Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Reconsidering Rehabilitation for Neurogenic Dysphagia: Strengthening Skill in Swallowing


Purpose of Review

Rehabilitation for oropharyngeal dysphagia aims to improve impaired swallowing biomechanics. However, adverse effects have been reported with strengthening exercises, such as effortful swallowing. Current research is highlighting improvements based on skill, rather than strength, training. Thus, the goal of this review is to determine what evidence exists for skill-based rehabilitation in dysphagia.

Recent Findings

Skill training may be defined as functional repetition and refinement of movement patterns. Skill-based rehabilitation paradigms have been reported for rehabilitation interventions such as lingual accuracy tasks, respiratory-swallowing coordination, and using biofeedback to improve the efficiency of oropharyngeal swallowing. The ultimate goal is to acquire skill in execution of specific swallowing biomechanics at a central level.


The studies reviewed provide favourable proof-of-concept and positive indicators that skill-based intervention may circumvent some limitations with existing strength-based intervention modalities. Skill-based training in dysphagia may be a promising area for future research.

This is a preview of subscription content, log in to check access.


  1. 1.

    Rugiu MG. Role of videofluoroscopy in evaluation of neurologic dysphagia. Acta Otorhinolaryngol Ital. 2007;27:306–16.

  2. 2.

    Logemann J. Evaluation and treatment of swallowing disorders. 2nd ed. San Diego: PRO-ED, Incorporated; 1998.

  3. 3.

    Huckabee ML, Lamvik K, Jones R. Pharyngeal mis-sequencing in dysphagia: characteristics, rehabilitative response, and etiological speculation. J Neurol Sci. 2014;343:153–8.

  4. 4.

    Carnaby GD, Harenberg L. What is "usual care" in dysphagia rehabilitation: a survey of USA dysphagia practice patterns. Dysphagia. 2013;28:567–74.

  5. 5.

    Shaker R, Easterling C, Kern M, Nitschke T, Massey B, Daniels S, et al. Rehabilitation of swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening. Gastroenterology. 2002;122:1314–21.

  6. 6.

    Troche MS, Okun MS, Rosenbek JC, Musson N, Fernandez HH, Rodriguez R, et al. Aspiration and swallowing in Parkinson disease and rehabilitation with EMST: a randomized trial. Neurology. 2010;75:1912–9.

  7. 7.

    Wheeler-Hegland KM, Rosenbek JC, Sapienza CM. Submental sEMG and hyoid movement during Mendelsohn maneuver, effortful swallow, and expiratory muscle strength training. Journal of Speech, Language, and Hearing Research. 2008;51:1072–87.

  8. 8.

    Burkhead LM, Sapienza CM, Rosenbek JC. Strength-training exercise in dysphagia rehabilitation: principles, procedures, and directions for future research. Dysphagia. 2007;22:251–65.

  9. 9.

    Langmore SE, Pisegna JM. Efficacy of exercises to rehabilitate dysphagia: a critique of the literature. Int J Speech Lang Pathol. 2015;17:222–9.

  10. 10.

    Todd JT, Lintzenich CR, Butler SG. Isometric and swallowing tongue strength in healthy adults. Laryngoscope. 2013;123:2469–73.

  11. 11.

    Moldover JR, Borg-Stein J. Exercise and fatigue. In: Downey JA, Myers SJ, Gonzalez EG, editors. The physiological basis of rehabilitation medicine. Oxford: Butterworth-Heinemann; 1994.

  12. 12.

    Clark HM. Neuromuscular treatments for speech and swallowing: a tutorial. Am J Speech Lang Pathol. 2003;12(4):400–15.

  13. 13.

    Baker S, Davenport P, Sapienza C. Examination of strength training and detraining effects in expiratory muscles. J Speech Lang Hear Res. 2005;48:1325–33.

  14. 14.

    Garcia J, Hakel M, Lazarus C. Unexpected consequence of effortful swallowing: case study report. J Med Speech Lang Pathol. 2004;12:59–66.

  15. 15.

    Bülow M, Olsson R, Ekberg O. Videomanometric analysis of supraglottic swallow, effortful swallow, and chin tuck in patients with pharyngeal dysfunction. Dysphagia. 2001;16:190–5.

  16. 16.

    Doeltgen SH, Macrae P, Huckabee ML. Pharyngeal pressure generation during tongue-hold swallows across age groups. Am J Speech Lang Pathol. 2011;20:124–30.

  17. 17.

    Pisegna JM, Kaneoka A, Pearson WG Jr, Kumar S, Langmore SE. Effects of non-invasive brain stimulation on post-stroke dysphagia: a systematic review and meta-analysis of randomized controlled trials. Clin Neurophysiol. 2016;127:956–68.

  18. 18.

    Lefebvre S, Dricot L, Laloux P, Gradkowski W, Desfontaines P, Evrard F, et al. Neural substrates underlying stimulation-enhanced motor skill learning after stroke. Brain. 2015;138:149–63.

  19. 19.

    Kitago T, Krakauer JW. Motor learning principles for neurorehabilitation. Handb Clin Neurol. 2013;110:93–103.

  20. 20.

    Krakauer JW. Motor learning: its relevance to stroke recovery and neurorehabilitation. Curr Opin Neurol. 2006;19:84–90.

  21. 21.

    Matthews PM, Johansen-Berg H, Reddy H. Non-invasive mapping of brain functions and brain recovery: applying lessons from cognitive neuroscience to neurorehabilitation. Restor Neurol Neurosci. 2004;22:245–60.

  22. 22.

    Huckabee ML, Rethinking Rehab MP. Skill based training for swallowing impairment. SIG 13 perspectives on swallowing and swallowing disorders. Dysphagia. 2014;23:46–53.

  23. 23.

    Plautz EJ, Milliken GW, Nudo RJ. Effects of repetitive motor training on movement representations in adult squirrel monkeys: role of use versus learning. Neurobiol Learn Mem. 2000;74:27–55.

  24. 24.

    Magill RA. Motor learning and control: concepts and applications. 9th ed. New York: McGraw Hill; 2011.

  25. 25.

    Rensink M, Schuurmans M, Lindeman E, Hafsteinsdottir T. Task-oriented training in rehabilitation after stroke: systematic review. J Adv Nurs. 2009;65:737–54.

  26. 26.

    Rose DJ, Robert WC. Multilevel approach to the study of motor control and learning. San Francisco: Pearson/Benjamin Cummings; 2006.

  27. 27.

    Schmidt RA, Lee TD. Motor control and learning: a behavioral emphasis. 3rd ed. Champaign: Human Kinetics; 1999.

  28. 28.

    Crary MA, Carnaby GD, LaGorio LA, Carvajal PJ. Functional and physiological outcomes from an exercise-based dysphagia therapy: a pilot investigation of the McNeill Dysphagia Therapy Program. Arch Phys Med Rehabil. 2012;93:1173–8.

  29. 29.

    Ohkubo M, Berretin-Felix G, Sia I, Carnaby-Mann GD, Crary MA. Normalization of temporal aspects of swallowing physiology after the McNeill dysphagia therapy program. Ann Otol Rhinol Laryngol. 2012;121:525–32.

  30. 30.

    Sia I, Carvajal P, Lacy AA, Carnaby GD, Crary MA. Hyoid and laryngeal excursion kinematics-magnitude, duration and velocity—changes following successful exercise-based dysphagia rehabilitation: MDTP. J Oral Rehabil. 2015;42:331–9.

  31. 31.

    Carnaby G, Miller D, LaGorio L, Silliman S, Crary MA. Exercise-based intervention (MDTP) with adjunctive NMES to treat dysphagia post stroke: a double blind placebo controlled trial. Neurorehabilitation & repair. Curr Opin Otolaryngol Head Neck Surg. 2014;22:172–80.

  32. 32.

    Stepp CE, Britton D, Chang C, Merati AL, Matsuoka Y. Feasibility of game-based electromyographic biofeedback for dysphagia rehabilitation. In: Neural Engineering (NER), 2011 5th International IEEE/EMBS Conference; 2011.

  33. 33.

    Athukorala R, Jones R, Sella O, Huckabee ML. Skill training for swallowing rehabilitation in patients with Parkinson's disease. Arch Phys Med Rehabil. 2014;95:1374–82.

  34. 34.

    Hughes TA, Wiles CM. Clinical measurement of swallowing in health and in neurogenic dysphagia. QJM. 1996;89:109–16.

  35. 35.

    Huckabee ML, McIntosh T, Fuller L, Curry M, Thomas P, Walshe M, et al. The Test of Masticating and Swallowing Solids (TOMASS): reliability, validity and international normative data. Int J Lang Commun Disord. 2018;53(1):144–56.

  36. 36.

    McHorney CA, Robbins J, Lomax K, Rosenbek JC, Chignell K, Kramer AE, et al. The SWAL-QOL and SWAL-CARE outcomes tool for oropharyngeal dysphagia in adults: III. Documentation of reliability and validity. Dysphagia. 2002;17(2):97–114.

  37. 37.

    Steele CM, Bailey GL, Polacco RE, Hori SF, Molfenter SM, Oshalla M, et al. Outcomes of tongue-pressure strength and accuracy training for dysphagia following acquired brain injury. Int J Speech Lang Pathol. 2013;15:492–502.

  38. 38.

    Hewitt, Hind, Kays, Nicosia, Doyle, Tompkins, et al. Standardized instrument for lingual pressure measurement. Dysphagia. 2008;23(1):16–25.

  39. 39.

    Molfenter SM, Hsu CY, Lu Y, Lazarus CL. Alterations to swallowing physiology as the result of effortful swallowing in healthy seniors. Dysphagia. 2018;33(3):380–88.

  40. 40.

    Ertekin C. Voluntary versus spontaneous swallowing in man. Dysphagia. 2011;26:183–92.

  41. 41.

    Lamvik K, Jones R, Sauer S, Erfmann K, Huckabee ML. The capacity for volitional control of pharyngeal swallowing in healthy adults. Physiol Behav. 2015;152:257–63.

  42. 42.

    Martin-Harris B, McFarland D, Hill EG, Strange CB, Focht KL, Wan Z, et al. Respiratory-swallow training in patients with head and neck cancer. Arch Phys Med Rehabil. 2015;96:885–93.

  43. 43.

    Hogan N, Krebs HI, Rohrer B, Palazzolo JJ, Dipietro L, Fasoli SE, et al. Motions or muscles? Some behavioral factors underlying robotic assistance of motor recovery. J Rehabil Res Dev. 2006;43:605–18.

  44. 44.

    Liu-Ambrose T, Taunton JE, MacIntyre D, McConkey P, Khan KM. The effects of proprioceptive or strength training on the neuromuscular function of the ACL reconstructed knee: a randomized clinical trial. Scand J Med Sci Sports. 2003;13:115–23.

  45. 45.

    Nelles G, Jentzen W, Jueptner M, Müller S, Diener HC. Arm training induced brain plasticity in stroke studied with serial positron emission tomography. NeuroImage. 2001;13:1146–54.

  46. 46.

    Risberg MA, Holm I, Myklebust G, Engebretsen L. Neuromuscular training versus strength training during first 6 months after anterior cruciate ligament reconstruction: a randomized clinical trial. Phys Ther. 2007;87:737–50.

  47. 47.

    Jensen JL, Marstrand PC, Nielsen JB. Motor skill training and strength training are associated with different plastic changes in the central nervous system. J Appl Physiol. 2005;99:1558–68.

  48. 48.

    Remple MS, Bruneau RM, Vandenberg PM, Goertzen C, Kleim JA. Sensitivity of cortical movement representations to motor experience: evidence that skill learning but not strength training induces cortical reorganization. Behav Brain Res. 2001;123:133–41.

  49. 49.

    Chhabra A, Sapienza C. A review of neurogenic and myogenic adaptations associated with specific exercise. Communicative Disorders Review. 2007;1:175–94.

  50. 50.

    Bülow M, Olsson R, Ekberg O. Supraglottic swallow, effortful swallow, and chin tuck did not alter hypopharyngeal intrabolus pressure in patients with pharyngeal dysfunction. Dysphagia. 2002;17:197–201.

Download references


The University of Canterbury is the owner and manufacturer of the Biofeedback in Strength and Skill Training software; the authors receive no direct income from this.

Author information

Correspondence to Maggie-Lee Huckabee.

Ethics declarations

Conflict of Interest

The authors declare that they have no competing interests.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Swallowing Disorders

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Huckabee, M., Lamvik-Gozdzikowska, K. Reconsidering Rehabilitation for Neurogenic Dysphagia: Strengthening Skill in Swallowing. Curr Phys Med Rehabil Rep 6, 186–191 (2018).

Download citation


  • Deglutition
  • Dysphagia
  • Rehabilitation
  • Strength
  • Skill training