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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
elevation. The particular device utilized by these investigators (Sapienza,
2008) can be adjusted to systematically
increase expiratory resistance during breathing, thereby strengthening
expiratory muscles. In patients with
tracheostomy, for example, it has been
demonstrated that occlusion of the tracheostomy tube results in improved
swallow timing, as opposed to swallows without occlusion of the tube
(Gross et al., 2003). The inference is
that the increased subglottal pressures
associated with occlusion of the tube
facilitate swallow.
Electromyography (EMG) has revealed increased activation of anterior
suprahyoid muscles during EMST (Park
et al., 2016; Wheeler et al., 2007). Troche
et al. (2010) demonstrated improved
airway safety, in the form of reduced
scores on the Penetration-Aspiration
Scale, in Parkinson’s patients undergoing 4 weeks of similar training.
Improvements in both cough and pulmonary function with EMST have also
been reported for Parkinson’s patients
who demonstrated penetration and/
or aspiration on fluoroscopic swallow
studies (Pitts et al., 2009). Patients with
idiopathic Parkinson’s disease reportedly demonstrated increased strength
in expiratory muscles following EMST
therapy (Silverman et al., 2006).
Of additional interest, Pauloski and
Yahnke (2022) reported increases in
the cross-sectional area of the geniohyoid muscle measured with ultrasound
following a 5-week EMST program.
The authors suggest this therapeutic
approach may be of particular value
in patients with weak hyoid or laryngeal elevation and reduced UES opening. Plowman et al. (2019) described
increases in maximum expiratory
muscle pressures and improved swal-
lowing function as assessed with
DIGEST (Dynamic Imaging Grade of
Swallowing Toxicity) in patients with
amyotrophic lateral sclerosis using an
in-home EMST program. Again, individual studies of EMST have shown
promise and pointed to the need for
further investigation. A recent, widescale review of the approach (Mancopes
et al., 2020), however, failed to reveal
clear evidence of the general utility of
EMST and underscores the need for
additional work in identifying populations and methodological details that
may be critical to its success. (Readers
are directed to Addendum 10–1 by James
Curtis for a detailed discussion of respiratory swallow coordination in the treatment
of dysphagia.)
Other evidence suggests that exercise directed to one function or system
of the upper aerodigestive tract may
produce cross-system benefits. For
example, patients with Parkinson’s
disease and dysphagia underwent fluoroscopic studies of swallowing before
and after undergoing a program of
Lee Silverman Voice Therapy (LSVT/
LOUD) (El Sharkawi et al., 2002). Goals
of the therapy were to improve vocal
loudness, in part by retraining patients’
perceptions of their own loudness levels. Although no specific efforts were
directed to swallowing, the authors
reported a 51% reduction in the number
of oropharyngeal swallow abnormalities observed posttreatment, including reductions in oral and pharyngeal
transit times, improved ability to form
a bolus, and reduced pharyngeal residue postswallow. Similarly, Miles et al.
(2017) reported that an LSVT-LOUD
program in patients with mild Parkinson’s disease demonstrated reductions
in pharyngeal residue and size of the
pharynx at rest, increases in maximal
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UES opening during swallow, and positive pressure and flow changes associated with involuntary cough reflexes.
Additional evidence from studies
in animals (primarily) and in stroke
patients suggests that exercise therapies lead to changes in brain function
or cortical reorganization, as well as to
changes in blood flow and muscle volume/composition (Barbay et al., 2006;
Behan et al., 2012; Carnaby-Mann et al.,
2012; Gobbo & O’Mara, 2005; Kleim et
al., 2003; Nudo, 2003, 2005, 2007; Nudo
& Friel, 1999; Ogura et al., 2012). These
intriguing findings again demand additional inquiry and, as noted, raise questions regarding which therapies may
be indicated for which patients and
how best to deliver these therapies. For
example:
n
Should an exercise simulate the
dynamics of the impaired function as closely as possible (i.e., be
task specific), or is more general,
nonspecific training directed to
strengthening involved structures
equally useful?
Current thinking widely sup-
ports the use of the “use it or
lose it” principle, that is, exercise that simulates the impaired
function as closely as possible
(Cerny & Burton, 2001). But a
case might be made that any exercise that strengthens pertinent
muscle groups may produce
some benefits. Sapienza and
Wheeler (2006) note, for example, that if a patient is aspirating, effortful swallow training
may not be indicated. Rather,
a nonswallowing exercise (or
facilitative maneuver) that is
safe and promotes improved
strength, coordination, or en-
durance of muscles involved
in swallowing is a useful substitute. Robbins and colleagues
(2007) discuss a potential neuromotor basis for therapies
that, as reported here, may
subserve multiple functions of
the oral cavity, pharynx, and
larynx, that is, breathing, eating, and speaking. Their findings suggest that our emerging
understanding of these multifunctional organs may eventually contribute to expanded or
novel treatments directed to
their mutual rehabilitation, as
well as to prevention of their
functional decline with aging.
n
Related to the first question, what
is the role of dynamic versus
static muscle training or isometric (muscle length stays the same)
versus isotonic (muscle tension is
constant)?
Again, dynamic exercises are
more likely to simulate target
functions involved in swallowing. Stathopoulos and Duchan
(2006) suggest, however, that
static exercises designed to improve neuromuscular support
for the function may be a useful or necessary prelude to dynamic training. And studies by
both Robbins et al. (2005) and
Shaker et al. (2002) incorporated static training exercises that
improved particular aspects of
function, tongue pressures, and
PES opening, respectively, that
are critical to effective swallow.
n
What are the best delivery meth-
ods for exercise programs? That
is, how many repetitions of the
exercise, how many times per day,
over how many weeks, constitutes
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
the best approach, and should this
protocol be tailored with respect
to patient group?
In general, available evidence
supports the use of multiple
repetitions of sets of exercises,
several times a day, over a period of several weeks. However,
precise combinations likely to
be more beneficial than others,
and under what circumstances,
have generally not been elaborated. Similarly, little information is available regarding the
permanence of exercise effects
or the necessary requirements
for maintaining any beneficial
gains of exercise. In a recent review of studies across exercise
therapies, Krekeler et al. (2021)
found great variability in reports of treatment frequency
and duration, as well as in performance instructions given
to patients and definitions of
treatment “intensity,” ranging,
for example, from measures of
force and duration of movements to subjective descriptions
(e.g., “as hard as possible”). The
authors note the difficulty such
issues present for interpretation
and reproducibility, as well as
for comparison across studies.
Related to the above, a critical
feature of any therapy protocol
that requires home practice is
patient adherence to the program. Govender and colleagues
(2017) described results of comprehensive interviews with patients designed to identify both
barriers and facilitators to exercise therapies. Though based
on a small number of patients,
results indicate a number of
factors that hinder treatment
success, including a lack of understanding of the treatment
rationale, feeling overwhelmed
by the need for information
processing, and forgetfulness.
Factors that appeared related
to successful adherence included support from friends
and family, motivation to avoid
aversive consequences (such as
long-term tube feeding), appropriate physical skills, and feedback regarding performance.
Patient compliance is an issue
that clinicians struggle with
daily, and this area of research
will hopefully provide new insights into conducting successful treatment programs.
n
Finally, what is “fatigue,” what
role should it play in designing
training programs, and is it more
or less important in certain types of
patients? Are there some types of
patients, in fact, for whom exercise
is contraindicated? Interestingly,
exercises have been shown to be
effective even in some populations with degenerative diseases,
such as spinal muscle atrophy and
Duchenne’s muscular dystrophy
(Koessler et al., 2001). But exercise
that exacerbates fatigue may not
be advisable in particular patients.
Obviously, no behavioral therapeusis is appropriate until disease processes resulting in neural, muscular, or
connective tissue changes have been
ruled out or identified and managed.
The etiology of the impairment dictates
the principles and goals of therapy.
Because etiologies of specific impair-
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197
ments vary widely between and even
within patient groups, the dysphagia
clinician will need to carefully question the referring physician or dentist
for information regarding the basis
for the impairment and the potential
for improvement. These specialists
should also caution against some exercises, if necessary. In burn patients, for
example, therapeutic approaches must
consider scar tissue or regenerating
superficial tissues, which are quite fragile. In cancer patients, bony structures
may have been removed or weakened,
muscle tissue may have been removed
or altered by radiation, and muscular attachments may be very different
from normal. Exercises undertaken
without regard to these possibilities
may result, for example, in breaking
a weakened bone. Understanding the
limitations and alterations unique to a
particular patient is critical to designing and implementing appropriate
therapy. If the dysphagia therapist is
to provide optimally safe and effective
therapy, familiarity with principles of
exercise therapy will also be of value,
even required (Clark, 2003; Stathopoulos & Duchan, 2006). In some instances,
multiple behavioral therapies, that is,
strengthening exercises and movement
therapy, or behavioral therapy combined and coordinated with surgical
or prosthetic treatments, can interact
to facilitate the success of all therapies.
Again, it is incumbent on the dysphagia clinician to recognize the need for,
understand the advantages of, and
work within the framework of multiple
treatment modalities when appropriate.
As noted previously, work to improve the strength, mobility, endurance,
and agility of the oral, pharyngeal, and
laryngeal structures cannot be done
without a stable platform (head/neck
and upper body postural stability) from
or against which the head, jaw, lips,
tongue, palate, and larynx can move. If
neck or torso stability is questionable or
unsupportive, consultation with occupational or physical therapists may be
indicated. Collaborative efforts will
help to develop a strengthening program and/or compensatory postural
support strategies that will allow work
on mandibular, labial, lingual, palatal,
and laryngeal gestures.
In summary, while evidence exists
that particular exercise approaches may
benefit dysphagia patients, research in
this area can suffer from issues such as,
for example:
n
Small treatment groups and, in
some cases, lack of a control group
n
Treatment group comprising only
normal subjects and variability
in particular patient populations
investigated
n
Details of specific treatment, as
well as assessment of outcomes,
unclear or variable
Investigators are beginning to explore these and related questions, and
it is likely that significant gains in our
understanding of exercise physiology and its applications in dysphagia
therapy will be forthcoming in the next
few years.
Performance Feedback Tools
The use of feedback in behavioral strategies for dysphagia has been frequently
described and, as noted in the previous
section, is a vital component of certain
therapies. If sensory mechanisms have
been affected, alternative or improved
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
sources of feedback may be particularly critical if patients are to receive the
fullest benefit of exercise therapies for
deglutition. A number of devices that
provide feedback regarding various
physiologic events may help serve this
purpose. As discussed in Chapter 4, our
own experience using visual feedback
provided by a flexible endoscope with
camera and monitor can provide excellent information to patient and clinician regarding a number of physiologic
events or maneuvers that are otherwise
difficult to observe (i.e., pharyngeal
constriction, laryngeal elevation, and
vocal-fold adduction).
A novel approach to respiratory
training has focused on coordination
of respiration and swallowing in a
manner that maximizes airway protection (Martin-Harris et al., 2015). The
technique described by these authors
utilizes biofeedback from computerized displays of respiratory and nasal
airflow activity (Swallowing Signals
Lab, Digital Swallowing Workstation,
Model 7100, Pentax, Lincoln Park, NJ).
Following training in identifying signals, patients were instructed to initiate
swallowing during the mid-expiratory
phase of quiet breathing and to then
continue to exhale following the swallow. Head and neck cancer patients
who underwent this training reportedly demonstrated improvements in
both airway protection and airway
clearance. (Readers are directed to Adden-
dum 10–1 by James Curtis for a discussion
of respiratory swallow training.)
Other commercially available systems provide immediate visual feedback
regarding muscle function. Computerassisted EMG biofeedback systems
(available from a number of vendors)
with surface electrodes present visual
evidence of the presence and amplitude
of the electrical activity of muscle units
close to the electrode. As an objective
indication of muscle effort in the area
of the electrode, such information may
be a very useful clinical tool. There are
some limitations to the use of EMG
in the head and neck, however. For
example, surface electrodes cannot be
targeted at a particular muscle. Wire or
needle electrodes must be used if this
is desired. In addition, an increase of
effort in a muscle, or group of muscles,
does not signal a successful movement
of a structure(s) directed to swallow.
Accomplishment of the goal gesture(s)
must be assessed by some other means.
This is of particular concern when the
gesture in question, for example, PES
opening, cannot be easily visualized by
the patient or clinician.
Another commercially available
feedback device is the Iowa Oral Performance Instrument (IOPI) (IOPI Medical, LLC., Redmond, TN). The system,
used by Robbins et al. (2005) in the
study cited earlier, consists of a pressure transducer connected to a batteryoperated display unit. The IOPI measures pressure produced by squeezing
a small bulb placed on the tongue (a
small bulb for hand squeezing strength
is included) and can be used to develop
strength or endurance of squeezing.
Normative data are presented in the
manual that accompanies the device.
When the IOPI intraoral bulb is used
to develop tongue strength or endurance, it may be helpful to isolate effort
to the tongue by supporting or stabilizing the mandible. The IOPI strengthens
lingual muscle groups that accomplish
elevation against the palate in a gently
rounded shape. Thus, it may strengthen
the lingual configuration required to
hold the bolus on the mid-tongue during oral preparation for swallow. The
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intraoral bulbs are small and require
a normal or near-normal lingual bulk,
however, limiting its use in glossectomy
patients. A dental laboratory may be able
to custom make bulbs for patients after
oral cancer or with orofacial anomalies
whose tongues do not fill the oral cavity. The bulb can be moved around in the
mouth and may be used to strengthen
specific tongue sites as long as the bulb
and the tongue can be seen (to ensure
the exercise is being done correctly).
Although there are no norms for this
kind of task, the patient’s performance
on successive trials can be compared.
Unfortunately, the bulb can be tolerated only in the oral cavity and, in some
patients, not at all sites in the oral cavity.
The TheraBite (Atos Medical, New
Berlin, WI) is an excellent tool for feedback regarding range of mandibular
opening. It can be used to develop
masseter strength in different positions
but gives no feedback regarding actual
strength or effort. Our own experience
with TheraBite in increasing mandibular opening in patients after oral cancer has been positive. We would stress,
however, the need for its careful application. For example, tissue changes
induced by radiation may render the
mandible particularly vulnerable to excessive jaw-opening efforts. The potential use of the instrument should be
discussed with the physician managing
the patient’s care. (Readers are directed
to Addendum 10–2 by Madeline Mills and
Maggie-Lee Huckabee for a discussion of a
novel performance feedback tool.)
MUSCLE AND NERVE
STIMULATION
These strategies of course are not mutually exclusive. That is, stimulation of a
muscle likely affects its innervation
and vice versa. In this section, we have
attempted to differentiate them according to the specific approach, or intent,
of the strategy discussed.
Indirect Muscle Stimulation
In addition to specific exercise regimens, there are a number of externally
implemented techniques to facilitate
stretching of muscles, connective tissue,
and scars, including the application
of temperature, massage, and ultrasound. One such approach, referred to
as neuromuscular electrical stimulation
(NMES) or electrical muscle stimulation
(EMS, E-STIM), has been used to treat
a wide variety of dysphagic impairments. This stimulation can take different forms — for example, be activated
continuously (Freed et al., 2001) or
only during swallow attempts (Leelamanit et al., 2002) — and vary according
to specific frequency-intensity-duration
patterns. One intent of stimulation has
been to enhance contraction of muscles
involved in swallowing, in particular by
increasing the number of motor action
potentials supplied to the muscle or
muscles involved. To date, the effects of
therapies incorporating electrical muscle stimulation have produced mixed
results (Barikroo et al., 2020; Beom et al.,
2011; Blumenfeld et al., 2006; CarnabyMann & Crary, 2008; Félix-Lusterman
et al., 2021; Freed et al., 2001; Heck et al.,
2012; Humbert et al., 2006; Ludlow et
al., 2007; Sun et al., 2020). In particular,
it is not clear whether electrical stimulation improves results over more traditional therapy strategies that are delivered according to the same protocol of
frequency/intensity as that associated
with stimulation (see Carnaby-Mann &
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
Crary, 2007; Clark et al., 2009; Humbert
et al., 2012; Ludlow, 2010). Langmore
etal. (2016) recently reported on results
of a 5-year randomized controlled trial
(RCT) investigating effects of exercise
and electrical stimulation in 170 head
and neck cancer patients. Results suggested that the inclusion of NMES to
the exercise protocol produced worse
results than the exercise program alone.
Other evidence suggests that, in poststroke patients with dysphagia, combining electrical stimulation with more
traditional therapies may be beneficial
(Alamer et al., 2020).
Furuta et al. (2012) described increased frequency of swallowing in
normal subjects with surface electrodes
delivering an “interferential current” to
tissues of the neck. This form of electrical stimulation differs from traditional
techniques by utilizing two high frequencies for stimulation that, as the
name implies, interfere with each other.
The combination produces a different,
lower frequency, that is, the “interferential” frequency. Purportedly, the resulting stimuli produce less discomfort
than the use of a single lower-frequency
stimulus, enabling greater or deeper
levels of stimulation. The potential of
interferential stimulation in dysphagia
therapy will likely be elaborated with
additional investigation.
Another muscle stimulation strategy, functional electrical stimulation
(FES), involves detecting the onset of an
attempted swallow using a combined
electromyography and impedance measurement at the submental muscle level.
When swallow onset is detected, FES is
used to stimulate the swallow in progress. Though preliminary findings in
normal subjects have been mixed, some
individuals have demonstrated greater
and more rapid laryngeal elevation
with stimulation, encouraging investigators to continue this line of inquiry as
a potential means of improving airway
safety during swallow (Schauer, 2017;
Schultheiss et al., 2016).
Other therapy approaches utilizing
some form of tissue stimulation, including manual or myofascial therapy, massage, and even acupuncture, have been
described but have typically lacked
robust evaluation and testing. One
intriguing study (McMillan et al., 2022)
described a form of intraoral manual
therapy used to address trismus in
more than 40 patients several years
postradiation for head and neck cancer. Interestingly, even one session of
the therapy demonstrated significantly
improved maximal interincisal openings in this group of subjects. Larger
and sustained investigations of this and
perhaps other manual approaches are
likely to follow.
Direct Muscle Stimulation
Other stimulation techniques involve
electrode placements directly into targeted muscles. Though more invasive,
these techniques offer more potential
for directly affecting muscle activity. Kagaya et al. (2011), for example,
have provided preliminary evidence
of greater movements in the hyoid
and laryngeal elevator muscles with
implanted, as compared with surface,
electrodes. Ludlow et al. (2000) reported
the use of electrodes implanted in the
thyroarytenoid muscle in dogs. Intermittent stimulation was provided to the
muscle over periods of up to 8 months
and appeared to produce changes in
muscle function consistent with improved airway protection. Burnett et al.
(2003) described the use of electrical
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201
stimulation applied via hooked wire
electrodes into the geniohyoid, mylohyoid, and thyrohyoid muscles of
nondysphagic subjects. Interestingly,
bilateral stimulation of the mylohyoid
and/or thyrohyoid with subjects at rest
produced approximately half of the
laryngeal elevation typically observed
during a swallow. Burnett et al. (2005)
reported an electrical stimulation device
that can be self-triggered. That is, when
a subject initiates a swallow, defined by
the authors as the onset of thyrohyoid
activity leading to a swallow, a button can be pushed that delivers electrical stimulation to the suprahyoid
muscles. To date, this technique has
not been shown to alter muscle activation patterns, but it does represent an
interesting concept that deserves further inquiry.
Neural Stimulation
The use of cortical stimulation techniques to facilitate swallowing, in particular, with stroke patients, has received
significant attention in the past few
years. Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS),
the techniques most often described,
involve the superficial application of
low levels of electrical current to the
brain. The stimulation can change the
polarity of neurons in the area of application. Purportedly, if cortical areas of
the unaffected hemisphere representing
the pharynx can be expanded (assuming intact brainstem and peripheral
structures), swallowing recovery may
be facilitated. Cortical stimulation may
be paired with other swallowing techniques, that is, exercise and maneuvers,
to maximize therapy efforts. Although
they are in early stages as therapeutic
techniques, early reports of their potential have been promising, including evidence that cortical activity produced by
pharyngeal stimulation may last for at
least some period of time after cessation of the stimulus and is associated
with improvement in swallow function (Gow et al., 2004; Hamdy, Aziz, et
al., 1998; Hamdy, Rothwell, et al., 1998;
Hummel et al., 2005; Khedr et al., 2009;
Schlaug et al., 2008; Simons & Hamdy,
2017). Research currently in progress
(including clinical trials in “Phagenyx”
treatment) is likely to expand on, and
elucidate, both pros and cons of the
approach. (Readers are directed to Adden-
dum 10–3 by Ivy Cheng and Shaheen
Hamdy for a discussion of neuromodulation
in dysphagia treatment.)
No exercises, especially stretches,
should cause pain. Patients, especially
eagerly aggressive patients, should be
counseled regarding potential injury
when doing stretching exercises. Frequency and intensity of exercise sessions will depend on patient tolerance
as well as on the specific goals of treatment. That is, strength exercises may
be more taxing than exercises designed
to improve endurance, leading to more
rapid patient fatigue and, of necessity, briefer sessions. If an exercise
approach seems indicated, it would
always behoove the clinician to review
the available literature and investigate
evidence regarding particular protocols
that have been found to be effective or,
perhaps, not effective. Typically, these
reports would describe specific details
of the frequency, intensity, and duration
of the exercise program being considered. Therapy strategies and exercises
that are directed to mobility/strength/
endurance impairments are summarized in Table 10–1.
Shaker’s regimen has been perceived by patients
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to be physically demanding, time-consuming,
and difficult to comprehend. Shaker can be
augmented with craniocervical flexion to reduce
sternocleidomastoid (SCM) activation that can
contribute to fatigue; however, this modification
does not increase suprahyoid muscle activation
Activation of the mylohyoid,
geniohyoid, thyrohyoid,
and digastric muscles
(Shaker etal., 1997).
Isotonic and isometric
head movements provide
resistive loading against
the suprahyoid muscles
(Shaker et al., 1997).
more than typical procedure. CTAR has greater
activation of the SCM than Shaker or resistance
jaw-oopening exercises; can contribute to fatigue
(Kilinc & Ünver, 2022).
Shaker does not address superior/anterior hyoid
and maximum superior laryngeal excursion,
maximum lateral diameter of narrowest area of
the upper esophageal sphincter (UES) (Shaker
et al., 1997). There is also less suprahyoid muscle
activation with Shaker than resistance jaw-opening
exercises and CTAR (Kilinc & Ünver, 2022).
Shaker is performed in the supine position which
can be beneficial for those with disease affecting
trunk stability. However, Shaker may be challenging
for those with cervical spine problems caused for
different reasons.
CTAR is contraindicated in those with tracheostomy
tubes due to the ball/towel/device being placed
close to the anterior cervical region (Kilinc & Ünver,
2022).
Resistance jaw-opening exercise is contraindicated
in those with temporomandibular dysfunction as it
may increase its degeneration (Kilinc & Ünver, 2022).
Shaker, chin tuck
against resistance
Table 10 –1. Rationale and Limitations of Exercises for Improving Movement, Strength, and Endurance of Swallowing Gestures
Exercise Overview of the Exercise Rationale Limitations
(CTAR), jaw lowering
against resistance
(JAR), sustained jaw
opening, or swallow
against laryngeal
resistance (SLAR)
202
There has been no direct relationship with either
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safety or efficiency changes and improved
swallowing pressures nor anterior and posterior
tongue strength in healthy older adults (Smaoui
etal., 2020).
Greater hyoid movement may be seen without
accompaniment of laryngeal elevation, bringing
physiological improvement into question (Steele
etal., 2013).
No significant differences from pre- to posttreatment
in average residue in the oral cavity or
cricopharyngeus (Robbins et al., 2007), in swallow
stage transition duration or Penetration Aspiration
Scale scores for thin or nectar liquids (Steele et al.,
2013), or in reduction of vallecular residue from pre-
to posttreatment for nectar liquids in stroke survivors
continues
(Steele et al., 2013).
Tongue strength did not significantly improve
for head and neck cancer (HNC) patients post-
treatment, though findings may be confounded by
cancer treatment toxicities (Lazarus et al., 2000).
Activation of lingual
skeletal muscles, floor of
Isometric pressure provided
as the anterior or posterior
Tongue press against
Exercise Overview of the Exercise Rationale Limitations
resistance (e.g., Iowa
mouth muscles, and jaw-
closing muscles. Anterior
resistance to engage
hyoid elevation. Posterior
resistance to elicit anterior
tongue presses against
the palate or tongue bulb
(Smaoui et al., 2020).
Oral Performance
Instrument or tongue
depressor)
hyoid movement (Smaoui
et al., 2020).
203
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