in patients
with dysphagia (Youmans and Stierwalt, 2006).
To assess the swallowing function, Mann Assessment of
Swallowing Ability (MASA), which is a clinical measurement
2International Journal of Rehabilitation Research 2018, Vol 00 No 00
Copyright r2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
tool for assessing oropharyngeal dysphagia, was used (Mann
et al., 1999). The MASA total score is 200. A score of
168–177 is characterized as mild dysphagia; a score of
139–167 is characterized as moderate dysphagia; and a score
of less than 138 is characterized as severe dysphagia (Mann
et al., 1999). In this study, the Korean version of MASA was
used. The test–retest reliability and the inter-rater reliability
of the Korean version of MASA were 0.98 and 0.99,
respectively (Oh et al., 2016).
To assess the swallowing-related quality of life in patients
with dysphagia, Swallowing-Quality of Life (SWAL-QOL)
was also used. The test–retest reliability of SWAL-QOL
for oropharyngeal dysphagia in adults was 0.6–0.91
(McHorney et al., 2002).
Statistical analysis
All values were expressed as the mean ±SD. The Mann–
Whitney U-test and the χ
2
-test were performed to analyze
the general characteristics between the two groups. The
Wilcoxon signed-ranks test was used to compare the changes
before and after intervention. The Mann–Whitney U-test
was used to compare the changes between the two groups.
APvalue of less than 0.05 was considered statistically sig-
nificant. All statistical analyses were carried out using SPSS
Statistics 21.0 (IBM Corp., Armonk, New York, USA).
Fig. 1
Selection of subjects
(n = 118)
Exclusion (n = 99)
- Not meeting inclusion criteria (n = 53)
- MMSE < 21 (n = 38)
- Other neurological diseases (n = 12)
- Discomfort of lip and tongue (n = 3)
- Declined to participate (n = 24)
- Discharged before randomized (n = 22)
Pre-assessment
Randomization (n = 19)
TPSAT group (n = 10) Control group (n = 9)
TPSAT Group
TPSAT: 30 minutes per day,
five per week, 8 weeks
+
Traditional dysphagia therapy
: 30 minute per day,
five per week, 8 weeks
Control Group
Traditional dysphagia therapy
: 60 minutes per day,
five per week, 8 weeks
Drop-out: Discharge (n = 2) Drop-out: Discharge (n = 1)
Analyzed (n = 8) Analyzed (n = 8)
Flow diagram of this study. MMSE, Mini-Mental State Examination; TPSAT, tongue pressure strength and accuracy training.
TPSAT for dysphagia managememt Moon et al. 3
Copyright r2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Results
The characteristics of the participants in both groups are
presented in Table 1. Before the intervention, there were no
significant differences in the general characteristics between
the two groups. Moreover, there was no significant difference
with respect to the outcome measures for all dependent
variables between the two groups before the intervention.
In the present study, MIPs of anterior and posterior ton-
gue were assessed using IOPI to determine the effect of
TPSAT on tongue strength improvement. Compared with
the preassessments, there were significant changes in
anterior MIPs (P=0.012) and posterior MIPs (P=0.011)
in the TPSAT group, and anterior MIPs (P=0.041) in the
control group (Table 2). In particular, the TPSAT group
showed significantly improved anterior (P=0.001) and
posterior (P=0.001) MIPs compared with the group that
received traditional therapy (Table 2).
To investigate the effect of TPSAT on swallowing function,
MASA was assessed. Compared with the preintervention
values, the TPSAT group showed a significant increase
inthetotalscoreofMASA(P=0.012), respiration
(P=0.024), respiratory rate (P=0.025), dysarthria
(P=0.025), saliva (P=0.020), lip seal (P=0.025), tongue
movement (P=0.007), tongue strength (P=0.017), tongue
coordination (P=0.011), oral transit (P=0.034), and voice
(P=0.020), as well as the pharyngeal response (P=0.025)
scores of subcategories in MASA (Table 3). Traditional
dysphagia therapy also showed improved scores MASA
(P=0.012), respiration (P=0.025), dysarthria (P=0.046),
oral preparation (P=0.025), cough reflex (P=0.008),
voluntary cough (P=0.041), and voice (P=0.046), as well as
the pharyngeal response (P=0.046) scores of subcategories
in MASA (Table 3). As shown in Table 3, compared with
the traditional dysphagia therapy only, TPSAT combined
with traditional dysphagia treatment significantly improved
tongue movement (P=0.021) and showed a marginally
significant difference in the tongue strength (P=0.070) and
coordination (P=0.052) in MASA subcategories.
Furthermore, the TPSAT group also showed a significant
increase in the total score of SWAL-QOL (P=0.012) as
well as burden (P=0.011), eating duration (P=0.027),
eating desire (P=0.027), symptom frequency (P=0.018),
food selection (P=0.020), communication (P=0.039), fear
(P=0.011), mental health (P=0.011), social (P=0.028),
fatigue (P=0.026), and sleep (P=0.023) scores of sub-
categories in SWAL-QOL compared with the scores before
the intervention (Table 4). In the control group, a total
score of SWAL-QOL as well as burden (P=0.024), eating
duration (P=0.026), eating desire (P=0.024), symptom
frequency (P=0.018), food selection (P=0.027), commu-
nication (P=0.041), mental health (P=0.017), social
(P=0.027), fatigue (P=0.026), and sleep (P=0.034) scores
in SWAL-QOL were significantly improved compared with
the preintervention values (Table 4).
Discussion
This study investigated the effects of TPSAT on tongue
pressure strength, swallowing function, and the quality of
life in subacute stroke patients with dysphagia. The
present study showed that (i) TPSAT with traditional
dysphagia therapy significantly improved anterior MIPs,
posterior MIPs, MASA, and SWAL-QOL compared with
the preintervention values, (ii) traditional dysphagia
therapy also improved anterior MIPs, MASA, and SWAL-
QOL, and (iii) the TPSAT group showed a significant
recovery of anterior MIPs and posterior MIPs compared
with the control group. Thus, we suggest that TPSAT
with traditional dysphagia therapy may be effective for
dysphagia in subacute stroke patients.
A previous study has reported that tongue strength training
for 8 weeks is highly effective for tongue pressure strength
Table 1 General characteristics of the participants
TPSAT group
(n =8)
Control group
(n =8) P
Sex (male/female) 3/5 4/4 0.614
Age (years) 62.00 ±4.17 63.50 ±6.05 0.792
Stroke type (ischemic/
hemorrhagic)
6/2 6/2 1.000
Lesion hemisphere (right/left) 6/2 5/3 0.590
Location of lesion 0.614
Supratentorial lesion 3 4
Infratentorial lesion 5 4
Poststroke duration (days) 56.00 ±17.35 59. 88 ±20.04 0.793
MMSE 22.87 ±2.47 23.50 ±2.00 0.748
Values are expressed as mean ±SD.
MMSE, Mini-Mental State Examination; TPSAT, tongue pressure strength and
accuracy training.
Table 2 Change in the maximum isometric tongue pressures in the two groups
TPSAT group (n=8) Control group (n=8) TPSAT vs. control
Pre Post PPre Post PChange score Change score P
Anterior MIPs 31.38 ±5.68 49.75 ±5.26 0.012
†
32.25 ±5.37 35.50 ±6.35 0.041
†
18.38 ±4.00 3.25±3.41 0.001
‡
Posterior MIPs 28.50 ±4.75 50.13 ±4.32 0.011
†
29.75 ±4.37 32.13 ±4.09 0.127 21.63 ±2.33 2.38 ±3.66 0.001
‡
Values are expressed as mean ±SD.
Pre, values before intervention; post, values before intervention; change score, postvalues−prevalues.
MIPs, maximum isometric tongue pressures; TPSAT, tongue pressure strength and accuracy training.
†
P<0.05.
‡
P<0.01.
4International Journal of Rehabilitation Research 2018, Vol 00 No 00
Copyright r2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
in stroke patients with dysphagia (Robbins et al., 2007).
After this training period, they showed that anterior and
posterior MIPs increased by 16.2 and 24.4 kPa, respectively.
Similarly, in this study, the TPSAT group showed
increased anterior (18.38 kPa) and posterior (21.63 kPa)
MIPs. This finding may be dependent on the types of
anterior and posterior tongue muscles. The anterior portion
ofthetonguemuscleismainlymadeupoftypeIIfast-
twitch muscle fibers and the posterior portion of the tongue
muscle is mainly comprised of type I slow-twitch muscle
fibers (Stål et al., 2003). Considering that type II muscle
fibers in the tongue decrease after stroke (Dattola et al.,
1993), posterior MIPs may show greater improvement than
anterior MIPs in subacute stroke patients.
In the present preliminary study, MASA was used to
assess the function of swallowing. Although previous
studies have reported changes of swallowing function
Table 3 Change in swallowing function in the two groups
TPSAT group (n=8) Control group (n=8) TPSAT vs. control
Pre Post PPre Post PChange score Change score P
MASA total 145.50±3.3 8 173.25 ±5.52 0.012
†
144.13 ±5.46 166.88 ±5.08 0.012
†
27.75 ±5.9 9 22.75 ±7.65 0.188
Alertness 9.50 ±0.93 10.00 ±0.00 0.157 9.25 ±1.04 10.00 ±0.00 0.083 0.50 ±0.93 0.75 ±1.04 0.602
Co-operation 9.25 ±1.04 9.75 ±0.71 0.157 9.50 ±0.93 9.50 ±0.93 1.000 0.50 ±0.93 0.00 ±1.07 0.332
Auditory comprehension 9.00 ±1.07 9.25 ±1.04 0.317 8.75 ±1.04 9.00 ±1.07 0.564 0.25 ±0.71 0.25 ±1.28 0.945
Respiration 7.00 ±1.07 9.25 ±1.04 0.024
†
7. 2 5 ±1.0 4 8.50 ±1.41 0.025
†
2.25 ±1.67 1.25 ±1.04 0.188
Respiratory rate 3.50 ±0.93 4.75 ±0.71 0.025
†
3.25 ±0.71 4.00 ±1.07 0.180 1.25 ±1.0 4 0.75 ±1.49 0.511
Dysphasia 3.38 ±0.52 3.63 ±0.52 0.157 3.25 ±0.46 3.75 ±0.4 6 0.046
†
0.25 ±0.46 0.50 ±0.53 0.317
Dyspraxia 3.63±0.52 4.00 ±0.53 0.083 3.38 ±0.74 4.00 ±0.76 0.096 0.38 ±0.52 0.63 ±0.92 0.421
Dysarthria 3.63 ±0.52 4.25 ±0.71 0.025
†
3.50 ±0.53 3.75 ±0.46 0.414 0.63 ±0.52 0.25 ±0.89 0.409
Saliva 4.13 ±0.64 5.00 ±0.00 0.020
†
4.50 ±0.53 4.88 ±0.35 0.083 0.8 8 ±0.64 0.3 8 ±0.52 0.112
Lip seal 4.13 ±0.64 4.75 ±0.46 0.025
†
4.00 ±0.76 4.75 ±0.46 0.063 0.63 ±0.52 0.75 ±0.89 0.908
Tongue movement 7.00 ±1.07 9.25 ±1.04 0.007
‡
6.75 ±1.04 7.50 ±0.93 0.180 2.25 ±0.71 0.75 ±1.49 0.021
†
Tongue strength 6.13 ±1.55 9.00 ±1.07 0.017
†
6.13 ±1.55 6.8 8 ±1.55 0.317 2.88 ±1.64 0.75 ±2.12 0.070
Tongue coordination 6.50 ±1.60 9.00 ±0.93 0.011
†
6.50 ±1.60 7.13 ±1.36 0.450 2.50 ±1.31 0.63 ±2.00 0.052
Oral preparation 7.00 ±1.07 7.75 ±0.71 0.083 7.00±1.07 8.25 ±0.71 0.025
†
0.75 ±1.04 1.25 ±1.04 0.333
Gag 3.88 ±0.99 4.88 ±0.35 0.038 3.8 8 ±0.99 4.63 ±0.52 0.119 1.00 ±0.93 0.75 ±1.28 0.742
Palate 7.00 ±1.51 7.75 ±0.71 0.257 7.00 ±1.07 7.5 0 ±0.93 0.317 0.75 ±1.83 0.50 ±1.41 0.864
Bolus clearance 5.75±1.3 9 7.25±1.3 9 0.102 5.75 ±1.39 7.63 ±1.06 0.059 1.50 ±2.27 1.88 ±2.23 0.653
Oral transit 6.50 ±0.93 8.00 ±1.07 0.034
†
6.00 ±1.51 7.50 ±0.93 0.063 1.50 ±1.41 1.50 ±1.77 0.910
Cough reflex 3.50 ±0.93 4.25 ±1.0 4 0.180 3.00 ±1.07 5.00 ±0.00 0.008
‡
0.75 ±1.49 2.00 ±1.07 0.107
Voluntary cough 7.25 ±1.39 8.00 ±0.00 0.157 6.88 ±1.55 8.75 ±1.04 0.041
†
0.75 ±1.39 1.88 ±1.81 0.199
Voice 7.50 ±1.77 9.25 ±1.04 0.020
†
8.00 ±1.51 9.00 ±1.07 0.046
†
1.75 ±1.28 1.00 ±1.07 0.232
Trachea 10.00 ±0.00 10.00 ±0.00 1.000 10.00 ±0.00 10.00 ±0.00 1.000 0.00 ±0.00 0.00 ±0.00 1.000
Pharyngeal phase 5.38 ±1.06 6.13 ±1.55 0.317 5.38 ±1.0 6 7.50 ±1.69 0.0 58 0.75 ±2.12 2.13 ±2.47 0.171
Pharyngeal response 5.00 ±0.00 8.13 ±2.5 9 0.025
†
5.00 ±0.00 7.50 ±2.67 0.046
†
3.13 ±2.59 2.50 ±2.67 0.626
Values are expressed as mean ±SD.
Pre, values before intervention; post, values before intervention; change score, post values −pre values.
MASA, Mann Assessment of Swallowing Ability; TPSAT, tongue pressure strength and accuracy training.
†
P<0.05.
‡
P<0.01.
Table 4 Change in Swallowing-Quality of Life in the two groups
TPSAT group (n=8) Control group (n=8) Experimental vs. control
Pre Post PPre Post PChange score Change score P
SWAL-QOL total 127.63 ±13.47 164.5 0 ±5.32 0.012
†
128.88 ±10.91 15 9.25 ±9.53 0.012
†
36.88 ±13.26 30.38 ±7.13 0.269
Burden 5.13 ±1.25 6.88 ±0.83 0.011
†
5.13 ±1.13 6.25 ±1.04 0.024
†
1.75 ±0.89 1.13 ±0 .83 0.220
Eating duration 6.00 ±1.20 7.63 ±0.92 0.027
†
6.38 ±1.06 8.00 ±0.76 0.026
†
1.63 ±1.41 1.63 ±1.51 0.957
Eating desire 8.88 ±2.10 11.63 ±0.92 0.027
†
8.75 ±1.28 9.88 ±0.64 0.024
†
2.75 ±2.60 1.13 ±0.99 0.277
Symptom frequency 45.00 ±6.74 57.5 0 ±4.93 0.018
†
45.50 ±4.21 54.00 ±3.5 9 0.018
†
12.50 ±8.35 8.50 ±5.86 0.246
Food selection 6.88 ±0.99 7.75 ±1.04 0.020
†
6.50 ±1.51 8.25 ±1.39 0.027
†
0.88 ±0.64 1.75 ±1.67 0.268
Communication 5.88 ±1.96 7.00±1.20 0.03 9
†
6.50 ±1.60 8.13 ±0.83 0.041
†
1.13 ±1.36 1.63 ±1.69 0.584
Fear 12.38 ±1.60 16.25±1.0 4 0.011
†
12.50 ±2.39 14.00 ±1.3 1 0.136 3.88 ±1.9 6 1.50 ±2.56 0.072
Mental health 10.00 ±3.63 16.88 ±3.80 0.011
†
10.25 ±5.60 16.00 ±2.78 0.017
†
6.88 ±2.95 5.75 ±3.24 0.634
Social 12.13 ±3.5 6 15.3 8 ±2.77 0.018
†
12.00 ±5.29 16.13 ±2.47 0.027
†
3.25 ±2.49 4.13 ±3.36 0.524
Fatigue 8.38 ±1.41 10.13 ±1.64 0.026
†
8.88 ±1.81 11 .13 ±1.96 0.026
†
1.75 ±1.39 2.25 ±1.58 0.449
Sleep 7.00±1.20 8.00 ±0.93 0.023
†
6.50 ±0.53 7.25±0.89 0.03 4
†
1.00 ±0.76 0.75 ±0.71 0.492
Values are expressed as mean ±SD.
Pre, values before intervention; post, values before intervention; change score, post values−pre values.
SWAL-QOL, Swallowing-Quality of Life; TPSAT, tongue pressure strength and accuracy training.
†
P<0.05.
TPSAT for dysphagia managememt Moon et al. 5
Copyright r2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
following TPSAT using VFSE (Robbins et al., 2007;
Yeates et al., 2008; Steele et al., 2013; Steele et al., 2016),
we mainly used MASA to avoid radiation exposure
from using VFSE (Wright et al., 1998). In this study,
both TPSAT and control groups showed a significant
improvement in swallowing function (a total score of
MASA) after the intervention period, and there was no
significant difference in the total score of MASA between
the two groups. This suggests that the effects of tradi-
tional dysphagia therapy may be similar to those of
TPSAT with traditional dysphagia therapy. However, the
TPSAT group showed a significant improvement in
tongue movement of MASA, showing marginally sig-
nificant differences for tongue strength and coordination
in MASA subcategories compared with the control group.
In addition, although there were no significant changes in
tongue strength and coordination in the control group,
there were significant changes in the TPSAT group after
the intervention. Moreover, there were significant
increases in the respiratory rate, dysarthria, saliva, lip seal,
and oral transit scores after the intervention in the
TPSAT group. Thus, TPSAT with traditional dysphagia
therapy is more effective than traditional dysphagia
therapy in managing dysphagia in stroke patients.
Subcategories of MASA in the pharyngeal phase showed
no significant difference between the two groups.
Previous studies have reported that the intervention
group showed no significant improvement with respect to
pharyngeal residues in stroke patients (Robbins et al.,
2007) and TPSAT showed no significant improvement in
residue vallecular and pyriform in the pharyngeal phase
(Steele et al., 2013). The present study also showed no
significant improvement in subcategories in the phar-
yngeal phase within and between the groups. Taken
together, TPSAT may not be effective for the removal of
residue in vallecular and pyriform sinuses.
With respect to the quality of life in terms of swallowing,
the two groups showed a significant improvement in the
total score of SWAL-QOL. There was no statistically
significant difference in SWAL-QOL between the
two groups, however the TSAPT group (36.88 ±13.26)
showed a slight improvement compared with the control
group (30.38 ±7.13). Considering that this study only
utilized a short intervention period and a small sample
size, it is possible that TPSAT may have a greater positive
effect on the improvement of QOL. In contrast to our results,
a study by Robbins et al. (2007) reported a significant
improvement in fatigue, communication, and mental scales in
SWAL-QOL after tongue strength training. This may be
attributed to the differences according to age and postinjury
duration of participants between our study and the study by
Robbins. Older age with longer postinjury duration tends to
decrease the quality of life (Chuluunbaatar et al., 2016). The
mean age of the participants in the study by Robbins was
69.7 years (n=10), and the number of patients with poststroke
duration of at least 3 months was only four. However, the
mean age and poststroke duration of participants in our study
were 62 years and up to 2 months, respectively. Taken
together, our study may be more effective for determining the
SWAL-QOL than Robbins’s study. Moreover, physical and
occupational therapies were performed as conventional reha-
bilitation as well as dysphagia management. These aspects
may affect the improvement of quality of life (Hartman-Maeir
et al., 2007; Ewan et al., 2010). Compared with the control
group, SWAL-QOL did not change significantly in the
TPSAT group, but the fear score of SWAL-QOL in the
TPSAT group showed a marginally significant increase
compared with the control group. In the TPSAT group, there
was a significant increase in the fear score of SWAL-QOL
compared with the preintervention values. The improvement
in tongue movement, coordination, and strength may decrease
fear of swallowing. Hence, recovery of swallowing function
through TPSAT may improve the quality of life (Ekberg et al.,
2002; Konaka et al., 2010).
On the basis of these findings, we suggest incorporating
TPSAT as part of the dysphagia rehabilitation program
for subacute stroke patients. However, there are some
limitations to consider when interpreting our findings.
First, our study represented data from a small sample.
Although 118 stroke patients with dysphagia were
recruited, only 19 patients fulfilled the inclusion criteria.
Fifty-three of the 118 participants recruited in this study
did not fulfill the inclusion criteria, and 38 of the 53
patients had Mini-Mental State Examination score of less
than 21, which meant a limitation in communication
(Fig. 1). Thus, in the present study, it was difficult to
recruit participants, given the inclusion criteria, because
stroke patients with dysphagia are associated with
decreased cognitive function (Schroeder et al., 2006).
Second, our results may not be generalized to those with
severe dysphagia because there were no patients with
severe dysphagia in our study and the small sample size
(n=8) in this study does not allow generalizability.
Therefore, to better demonstrate the effects of TPSAT
for dysphagia rehabilitation, further studies with adequate
sample sizes according to dysphagia severity are necessary.
Acknowledgements
This work was supported by the Gachon University
research fund of 2016 (GCU-2016-0219).
Conflicts of interest
There are no conflicts of interest.
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