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ADDENDUM 10–1
Treatment: Respiratory-Swallow Training (RST)
James A. Curtis
237
BACKGROUND/INTRODUCTION
Respiratory-swallow coordination is
thought to be important for safe and
efficient swallowing because of its
potential impact on spatial swallowing
kinematics and pressure generation
within the pharynx and esophagus during swallowing. Decades of research
also demonstrate that respiratoryswallow coordination in healthy adults
tends to be different in patient populations known to be at an increased risk
of dysphagia
the notion that respiratory-swallow
coordination is important for safe and
efficient swallow function.
In healthy adults, respiratory-swallow
coordination is typically characterized
by a respiratory pause duration of
~1second (Ayuse et al., 2006; Butler et
al., 2007; Gross et al., 2008; Hårdemark
Cedborg et al., 2009, 2010; Huff et al.,
2018; Klahn & Perlman, 1999; Krishnan
& Goswami, 2019; Leslie et al., 2002;
Martin et al., 1994; Martin-Harris et
al., 2003; Ogna et al., 2017; Pinto et al.,
2017; Preiksaitis et al., 1992; Shaker et
al., 1992; Valenzano et al., 2020; Wang,
2015; Wang et al., 2017; Yagi, Nagami,
et al., 2017; Yagi, Oku, et al., 2017), an
exhale-swallow-exhale pattern (Ayuse
et al., 2006; Boden et al., 2009; Butler et
al., 2007; Dozier et al., 2006; Hårdemark
Cedborg et al., 2009, 2010; Hiss et al.,
2001; Hopkins-Rossabi et al., 2019;
— further contributing to
Kijima et al., 2000; Klahn & Perlman,
1999; Krishnan & Goswami, 2019;
Kumar & Bhat, 2012; Leslie et al., 2002;
Martin et al., 1994; Martin-Harris et al.,
2003, 2005; Melciades Barbosa Costa &
Maria de Oliveira Lemme, 2010; Nilsson et al., 1996; Nishino et al., 1985;
Ogna et al., 2017; Perlman et al., 2000;
Pinto et al., 2017; Preiksaitis & Mills,
1996; Wang, Chen, et al., 2015; Wang et
al., 2017; Wheeler Hegland et al., 2009;
Yagi, Nagami, et al., 2017; Yagi, Oku, et
al., 2017), and a swallow that is initiated
in the mid-lung volume range (Drulia,
2016; Gross et al., 2008, 2009; Huff et al.,
2018; Klahn & Perlman, 1999; Lederle et
al., 2012; Matsuo et al., 2008; McFarland
et al., 1994, 2016; McFarland & Lund,
1995; Palmer & Hiiemae, 2003; Paydarfar et al., 1995; Preiksaitis et al., 1992;
Selley et al., 1989; Smith et al., 1989;
Wheeler Hegland et al., 2009, 2011; Yagi,
Oku, et al., 2017). However, these
typical respiratory-swallow coordination behaviors often occur at disproportionately lower rates in dysphagic
patient populations, including people
with chronic obstructive pulmonary
disease (Cvejic et al., 2011; Gross et al.,
2009; Shaker et al., 1992), cerebral vascular accidents (Butler et al., 2007),
neuromuscular diseases (Hadjikoutis
et al., 2000; Terzi et al., 2007), Parkinson’s disease (Curtis et al., 2022; Curtis
& Troche, 2020; Gross et al., 2008; Troche et al., 2011), tracheostomy tubes
(Gross et al., 2007), and head and neck
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
cancer (Brodsky et al., 2010; Fullerton
et al., 2020; Martin-Harris et al., 2015).
Specifically, people with these medical
morbidities tend to exhibit longer respiratory pauses, more frequent inhalations before and/or after swallowing,
and swallows that are initiated near or
below the end-expiratory level of tidal
breathing.
Given the above, there has been
growing interest in clinical and research
practices in exploring the use of training “typical” respiratory-swallow coordination behaviors as a potential way
to improve swallowing in people with
dysphagia. This treatment paradigm is
now frequently referred to as respiratory-swallow training (RST).
TECHNOLOGY
RST is a skill-based exercise intended to
train the accurate and consistent performance of the exhale-swallow-exhale
pattern whenever eating, drinking, or
swallowing one’s saliva. The exhaleswallow-exhale pattern is the primary
target of RST because it is thought to
(a) position the pharynx and larynx in
an anatomic configuration that is more
favorable for safe and efficient swallowing (Martin-Harris et al., 2022) and
(b)promote greater pressure differentials between the pharynx and esophagus during bolus transit (Gross, 2014;
Irvin et al., 1984; McFarland et al., 2018;
Paydarfar et al., 1995). Lung volume
initiation may also be targeted as part
of RST, either in isolation or in combination with the exhale-swallow-exhale
pattern. However, more research is
needed to empirically determine which
lung volume range is most optimal for
swallowing across different patient
populations (e.g., near/above endinspiratory level of tidal breathing vs.
mid-to-low tidal volume range).
Technology can be used to assist with
RST, though it is not required. Technology can be potentially used for RST for
two reasons. First, technology can assist
in visualizing airflow and respiratory
activity, which may improve the accuracy and reliability in determining if a
patient completed an exhale-swallowexhale. Second, technology can be used
to facilitate biofeedback training. In
this context, a patient performs a practice trial while simultaneously viewing
their airflow and breathing activity on
a viewing screen. No studies have compared the effects of biofeedback versus
no biofeedback on long-term retention
and motor learning outcomes, and
therefore the clinical necessity to incorporate biofeedback into an RST regimen is unknown.
Current technology that can be used
to facilitate RST within clinical practice includes any form of spirometry
capable of visualizing inspiratory and
expiratory airflow. Such equipment
includes the Phonatory Aerodynamic
System (PAS) by PENTAX Medical or
the Aeroview system by Glottal Enterprises, both of which are commonly
used to facilitate acoustic and aerodynamic assessments of voice.
Without technology, a clinician would
rely on visual-perceptual assessments
to determine a patient’s respiratoryswallowing pattern. From an evaluation standpoint, visual-perceptual
assessments are likely less reliable and
less accurate than using technology,
though this has not been empirically
tested. Furthermore, it remains unclear
what is a clinically meaningful difference in assessment error. From a treat-
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239
ment standpoint, patients undergoing
RST without technological assistance
would rely more on intrinsic feedback,
awareness building, and augmented
verbal feedback from the clinician.
APPLICATION
RST should be thought of as a treatment paradigm rather than a specific
treatment protocol. Because it is a
skill-based exercise whereby patients
are learning to swallow in a new way
(exhale-swallow-exhale), it should
rely on principles of motor learning
to guide how the therapy is delivered.
Clinicians should specifically consider
(a) the type, timing, and frequency of
feedback being given to a patient; (b)
the types of instructions and models
being provided to the patient; (c) practice conditions and structure; and (d)
inclusion of error-processing questions.
For more information on principles of
motor learning and these practice considerations, clinicians are encouraged
to refer to the textbook Motor Learning
and Control: Concepts and Applications.
One example structuring of RST is
to plan for 5 repetitions per set, 10 sets
per practice session. To incorporate
some variable practice with the exhaleswallow-exhale practice, patients may
alternate using different bolus delivery methods (e.g., cups, straws, utensils) and whichever bolus volumes
and/or consistencies were found to be
safe during instrumental swallowing
assessments.
To create RST protocols that are
both standardized but also individualized to the patient, clinicians should
develop performance bandwidth rules.
Performance bandwidth rules dictate
when and how to provide feedback
and adjust practice conditions in a systematic and standardized way based
on the real-time performance accuracy
of the patient. For example, following
a set with <80% accuracy, a clinician
may consider providing knowledge of
results and prescriptive feedback after
every trial, whereas following a set
with ≥80% accuracy, the clinician may
adjust to instead provide knowledge
of results and descriptive feedback
after every five trials. Performance
bandwidth rules can also be used to
guide when error-processing questions
are asked in order to scaffold awareness building and self-monitoring. For
example, a clinician may consider asking a patient if they thought they completed a practice trial correctly or not
after every trial until 10 consecutive
trials were observed to be correct, after
which point, the clinician may consider
withdrawing the questions until an
incorrect trial is observed again.
For more details on example RST
protocols, consider reviewing the three
RST articles outlined below and any
additional studies that have since been
published.
RESULTS/EVIDENCE
To date, three studies have been published assessing the effects of RST on
swallowing rehabilitation in people
with dysphagia. The first study was
published by Dr. Bonnie Martin-Harris
and colleagues, which found biofeedback-facilitated RST resulted in significant improvements to respiratoryswallow coordination, base of tongue
retraction, laryngeal vestibule closure,
pharyngeal residue, and penetration-
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
aspiration in a group of people with
head and neck cancer (Martin-Harris
etal., 2015). The second study was a
single-subject research study in a person with mid-stage Parkinson’s disease
and severe dysphagia. The findings
from this study found that four sessions of RST (no biofeedback) resulted
in large improvements in respiratoryswallow coordination, swallowing
safety, and swallowing efficiency as
seen during flexible endoscopic evaluation of swallowing (Curtis, Dakin,
et al., 2020). The third study was also
a single-subject treatment study that
found similar improvements in respiratory-swallow coordination, swallowing safety, and swallowing efficiency
in a person with anoxic brain injury,
severe dysphagia, and atypical respiratory-swallow coordination (Curtis,
Seikaly, et al., 2020). Further evidence
that respiratory-swallow coordination
is trainable is evidenced by work demonstrating that respiratory-swallow
coordination can change as an immediate effect of verbal cueing (Curtis &
Troche, 2020) and bolus holding (Curtis
et al., 2022) techniques.
CONCLUSION/FUTURE WORK
More research is needed with larger
sample sizes and patients of differing
medical diagnoses. Several research
projects are currently under way
across different clinical research labs
to contribute to this need. Additionally, RST is relatively new, and as such,
significantly more research is needed to
further refine the training paradigm.
For example, is it better to only target the exhale-swallow-exhale pattern
or to also include a lung volume ini-
tiation target? Similarly, are longterm motor learning outcomes greater
when incorporating biofeedback or
without biofeedback when a patient
has to rely more on awareness building and self-monitoring, or does this
depend on the patient population and
person’s cognitive status? Lastly, more
research is needed to further explore
effects of dosing, practice condition,
type/timing/frequency of feedback,
and home practice recommendations
on RST training effects. Despite these
current gaps in knowledge, RST
appears to be a promising and relatively easy new therapy that clinicians
can begin to explore in the patients they
are serving.
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