Chin tuck against resistance exercise with feedback to improve swallowing, eating and drinking in frail older people admitted to hospital with pneumonia: a randomised controlled feasibility study (CTAR-SwiFt)

Background:

Community-acquired pneumonia requiring hospital admission is considered to be frequently associated with swallowing difficulties (dysphagia), is common in frail older people. A rehabilitation programme (Chin tuck against resistance (CTAR)) targeting the anterior neck musculature involved in laryngeal movement can improve swallowing safety. We have developed a swallowing exercise rehabilitation intervention (CTAR-SwiFt) by adapting a previously established swallowing exercise to ensure patient safety and ease of execution in the frail elderly population. The CTAR-SwiFt intervention consists of a feedback-enabled exercise ball that can be squeezed under the chin, with real-time feedback provided via a mobile application.

Objective:

The aim of this study was to assess the “usability” of the CTAR-SwiFt intervention and the feasibility of recruiting participants to take part in a larger-scale multi-centre randomised controlled trial to improve swallowing ability and thus reducing community-acquired pneumonia and hospital admission.

Methods:

Methods Patients ≥75 years, admitted with a diagnosis of pneumonia to the acute frailty wards at two participating hospitals in the UK were recruited. Patients had to be medically stable. Study participants were randomised to one of three groups: standard care, low intensity (once daily), or high intensity (twice daily) CTAR-SwiFt exercises. The intervention period lasted for 12 weeks, the final follow-up assessment was conducted at 24 weeks. Feasibility outcomes, including participant recruitment rate and retention, compliance with the exercise regime and adverse incidents were assessed. Additionally, we assessed the usability and acceptability of the intervention device and performance of different clinical outcome measures (e.g., Chin Tuck Strength, Functional Oral Intake Scale, SWAL-QOL, EQ-5D and swallow speed).

Results:

24 participants were recruited and 21 randomised, which was 40% of target, at the rate of 0.9 recruits per month (0.9-1). Of those approached 87.5% were willing to take part and of those recruited 11 (45.8%) completed the study. The major reason for failing to complete the study was medical with people becoming unwell or being re-admitted to hospital. The outcome measures assessed showed suggested that there was an improvement in the swallow assessed by the EAT-10 and 4QT though there was minimal impact on food intake (FOIS). Quality of life as measured by the EQ5D showed an improvement with time, the low intensity intervention demonstrated the best improvement. Participants were able to partake in the CTAR-SwiFt exercises and improve their consistency of ball squeeze over the course of the intervention, and increase their maximum chin touch strength, by a mean of 21%.

Conclusions:

CTAR has been demonstrated to improve the ability to swallow in different cohorts of patients. By improving the ability to swallow, in frail older patients admitted to hospital with pneumonia, using CTAR-SwiFt chin tuck exercises, the recurrence of pneumonia, readmission and an improvement in nutrition can be anticipated. 

Clinical Trial: ISRCTN, ISRCTN12813363. Registered 20 January 2020, https://www.isrctn.com/ISRCTN12813363.