One Person’s Abilex™ Success Story

for Tongue Exercise

By Karen Sheffler, MS, CCC-SLP, BCS-S of SwallowStudy.com

Meet Paul (not his real name to protect identity), a 71 year-old male with a long history of chronic-multi-factoral dysphagia. In other words, he has had trouble swallowing for years. He had a major neck surgery called an anterior cervical discectomy and fusion (ACDF) with a second surgery for revision in 2011. Additionally, he has reflux that gets up high into his throat (gastroesophageal reflux disease or GERD and laryngopharyngeal reflux disease or LPR), chronic obstructive pulmonary disease (COPD), sleep apnea, and severe dry mouth (xerostomia). An otolaryngologist noted in December 2018 that his GERD/LPR symptoms were resolved (as these were addressed in a first round of therapy).

Summary of 1st Round of Dysphagia Evaluation & Dysphagia Treatment:

That first round of therapy started with a videofluoroscopic swallow study (VFSS) followed by dysphagia therapy from October 2017 to January 2018. In addition to slight diet modifications, he needed many compensatory swallowing strategies. Therapy also targeted rehabilitation, and Paul used the EMST device (expiratory muscle strength trainer). This was chosen due to his known risk for aspiration (material getting into the top of the airway/larynx and dropping below the vocal cords into the trachea and lungs) and his poor sensation of aspiration. We hoped the EMST would strengthen his cough and ability to eject any material that got down the wrong way. He also worked on effortful swallows and several non-device assisted lingual exercises (for examples, pushing his tongue into a tongue depressor and the Masako Tongue Hold, which has people swallow while their tongue is sticking out. He really had trouble with that Masako and usually skipped that exercise).

Second Round of Dysphagia Evaluation & Dysphagia Treatment with Abilex:

He returned in December 2018 for a repeat VFSS and another round of treatment due to his report of a worsening of his dysphagia, especially after a motor vehicle accident in September 2018 where he was struck from behind (without head strike). The study described a moderate oropharyngeal dysphagia, similar to that in 2017. Briefly, his specific swallowing problems were as follows:

Key safety issues were: Decreased bolus control (a bolus is the ball of liquid or food) with thin liquids with loss of the bolus to the pharynx and larynx, causing penetration before the swallow. Before the swallow started, his boluses dropped down to the pyriforms (pockets in your throat way down by the opening to the airway or larynx) or were already into the laryngeal vestibule (top of the airway). He was then slow in moving his structures to reach the height of his swallow or the height of when the airway/larynx are closed (for therapists: this is a delayed laryngeal vestibule closure reaction time). This slow closure contributed to penetration and aspiration just before and during the swallow. He had no response to the aspirations and had an ineffective cough when told to cough. He aspirated on thin liquid by cup, thin liquid in mixed consistencies, and thin liquid when taking a barium pill (even when using a chin tuck – or tucking the chin down while swallowing).

Main efficiency issues were: He used many piecemeal swallows to clear residue off tongue. Then a significant amount of residue built up in the valleculae (pockets behind the tongue). He had a full valleculae space after the swallow with solids. This was suspected to be due to decreased tongue strength and base of tongue propulsion. His tongue base retraction was reduced with decreased contact of the back of the tongue to posterior pharyngeal wall, whereas his pharyngeal constriction (squeeze of pharyngeal or throat muscles) appeared functional. He needed 5 swallows to clear boluses of cracker and bread. After just two swallows, a significant collection of residue was present on his oral tongue and tongue base and his valleculae was still full bilaterally with residue. Even with performing an effortful swallow with biofeedback (watching video screen during swallow), he still needed 3-4 swallows to clear barium pudding out of the valleculae.  

In addition to further teaching about some slight diet modifications (i.e., adding moisture) and safe swallow strategies (i.e., multiple effortful swallows and taking pills in applesauce), a device-assisted therapy was performed this time. He expressed his past difficulty with some of the standard tongue exercises given in 2017 (he really disliked that Masako, as noted above). We continued the EMST for its potential benefit to help with strengthening his cough response as he was still a known aspirator, and thin liquid was still risky even with the strategies of: small sip, chin tuck, and cough/reswallow.

Device-Assisted Dysphagia Treatment:

Therapy newly and aggressively targeted tongue strengthening with the Abilex device. He performed daily anterior and posterior lingual presses against the Abilex bulb (See exercises #3 and 4 that come with the device instructions. His modification to #4 was to hold the posterior tongue press).

He started training with the Abilex with 5 per set and 5 sets a day, for at least 4 days a week. He was holding the tongue presses for about 3 seconds. After 3-4 weeks, he ramped up his exercise to 10 repetitions per set and 5 sets a day, over at least 5 days a week. After 8 weeks, he reported switching to a maintenance level of 3-5 times a week.

Then, during each outpatient clinic session, we took his IOPI pressure measurements.

Note: The IOPI is the Iowa Oral Performance Instrument that can give you a digital display of a person’s maximum isometric pressures/MIPs while pushing on a small bulb. It can also be used for skill-based training and provides biofeedback with numbers and lights. However, it is quite expensive – over $1,000 expensive — and the small bulb size is not for everyone.

Paul would push into the IOPI bulb over 8-10 repetitions on both the anterior and posterior positions, as indicated by the IOPI. His maximum isometric pressures are listed in the chart below. We recorded his range of pressures, as well as his average anterior and posterior pressure for that day.

His results are in the following chart:

Note: IOPIMedical’s reported norm for “older” adults >60 years old is a mean of 56 kPa for anterior position, which is close to his mean on Jan 28 and Feb 8, 2019, and he reached that on the day of the repeat videofluoroscopic swallow study (VFSS).

Therapy Success After Tongue Exercise with Abilex:

Within the first few weeks, Paul said he could feel the effort in his tongue and in the muscles under his chin.

He liked the convenience of the Abilex, as he exercised while watching TV. His wife and grandson call it his lollipop! He commented that the Abilex air pocket is easier to push on than the IOPI. He noted that it could be positioned exactly where he wanted it and it gave more feedback to push harder. Whereas, the smaller IOPI bulb caused his tongue to “swing all over it and slip to the side.” Even when his tongue was cracked from being so dried out by his CPAP machine and due to side-effects of medications, he reported no pain when pushing into the broader cushion.

His repeat VFSS was in the end of February 2019. Briefly, he had minimal oropharyngeal dysphagia, and here is a summary of safety and efficiency improvements:

• Improved bolus control with no loss of thin liquid bolus, even with mixed consistencies (e.g., a solid plus a liquid in one bite, like cold cereal).
• Improved swallow initiation with bolus head at ramus of mandible (higher up at the jaw line), rather than in pyriforms or airway, like in December 2018. Therefore, he had no aspiration before the swallow.
• Quicker and a greater extent of movement to reach the height of the larynx or airway closure (for therapists: he had better hyolaryngeal excursion and laryngeal vestibule closure with improved laryngeal vestibule closure reaction time). This eliminated penetrations just before the height of the swallow (as was seen on the prior study). Note: we tried to train “volitional laryngeal vestibule closure” (vLVC) on the first round of therapy, but this device may also have allowed for this improved speed of movement, as the vLVC skill was not trained during this second round of therapy. Due to these physiological improvements, he had NO penetrations during rapid drinking of thin liquid by cup. He only had penetration on the 4th sip of thin liquid by straw, and that was above the level of the vocal cords and ejected (Penetration/Aspiration Scale Score of 2). This is within functional limits, and he even detected this and responded with a cough.
• Improved oral and pharyngeal clearance with improved lingual/tongue stripping motion to clear bolus more efficiently off the tongue. No piecemeal swallows were needed to get the bolus out of the mouth. We suspected improved tongue base strength and propulsion as he no longer had a wide column of contrast between tongue base and posterior pharyngeal wall. This shows improved tongue base to pharyngeal wall contact to initiate a good driving force on the bolus.
• He only had trace lingual and valleculae residue after 2 swallows. He could clear a cracker or bread bolus with 2 swallows rather than 5.

Now Paul can continue to do all the terrific traveling that he loves to do, as he does not need weekly outpatient swallowing therapy anymore. He will continue his maintenance program with his Abilex device to hopefully prevent the dysphagia exacerbation that he had last fall of 2018.

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Disclosures:

This patient was given this device by the company, and the patient was motivated to give feedback.

Karen received small stipends for writing articles for this company, but Karen does not make money on individual sales of the product.

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Bottom-Line on ABILEX™ Oral Motor Exerciser:

I really do think it is a great device with key points being:

• inexpensive,
• motivating to help you complete your rehabilitation program,
• easy to use,
• durable to carry it with you anywhere and can withstand even the strongest of bite-reflexes,
• comfortable air-filled bulb especially for people with irregular palates, high palates or sore mouths, and
• potential for a preventative exercise program for people who are at risk, frail and have sarcopenia (loss of skeletal muscle mass with aging).

A preventative exercise program can be done along with other health-maintenance exercise programs provided by physical therapists, occupational therapists and the medical team. Can we prevent an acute onset of dysphagia in an older at-risk individual who ends up hospitalized, critically ill and weak? If that person had built up a “functional reserve” of a stronger tongue prior to the prolonged hospitalization, would their swallow safety and function stay more preserved? We don’t know, but it would make sense.

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Again, please see the prior blog on SwallowStudy.com about Tongue Exercise and Lingual Strengthening.

Again, the ABILEX device is no longer available, but seeing it demonstrated in this YouTube video below may help people with dysphagia understand importance of exercise and may stimulate further device research and development. 

Please see these current devices that are more costly but certainly have demonstrated effectiveness: 

• The Tongueometer: https://e2scientific.com/product/tongueometer/
• Iowa Oral Performance Instrument (IOPI): https://iopimedical.com/

Check it out on YouTube:

Read More About Medical Supplies for People with Dysphagia

Product review of Thickened Liquids.

Why Puree?