Review article

Effects of the head lift exercise on the swallow function: a

systematic review

Eva Bolle Antunes1 and Nuno Lunet2

1
Faculty of Health Sciences, University Fernando Pessoa, Porto, Portugal; 2Department of Hygiene and Epidemiology, University of Porto
Medical School, Public Health Institute of University of Porto (ISPUP), Porto, Portugal

Gerodontology 2012; doi: 10.1111/j.1741-2358.2012.00638.x

Effects of the head lift exercise on the swallow function: a systematic review
Objective: Ageing is associated with modifications in upper oesophageal sphincter function that may be
deleterious to deglutition. The head lift exercise (Shaker exercise) is a head-raising work out aiming to
improve the opening of this segment, and ultimately to reduce aspiration. We aimed to review critically the
evidence on the effects of this structured intervention programme and to identify gaps to be filled by future
research.
Material and Methods: We identified published reports addressing the effect of this exercise in
increasing the anteroposterior diameter and cross-sectional area of the deglutitive upper oesophageal
sphincter opening or dysphagic symptoms.
Results: Nine methodologically heterogeneous studies were included in the review, and the reported
effects of the head lift exercise were an increase in the anterior excursion of the larynx and in the
anteroposterior diameter of the upper oesophageal sphincter opening, and the elimination of dysphagic
symptoms.
Conclusion: Further studies including control groups and accounting for potential confounders are
needed for a sound assessment of the effectiveness of this technique. The data on the functional results are,
however, promising for dysphagia interventions.

Keywords: deglutition disorders, exercise therapy, oesophageal sphincter, upper.

Accepted 25 September 2011

from the pull of the thyrohyoid, mylohyoid, geni-

Introduction
With ageing, the organ systems usually become
slower and lose strength, stability, coordination and
endurance1. The ability to compensate for natural
age-related changes in deglutition may cease when
there are comorbid acute or progressive illnesses,
and this may interfere with the feeding indepen-
dence and enjoyment2. Changes in upper oesoph-
ageal sphincter function occur as we age, and the
abnormalities in the pharyngoesophageal transport
may lead to longer feeding times, increased pha-
ryngeal residue and aspiration in some elderly
patients2.
The head lift exercise, also known as the Shaker
exercise3,4, was defined after the description of the
upper oesophageal sphincter opening function,
using the information that the upward and forward
movement of the hyolaryngeal structures results
ohyoid and anterior belly of diagastric muscles
contracting. The purpose is the improvement of
both strength and endurance in these muscles and
thereby increasing the opening width of the upper
oesophageal sphincter5–7. The procedure is a head-
raising exercise, with an isometric high-intensity
portion with three head lifts held for 60 s with a
60-s rest period between each one, and an isoki-
netic low-intensity portion that includes 30 con-
secutive head lifts of constant velocity without
holding. Its intent is to increase the anteroposterior
diameter and cross-sectional area of the deglutitive
upper oesophageal sphincter opening5,7,8. This
exercise is non-invasive, purposely conceived for
dysphagia due to upper oesophageal sphincter
dysfunction7, and is an alternative to invasive
procedures such as the cricopharyngeal myotomy
or botulinum toxin injections9,10. The difficulty in

 2012 The Gerodontology Society and John Wiley & Sons A/S 1
2 E. B. Antunes, N. Lunet
managing swallowing disorders associated with
cricopharyngeal dysfunction in the elderly popu-
lation is multifactorial, and further research is
needed to understand the usefulness of the avail-
able intervention modalities2.
Despite the theoretical grounds for the head lift
exercise, its efficacy remains to be demonstrated.
Therefore, we aimed to review critically the evi-
dence on the effects of this structured intervention
programme in changing the upper oesophageal
sphincter opening or dysphagic symptoms in pa-
tients with post-deglutitive dysphagia and to iden-
tify gaps to be filled by future research.
Methods
The electronic databases PubMed (http://www.ncbi.
nlm.nih.gov/pubmed), ISI Web of Knowledge,
Scopus, Scielo (http://www.scielo.org) and Lilacs
(http://www.bases.bireme.br/cgi-bin/wxislind.exe/
iah/online/?IsisScript=iah/iah.xis&base=LILACS&
lang=p) were searched from inception to Septem-
ber 2010. The searches were conducted using the
following general search expression: (therapeutic
exercise OR therapy OR rehabilitation OR treat-
ment OR exercise OR intervention) AND [(swallow
OR swallowing OR deglutition OR dysphagia OR
deglutition disorders) AND (ues OR (upper AND
(esophageal OR oesophageal) AND sphincter)].
Articles were excluded when describing studies
on animals, the conditions associated with upper
oesophageal sphincter dysfunction, assessment of
the upper oesophageal sphincter mechanism or
other procedures (such as cricopharyngeal myoto-
my or botulinum toxin injections) for oropharyn-
geal dysphagia. Papers were included if specifically
addressing the potential effect of the head lift
exercise in changing the upper oesophageal
sphincter opening or in dysphagic symptoms in
patients with post-deglutitive dysphagia. The pa-
pers were considered for systematic review
regardless of the study design. Scrutiny of the ref-
erence lists of all the included papers and forward
citation tracking (using the electronic database ISI
Web of Knowledge) were used so as to seek addi-
tional literature.
From each paper, we extracted information
related to sample characteristics, study design, the
methods used to evaluate the outcomes (videoflu-
oroscopy, bolus pressure measurement, surface
electromyography of muscle activity, question-
naire), the outcome(s) (pressure changes, biome-
chanical measures of structural movement, muscle
fatigue and contractility, and swallowing compe-
tency), the main results and the authors’ conclusions.
Results
Nine studies met the previously defined inclusion
criteria and were considered for the systematic re-
view, as described in the flowchart presented as
Fig. 1. All studies were conducted in the United
States of America. The populations evaluated in-
cluded either healthy subjects 4–8,11–13 or patients
with upper oesophageal sphincter opening dys-
function3,8,11. The average ages of seven studies
were in the elderly category3,5–8,11,12, while two
were with younger adults4,13. The outcomes con-
cerning the swallow function were assessed using
videofluoroscopy3,5–8,11, pressure sensors4,7, surface
electromyography4,12,13, and questionnaire3. Five
studies did not have a control group, while four
carried out between group comparisons with ran-
domisation of exposure3,7,8,11. Seven of the nine
studies included compared pre- and post-evalua-
tions of the head lift exercise programme3,5–8,11,12.
Sample sizes had a median of 21 subjects, ranging
between 6 and 53. The methodological character-
istics and results of the studies are described in
detail in Table 1.
Four studies matched up the head lift exercise to
other exercises3,4,8,11. The most recent study was a
randomised multi-institutional clinical trial, which
487 potentially relevant reports identified
(titles and abstracts screened)
475 exclusions of articles describing:
− Studies on animals
− Only the conditions associated with
UOS dysfunction
− Assessment of the UOS mechanism
− Only other procedures for
oropharyngeal dysphagia
(cricopharyngealmyotomy, botulinum
toxin injections)
Full text of 12 reports retrieved for further
assessment
The search conducted in ISI Web of
Knowledge, Scopus, Lilacs and Scielo, as
well as forward and backward citation
tracking, and contact with the head lift
exercise author yielded no additional
eligible reports
Three exclusions:
− two did not report original research
− one did not assess HLE effects
Nine studies describing original research
on the anatomo-physiological effect of the
HLE on the swallow function considered
for review
Figure 1 Systematic review flowchart. HLE, Head Lift
Exercise; UOS, upper oesophageal sphincter.
 2012 The Gerodontology Society and John Wiley & Sons A/S
 Table 1 Detailed description of the studies addressing the effects of the head lift exercise on the swallow function.

References Sample Outcome(s) Results Author’s conclusions

Shaker7 Sample size: Evaluation pre- and post-6-week Pre- vs. post-6-week exercise The anteroposterior diameter
Enrolled: n = 30 exercise programme and programme: and cross-sectional area of the
Recruited: measures analysed blindly with Significant increase (p < 0.05) in the deglutitive UOS opening in
n = 19 for HLE; respect to group identity and real-exercise group of the: creased significantly in all el
n = 12 for sham exercise exercise status: • maximum anterior excursion of the derly volunteers following
(fist clenching) Videofluoroscopy of deglutition larynx 6 weeks of therapy using the
Age, mean ± SD (range): to evaluate: • anteroposterior diameter of the HLE.
HLE: 74 ± 4 (62–91) (1) anteroposterior and lateral maximum UOS opening This augmentation seems to be
Sham exercise: 73 ± 4 diameters of UOS opening; • UOS cross-sectional area caused by an increase in the
(67–77) (2) superior and anterior Significant decrease (p < 0.05) of swallow-induced anterior
Characteristics: excursion of the hyoid bone hypopharyngeal intrabolus pressure, excursion of the larynx and re
age-matched healthy elderly and the larynx; in the real-exercise group sults in a significant decrease in
subjects (not dysphagic) (3) duration of UOS opening No significant differences in the hypopharyngeal intrabolus
Randomisation of exposure Strain-gauge probe to evaluate: real-exercise group for: pressure, suggesting a decline in
(exercise) (1) hypopharyngeal intrabolus • maximum superior and anterior pharyngeal outflow resistance.

 2012 The Gerodontology Society and John Wiley & Sons A/S
pressure in 12 of the HLE and hyoid excursion
six of the sham-exercise groups • maximum superior laryngeal
excursions
No significant differences in any of the
parameters, for the sham-exercise
group
No change in the duration of UOS
opening in either group
one participant in the sham-exercise
group did not complete the
programme.
Ferdjallah13 Sample size: Evaluation during the isometric During the HLE: All the muscle groups showed
n = 5 male; portion of the HLE: suprahyoid, infrahyoid and signs of fatigue as soon as they
n = 6 female sEMG to evaluate: sternocleidomastoid muscle groups became active. The
Age, mean ± SD: (1) fatigue of the suprahyoid, show signs of fatigue sternocleidomastoid muscle
32.36 ± 8.32 infrahyoid and sternocleidomastoid muscles fatigued group fatigued sooner and
Characteristics: sternocleidomastoid muscle faster (p < 0.05) progressively, with limited
healthy subjects groups suprahyoid and infrahyoid muscle recovery. Hence, the
(not dysphagic) groups recovered quickly during the sternocleidomastoid muscles
60 s rest period may be a limiting factor in the
timing of the HLE, since it does
not have a role in the swallow
Effects of the head lift exercise on the swallow function

process.
3

Table 1 Continued
References Sample Outcome(s)
Shaker3 Sample size: Evaluation pre- and
n = 27 post-6-week exercise
n = 11 for HLE; programme and measures
n = 7 for sham exercise analysed blindly with respect
(tongue lateralisations), to group identity and
who were crossed over to exercise status:
HLE group after 6 weeks Videofluoroscopy of
Age, mean (range): deglutition to evaluate:
72 (62–89) (1) anteroposterior and lateral
Characteristics: diameters of UOS opening;
With abnormal UOS (2) superior and anterior
opening (post-swallow excursion of hyoid bone and
residue and aspiration); the larynx;
able to exercise (3) pyriform sinus residue;
independently (4) presence or absence of
Randomisation of aspiration.
exposure (exercise) Evaluation during the 6-week
exercise programme:
Daily exercise log
Evaluation post-6-week
exercise programme:
FOAMS (Functional Outcome
Assessment Measure of
Swallowing) to evaluate:
(1) level of swallowing
competency
 2012 The Gerodontology Society and John Wiley & Sons A/S
4
Results Author’s conclusions
Between group comparison (sham exercise The HLE and its suprahyoid
vs. HLE): muscle strengthening
No statistical difference in biomechanical exercise programme was
parameters, before exercise successful in restoring oral
Significant difference in FOAMS (p < 0.01), intake in patients with
E. B. Antunes, N. Lunet
after exercise dysphagia due to abnormal
No statistical difference in anteroposterior UOS opening.
diameter of the UOS (although larger after real Aetiology and duration of
exercise), after exercise dysphagia did not affect the
Pre- vs. post-6-week exercise programme: outcome.
Significant improvement (p < 0.01) in The muscle group-specific
anteroposterior diameter of UOS opening, exercises aimed at the
anterior laryngeal excursion, and FOAMS; in striated muscles of
real-exercise group deglutition can make a
Resolution of post-deglutitive aspiration and significant contribution to
able to resume oral feeding, in real-exercise the rehabilitation of swallow
group function.
No significant changes in superior laryngeal
excursion, anterior and superior hyoid bone
excursions, in real-exercise group.
No significant changes in biomechanical
parameters, in sham-exercise group
Pre- vs. post-6-week programme, after
cross-over:
The seven crossed-over patients exhibited
similar results to real-exercise group:
significant increase in anteroposterior diameter
of the UOS opening (p < 0.01), anterior
excursion of the larynx (p < 0.05), and FOAM
(p < 0.05).
No statistically significant changes in other
biomechanical parameters.
Significant decrease (p < 0.01) in post-swallow
pyriform sinus residue.
Resolution of post-deglutitive aspiration and
able to resume oral feeding
All patients successfully completed the exercise
protocols (no losses to follow-up)
 Table 1 Continued
References Sample Outcome(s)
Easterling6 Sample size: Evaluation pre- and post-6-week
Enrolled: n = 19 exercise programme and
Recruited: measures analysed blindly with
n = 7 male; respect to participant identity
n = 19 female and exercise status:
Age, range: 66–93 Videofluoroscopy of deglutition
Characteristics: to evaluate:
Healthy subjects (not (1) anteroposterior diameter of
dysphagic); able to UOS opening;
exercise independently (2) superior and anterior
four randomly chosen excursion of hyoid bone and
subjects for pre- and the larynx.
post-exercise Evaluation during the 6-week
videofluoroscopy exercise programme:
 2012 The Gerodontology Society and John Wiley & Sons A/S
Daily exercise log
Weekly visits by a speech-
language pathologist to
monitor:
(1) accuracy and recordings of
performance;
(2) comments or complaints.
Yoshida4 Sample size: Evaluation during the exercises:
n = 20 male; Pressure sensors and Submental
n = 33 female sEMG simultaneously, to
Age, mean (range): compare muscle activity
35.3 (21–60) between:
Characteristics: (1) HLE (isometric and isotonic
Healthy subjects (not portions)
dysphagic) and
(2) Tongue press against hard
palate (isometric task); and
sustained lingual force against
hard palate (isotonic task)
Results Author’s conclusions
Pre- vs post-6-week exercise The HLE can be performed
programme: independently, but a structured
Significant increase (p < 0.05) in: and gradually progressive
maximum anterior hyoid excursion programme is needed.
(in mm), maximum anterior
laryngeal excursion (in mm),
maximum anteroposterior UOS
deglutitive opening (in mm)
No difference in superior laryngeal and
hyoid bone excursions.
Mild muscle discomfort, which
resolved spontaneously after 2 weeks.
seven participants did not complete the
programme due to muscle discomfort
and time constraints.
Between exercise comparison (tongue The tongue press exercise may
press exercise vs. HLE): be a viable alternative to the
No sEMG (muscle activity) differences HLE to exercise the submental
were identified between the isometric muscle group, as it may be less
tongue press task and HLE. strenuous while achieving the
For the isotonic activities, the tongue same therapeutic effect.
press exercises resulted in However, future clinical studies
significantly higher maximum and will be required to evaluate the
mean sEMG values (p < 0.001) than impact of tongue press activity
the HLE. on UOS opening and other
The submental sEMG activity from the biomechanical aspects of
tongue press exercise was equal swallowing.
(isometric) to, or greater (isotonic)
than comparable muscle activation
obtained during the HLE.
Effects of the head lift exercise on the swallow function
5
 6

Table 1 Continued

References Sample Outcome(s) Results Author’s conclusions

12
White Sample size: Evaluation pre- and post-6-week Pre- vs. post-6-week exercise programme: The HLE initially leads to
Enrolled: n = 2 exercise programme, during the Fatigue-related changes were manifested increased fatigue resistance of the
Recruited: isometric portion of the HLE: during the 20-s hold. sternocleidomastoid muscles,
n = 4 male; sEMG to evaluate: There was early fatiguing of the after which the exercise loads the
E. B. Antunes, N. Lunet

n = 2 female (1) the progression of fatigue in sternocleidomastoid muscles, but less fatigue-resistant suprahyoid
Age, mean (range): suprahyoid, infrahyoid and improved fatigue resistance. The and infrahyoid muscle groups,
73 (70–78) sternocleidomastoid muscle sternocleidomastoid muscle group is potentiating the therapeutic
Characteristics: groups strengthened, while the contractility of effect with continued exercising.
Healthy elderly Evaluation during the 6-week the suprahyoid and infrahyoid muscle If the subjects were to continue to
subjects (not exercise programme: groups is increased. practice the HLE, as the increased
dysphagic) Daily exercise log four losses to follow-up (inadequate fatigue resistance of the
sEMG recordings). sternocleidomastoid muscle
group has enabled increased
loading and effort, the
suprahyoid and infrahyoid
muscles would increase their
fatigue resistance.
Easterling5 Sample size: Evaluation pre- and post-6-week Pre- vs post-6-week exercise programme: The HLE could be recommended
n = 10 male; exercise programme and Significant improvement (p < 0.05), in 10 as a preventative measure to
n = 11 female measures analysed blindly: of 21 participants, in biomechanical diminish the effect of sarcopenia
n = 5 age-matched Videofluoroscopy of deglutition measures (maximum anterior hyoid and on the muscles used in
controls (three to evaluate: laryngeal excursion, and anteroposterior deglutition and voice and alter
females and two (1) anteroposterior and lateral UOS deglutitive opening diameter) and the progression of the
males) that did diameters of UOS opening; DSI characteristic senescent voice and
not perform HLE (2) superior and anterior No changes in superior laryngeal and swallow changes.
Controls participated in excursion of hyoid bone and hyoid bone excursions The overweight and obese were
voice analysis only. the larynx; No significant change in biomechanical slower to attain the exercise
Age, mean ± SD Acoustic analysis of voice measures or DSI for the other 11 exercise regimen goals and showed poor
(range): DSI (Dysphonia Severity Index) enrollees and the control group compliance in exercise
70 ± 4 (65–78) Evaluation during the 6-week The participants who were not able to performance frequency and duration.
Characteristics: exercise programme: attain exercise goals and thus showed no
Healthy subjects Daily exercise log swallow or vocal function benefit from
(no swallowing Four visits to monitor: the 6-week exercise regimen were in the
or voice (1) accuracy of performance and overweight or obese category.
disorders) of compliance with frequency
and duration

 2012 The Gerodontology Society and John Wiley & Sons A/S
 Table 1 Continued
References Sample
8
Mepani Sample size:
Enrolled: n = 11 (six traditional
and five HLE)
Recruited:
traditional therapy
n = 5 male; 1 female
HLE:
n = 3 male; 2 female
Age, mean ± SD (range):
traditional therapy:
 2012 The Gerodontology Society and John Wiley & Sons A/S
70.5 ± 9.5 (56–81)
HLE:
64 ± 22.8 (26–84)
Characteristics:
With UOS dysfunction; 5 cancer
(two from traditional therapy,
three from HLE) and six stroke
(four from traditional therapy
and two from HLE
Randomisation of exposure (six
traditional therapy; five HLE)
Outcome(s) Results Author’s conclusions
Evaluation pre- and Between group comparison The results demonstrate a trend
post-6-week exercise (traditional therapy vs. HLE): toward increasing deglutitive
programme: No statistically significant difference in thyrohyoid shortening with the
Videofluoroscopy of thyrohyoid distance (p = 0.54), before HLE muscles compared to that
deglutition to evaluate: therapy seen with traditional dysphagia
1) deglutitive thyrohyoid Maximum thyrohyoid muscle therapy and manoeuvres, in
shortening shortening occurred at close temporal addition to strengthening the
Evaluation during the proximity to the time of maximal suprahyoid muscle group.
6-week exercise thyroid cartilage excursion, before This effect would be expected to
programme: therapy. contribute to the enhanced
Supervision by Statistically significant difference in deglutitive UOS opening and
speech-language thyrohyoid distance (p = 0.034), after improved dysphagic symptom
pathologist to: therapy. relief in patients with
(1) demonstrate the Pre- vs. post-6-week exercise post-deglutitive dysphagia.
exercises, programme:
(2) monitor accuracy of No statistically significant difference in
performance thyrohyoid distance (p = 0.48), for
(3) review of the therapy traditional therapy
practice log No statistically significant difference in
thyrohyoid distance (p = 0.066), for
HLE.
three losses to follow-up (two from
traditional therapy group and one
from the head lift exercise group) and
five excluded (three from traditional
therapy and two from HLE, due to
failed swallow or poor radiographic
landmark)
Effects of the head lift exercise on the swallow function
7

Table 1 Continued
References Sample
Logemann11 Sample size:
Enrolled: n = 11 (six
traditional, five HLE)
Recruited:
traditional therapy:
n = 10 male; 1 female
HLE:
n = 6 male; 2 female
Age, mean ± SD (range):
traditional therapy:
70.9 ± 9.5 (56–81)
HLE:
63.1 ± 22.8) (26–84)
Characteristics:
With UOS dysfunction and
3-month history of
aspiration
Multi-institutional
Randomisation of
exposure and
stratification by aetiology
(head & neck cancer,
stroke)
HLE, Head Lift Exercise; UOS, upper oesophageal sphincter; sEMG, surface electromyography; SD, standard deviation.
 2012 The Gerodontology Society and John Wiley & Sons A/S
Outcome(s)
Evaluation pre- and
post-6-week exercise and
measures analysed blindly
with respect to group
identity and speech-
language pathologist’s
previous observations:
Videofluoroscopy of
deglutition to evaluate:
(1) superior and anterior
excursion of the hyoid bone
and the larynx
(2) UOS opening
(3) post-swallow residue
Evaluation during the 6-week
exercise programme:
Daily exercise log
Supervision by
speech-language pathologist
to:
(1) demonstrate the exercises
(2) monitor accuracy of
performance
Results
Between group comparison (traditional
therapy vs HLE):
The HLE significantly reduced post-swallow
aspiration to a greater degree than the
traditional therapy.
After both types of therapy there is a
significant increase in UOS opening width
on 3-ml paste swallows.
After both types of therapy, the location of
residue remained the same.
Traditional therapy resulted in
improvements in swallow measures on
3-ml paste swallows.
Traditional therapy resulted in significant
increases from pre- to post-therapy, in
biomechanical measures: superior laryngeal
movement and superior hyoid movement
on 3-ml pudding swallows and anterior
laryngeal movement on 3-ml liquid boluses,
indicating significant improvement in
swallowing physiology.
Eight losses to follow-up (two from
traditional therapy group, three from head
lift exercise group, and three excluded due
to inability to identify necessary landmarks
on videofluoroscopy)
8
Author’s conclusions
E. B. Antunes, N. Lunet
Traditional therapy often
utilises greater muscle effort
than the HLE, which may
explain the changes in paste
swallows after traditional
therapy (paste requires
greater pressure to swallow
than liquid).
Both traditional therapy and
HLE resulted in significant
but different changes in the
swallow. When selecting
therapy for a patient, the
clinician should consider
whether the patient aspi
rates (in particular, after
swallowing) and should
recommend the HLE. If the
patient has reduced range of
movement of structures in
the pharynx, traditional
therapy should be the
choice.

showed improvements in post-swallow aspiration
to a greater degree with the head lift exercise pro-
gramme in comparison with traditional therapy
(exercises practiced for 5 min 10 times per day for
6 weeks, including the super-supraglottic swallow,
the Mendelsohn manoeuvre and tongue base
exercises), in groups of elderly dysphagic patients
with abnormal upper oesophageal sphincter open-
ing11. It showed as well that there was a significant
increase in upper oesophageal sphincter opening
width on paste swallows after both types of ther-
apy11. There was also a significant difference in the
changes in thyrohyoid distance with the head lift
exercise vs. traditional therapy8.
However, there were no significant differences in
the upper oesophageal sphincter diameter opening
between groups of elderly dysphagic patients per-
forming the head lift exercise and a sham exercise
(tongue lateralisations)3. Furthermore, a study in
healthy young subjects put side by side the head lift
exercise and a tongue press exercise intended to
achieve the same therapeutic effect (isometric press
against the hard palate and isotonic sustained
lingual force against hard palate) reported no dif-
ferences in submental muscle activity for the
isometric portion and moreover, stated significant
higher values for the isotonic activity of the tongue
press exercise4.
Assessments of muscle fatigue were conducted
with surface electromyography in healthy young 13
and elderly 12 subjects. In both studies, there was
early fatiguing of the sternocleidomastoid mus-
cles12,13. The suprahyoid and infrahyoid muscle
groups also demonstrated fatigue but with quick
recovery 13 and increased contractility12. Thus, the
sternocleidomastoid muscles might limit patient
performance and attainment of the exercise goals.
Nevertheless, after the programme, muscle fatigue
was delayed for the sternocleidomastoid muscles,
after which the exercise loaded the less fatigue-
resistant infrahyoid and suprahyoid muscle groups,
indicating the therapeutic effect of performing the
exercise for 6 weeks, which was attributed to
improved muscle strength12,13.
Research on the head lift exercise began with
examining how it improved the duration and the
width of the upper oesophageal sphincter opening
in the normal elderly 7 and young13. This was fol-
lowed by a study of the effect of the exercise in
elderly patients with oropharyngeal dysphagia
secondary to an abnormal upper oesophageal
sphincter opening3, and in healthy elderly 5,6,12
and young subjects.4 The more recent studies were
conducted on elderly patients with upper oesoph-
ageal sphincter dysfunction8,11. The results
 2012 The Gerodontology Society and John Wiley & Sons A/S
Effects of the head lift exercise on the swallow function 9
analysed were mainly focused on the anatomo-
physiological effects of the head lift exercise on the
swallow function, namely the increase in the
excursion of the hyoid bone and the laryngeal
structures, the shortening of the thyrohyoid
distance, the augmentation and the duration of the
upper oesophageal sphincter opening, the decrease
of hypopharyngeal intrabolus pressure and muscle
fatigue. Post-deglutitive aspiration, a dysphagic
symptom variable, was assessed in two of the three
studies with dysphagic patients3,11.
The studies describing comparisons before and
after the 6-week head lift exercise programme and
using videofluoroscopy all included elderly subjects
(average age above 63), and while three had a
sample of dysphagic patients (with abnormal upper
oesophageal sphincter opening)3,8,11, the other
three were with healthy individuals5–7. Table 2
depicts the diversity of outcomes assessed in nine
studies, involving healthy subjects or dysphagic
patients, comparing the participants before and
after the intervention. Improvements were
reported for direct dysphagic symptom relief, in
anterior larynx excursion, in upper oesophageal
sphincter diameter opening and in bolus pressure.
No significant differences were found for most of
the other anatomo-physiologic parameters: thyro-
hyoid distance, superior larynx and hyoid excur-
sion, and duration of upper oesophageal sphincter
opening. For anterior hyoid excursion, the findings
are contradictory.
Figure 2 depicts a summary of the methodolog-
ical characteristics potentially associated with bias
or confounding. All the studies used appropriate
assessment methods for the outcomes measured. In
four studies, there was a control group and ran-
domisation of exposure3,7,8,11, which was consid-
ered as an appropriate method for confounding
control, despite the small number of participants.
Of the seven studies with follow-up3,5–8,11,12, one
was considered to comprise low risk of bias since
there were no losses to follow-up3. The remaining
six studies did not report sufficient information so
as to allow quantification of completeness of fol-
low-up.
Discussion
Changes in physiology with ageing are seen in the
upper oesophageal sphincter and pharyngeal
region in both symptomatic and asymptomatic
older individuals14. One of the more perplexing
causes of dysphagia in the elderly is cricopharyn-
geal dysfunction, and the assessment of the impact
of non-invasive management of upper oesophageal
10 E. B. Antunes, N. Lunet

Table 2 Pre- vs. post-evaluation of the head lift exercise programme (nine studies).

Number of studies assessing each outcome, according to the participants’

characteristics and the conclusions of the original articles

Dysphagic patients Healthy subjects

Outcome Effective Not effective Total* Effective Not effective Total *

Decrease in thyrohyoid distance (n = 2) – 1 1 – 1 1

Increase in Anterior Larynx Excursion (n = 4)
Increase in Superior Larynx Excursion (n = 4)
Increase in Anterior Hyoid Excursion (n = 4)
Increase in Superior Hyoid Excursion (n = 4)
Increase in UOS Diameter Opening (n = 5)
Increase in duration of UOS opening (n = 1)
Decrease in bolus pressure (n = 1)
Decrease in post-swallow aspiration (n = 2)
Improvement in level of swallowing
competency: FOAMSa (n = 1)
a
FOAMS, Functional Outcome Assessment Measure of Swallowing.
*The sum of the studies assessing all of the outcomes is higher than 9 because each study may address more than one
outcome.
Yes Unclear
Appropriate outcome
assessment method
Appropriate completeness
of follow-up *
Study design including
a control group
Randomization of
exposure **
Appropriate confounding
control ***
0% 20% 40%
Figure 2 Risk of bias and confounding graph. *Applies
only to studies with follow-up (n = 7). **Apllies only to
studies with a control group (n = 4). ***Applies only to
studies with a control group (n = 4), and assumes
randomisation as an appropriate method for confounding
control, despite the small number of participants.
sphincter disorders is needed2. This systematic
review provides a summary evaluation of the
available evidence on the efficacy of the head lift
exercise. To our knowledge, this is the most com-
prehensive review on this topic. It was undertaken
searching several electronic databases with an
unspecific search expression, and complemented
by backward and forward citation tracking as well
as contacts with experts in this field, which con-
tributes to an unbiased search with potential to
include all the relevant evidence published
regarding this issue. The heterogeneity of the
studies included in the review, regarding the par-
ticipants¢ characteristics and study designs, as well
as the diversity of the outcomes evaluated and in
1 – 1 3 – 3
– 1 1 – 3 3
– 1 1 2 1 3
– 1 1 – 3 3
2 – 2 3 – 3
– – – – 1 1
– – – 1 – 1
2 – 2 – – –
1 – 1 – – –
No
the presentation of the results, is remarkable and,
unfortunately, precludes the conduction of a meta-
analysis or the use of other more efficient methods
to summarise the results.
There is evidence that the head lift exercise
showed better effects regarding post-swallow aspi-
ration than traditional therapy3,11. However, even if
the treatments of dysphagia in older patients are
similar to those in younger patients, more aggressive
therapies may not be possible14. This makes less
60% 80% 100%
demanding interventions more attractive14. So,
when selecting the line of treatment, the clinician
should also consider if there is reduced range of
movement of structures in the pharynx, in which
case traditional therapy should be recommended11.
Additionally, given that the tongue press exercise
may be less strenuous while achieving the same
therapeutic effect, it could be a viable alternative for
those unable to comply with the demands of the
head lift programme4. More research conducted
with other study designs and investigators are nec-
essary, especially for comparison with other feasible
options, such as multiple swallowing, which has
been shown to contribute to the amount of pha-
ryngeal residue (a higher risk for aspiration) in the
elderly with declining oropharyngeal ability15.
There are other limitations to these studies, the
most important of which is the small sample sizes
that lead to limited statistical power for certain
analyses, such as the within-group change. More-
over, additional studies need to be undertaken to
evaluate the precise effects both on cancer and
stroke patients. The behavioural, dietary and

 2012 The Gerodontology Society and John Wiley & Sons A/S

environmental modifications for elders with dys-
phagia emerging in this past decade are promising,
nonetheless, the state of the evidence calls for more
research16. Likewise, the results of this review
indicate that the establishment of a standard is
premature and hinder the determination of the
merit of the head lift exercise. The studies need to
be replicated considering more carefully the vari-
ables that may influence and confound the out-
comes, such as age, gender, duration of dysphagia,
aetiology of dysphagia, initial severity of dysphagia,
mental status, physical status, respiratory status
and patient compliance with the home protocol.
Randomised controlled trials with an appropriate
sample size may provide more robust findings on
this topic.
In conclusion, despite the theoretical grounds for
the head lift exercise, its efficacy has not yet been
fully established. Even if the basis for current
management of dysphagia in elderly patients is a
thorough understanding of the complex anatomy
and physiology of deglutition, not only numerous
redundant mechanisms exist to allow competent
swallowing, but also the changes that predispose an
individual to dysphagia are diffuse2. Most of the
reviewed studies do not assess direct outcomes of
dysphagic symptom relief4–8,12,13. Instead, they
analyse surrogate endpoints, such as anatomo-
physiologic changes that suggest expected effects in
the swallowing function, through the predictable
strengthening of the muscle groups involved and
decline in pharyngeal outflow resistance, and res-
idue. There is an insufficient level of evidence
considering that few clinical trials were conducted,
and more research ought to be accomplished before
the recommendation that the head lift exercise
programme is to be seen as an evidence-based
practice. However, the data on the functional
results are promising for dysphagia interventions.
References
1. Gleeson DC. Oropharyngeal swallowing and aging: a
review. J Commun Disord 1999; 32: 373–395.
2. Schindler JS, Kelly JH. Swallowing disorders in the
elderly. Laryngoscope 2002; 112: 589–602.
3. Shaker R, Easterling C, Kern M et al. Rehabilita-
tion of swallowing by exercise in tube-fed patients
with pharyngeal dysphagia secondary to abnormal
UES opening. Gastroenterology 2002; 122: 1314–1321.
4. Yoshida M, Groher ME, Crary MA, Mann GC,
Akagawa Y. Comparison of surface electromyo-
 2012 The Gerodontology Society and John Wiley & Sons A/S
Effects of the head lift exercise on the swallow function 11
graphic (sEMG) activity of submental muscles be-
tween the head lift and tongue press exercises as a
therapeutic exercise for pharyngeal dysphagia.
Gerodontology 2007; 24: 111–116.
5. Easterling C. Does an exercise aimed at improving
swallow function have an effect on vocal function in
the healthy elderly? Dysphagia 2008; 23: 317–326.
6. Easterling C, Grande B, Kern M, Sears K, Shaker
R. Attaining and maintaining isometric and isokinetic
goals of the Shaker exercise. Dysphagia 2005; 20: 133–
138.
7. Shaker R, Kern M, Bardan E et al. Augmentation
of deglutitive upper esophageal sphincter opening
in the elderly by exercise. Am J Physiol (Gastroin-
testinal and Liver Physiology) 1997; 272: G1518–
G1522.
8. Mepani R, Antonik S, Massey B et al. Augmen-
tation of deglutitive thyrohyoid muscle shortening by
the Shaker Exercise. Dysphagia 2009; 24: 26–31.
9. Logemann JA. Evaluation and Treatment of Swallow-
ing Disorders, 2nd edn. Austin, TX: Pro-Ed, 1998.
10. Groher ME. Treatment considerations, options and
decisions. In: Groher ME, Crary MA eds. Dysphagia:
Clinical Management in Adults and Children. Maryland
Heights: Mosby Elsevier, 2010: 231–252.
11. Logemann JA, Rademaker A, Pauloski BR et al.
A randomized study comparing the Shaker exercise
with traditional therapy: a preliminary study. Dys-
phagia 2009; 24: 403–411.
12. White KT, Easterling C, Roberts N, Wertsch J,
Shaker R. Fatigue analysis before and after shaker
exercise: physiologic tool for exercise design. Dys-
phagia 2008; 23: 385–391.
13. Ferdjallah M, Wertsch JJ, Shaker R. Spectral
analysis of surface electromyography (EMG) of upper
esophageal sphincter-opening muscles during head
lift exercise. J Rehabil Res Dev 2000; 37: 335–340.
14. Achem SR, Devault KR. Dysphagia in aging. J Clin
Gastroenterol 2005; 39: 357–371.
15. Ono T, Kumakura I, Arimoto M et al. Influence of
bite force and tongue pressure on oro-pharyngeal
residue in the elderly. Gerodontology 2007; 24: 143–
150.
16. Ney DM, Weiss JM, Kind AJ, Robbins J. Senes-
cent swallowing: impact, strategies, and interven-
tions. Nutr Clin Pract 2009; 24: 395–413.
Correspondence to:
Eva Bolle Antunes, Universidade Fernando Pessoa,
Faculdade de Ciências da Saúde, Rua Carlos da
Maia, 296 – 4200-150 Porto, Portugal.
Tel.: +351 22 5074630
Fax: +351 22 5074637
E-mail: eva@ufp.edu.pt