Erich S. Luschei, Ph.D
President
IOPI Medical LLC
IOPI measures maximum pressure in an
air-filled bulb that is pressed with the
tongue “as hard as you can.” This
pressure is interpreted as a measure of
tongue strength.
Green light
Show lights
Red light array
Show timer
Peak mode
Power
Clinical uses of the IOPI:
Deciding whether a patient’s tongue is
weak.
If yes, start tongue exercise therapy.
if no, try a more useful therapy.
Documenting the basis of your decision.
Convincing the patient that exercises will
be helpful.
Convincing the administration and thirdparty payer.
Assessing and demonstrating the effect of
tongue exercise therapy.
Steps to measure tongue strength:
1. Attach connecting tube to the IOPI.
2. Open tongue bulb package and attach
connecting tube to tongue bulb.
3. Turn on the IOPI.
4. Press “Peak” button, then “Reset peak”
(if the display is not “0”).
5. Help the patient position the tongue
bulb (see next slide).
6. Instruct the patient to press the
tongue bulb against the roof the
mouth “as hard as you can.”
7. For safety, hold on to the tongue
bulb tube when it is in the patient’s
mouth.
Standard procedure:
Three trials separated by 10-15
second of rest.
The maximum pressure of
these three trials is recorded as
the tongue strength for this
patient.
Tongue endurance measurement:
Time how long a patient can maintain
a pressure of 50% of their maximum
pressure (tongue strength) when
instructed to keep the green (top)
light on. Pressure to turn on the
green light is set to 50% of maximum.
Lip strength measurement:
Place the IOPI tongue bulb under
the cheek at the corner of the
mouth and ask the patient to
“grimace” as hard as they can. Use
the IOPI to record the maximum
pressure.
Alternative method of measuring lip strength
(used by Clark and Solomon :Dysphagia eprint DOI 10.1007)
What are Normal Values of tongue
strength?
Published studies of tongue strength
using the IOPI or IOPI-like devices.
Reference #
Tongue
strength
(kPa)
Tongue
endurance
(s)
1 Kydd
2 Dworkin
3 Robin
4 Robin
5 Murdoch
6 Robbins
7 Solomon
8 Theodoros
9 Crow
10 Lazarus
11 Nicosia
12 Clark
13 Lazarus
14 Solomon
15 Robbins
16 Neel
17 Youmans
18 Stierwalt
19 Robbins
20 Clark
21 Solomon
22 Utanohara
23 Youmans
54
200
70
70
65
65
69
73
75
60
75
38
70
60
41
50
60
61
36
60
60
45
70
24 Clark
Note#2
Note #12
Note #15
Note #19
Note #21
Note #22
60
IOPI
39
not reported
Protrusive force on 12mm diameter load cell (force transducer)
All subjects referred for swallowing problems; also, possible methological difference
Subject age range: 70-89
All subjects had suffered a CVA (stroke)
Estimate from scatter of measures from asymptomatic patients judge "normal
Used tongue bulb larger and softer than IOPI tongue bulb
35
35
30
45
38
20
40
33
Instrument
Young(#)
Old(#)
Old<Young?
Female<Male?
press. cell
load cell
IOPI
IOPI
IOPI-like
IOPI
IOPI
IOPI-like
IOPI
IOPI
Kay system
IOPI
IOPI
IOPI
IOPI
IOPI
IOPI
IOPI
IOPI
IOPI
IOPI
IOPI-like
IOPI
30
125
175
12
6 children
10
13
18
65
11
10
32 (est.)
31
10
0
2
75 (est.)
32
6
40
44
652
64
0
0
25
0
0
14
6
0
34
2
10
31(est.)
0
0
10
0
15 (est.)
18
4
NA
NA
no
NA
NA
yes
no diff.
NA
yes
not reported
yes
NA
NA
NA
NA
NA
yes
yes
not reported
NA
not reported
males only
yes
all male
yes
yes
not reported
not reported
not reported
yes (small diff.)
not reported
yes
not reported
not reported
yes (small diff.)
not reported
not reported
not reported
not reported
yes
yes
not reported
yes (small diff.)
not reported
young only
yes (barely)
few
201
32
not
reported
not reported
References for Normal Values
Selected set of 10 published studies that
report means and standard deviations of
tongue elevation strength in normal adults,
or in normal controls used in studies of
swallowing or speech abnormalities.
References
Clark, HM, O'Brien, K, Calleja, A, and Corrie, SN. Effects
of directional exercise on lingual strength. J. Speech Lang.
Hear. Res., 52:1034-1047, 2009.
Lazarus, C; Logemann, JA; Huang, C-F, and Rademaker,
AW. Effects of two types of tongue strengthening exercises
in young normals. Folia Phoniatr. Logop., 55: 199-205,
2003.
Lazarus, CL; Logemann, JA; Pauloski, BR; Rademaker,
AW; Larson, CR; Mittal, BB, and Pierce, M. Swallowing
and tongue function following treatment for oral and
oropharyngeal cancer. J. Speech Lang. Hearing Res.,
43:1011-1023, 2000.
Robbins, J; Levine, R; Wood, J; Roecker, EB, and Luschei,
E. Age effects on lingual pressure generation as a risk
factor for dysphagia. J. Geront. Med. Sci., 50: M257-M262,
1995.
Solomon, NP, and Munson, B. The effect of jaw position on
measures of tongue strength and endurance. J. Speech
Lang. Hearing Res., 47: 584-594, 2004.
Solomon, NP; Lorell, DM; Robin, DA; Rodnitzky, RL, and
Luschei, ES. Tongue strength and endurance in mild to
moderate Parkinson's Disease. J. Med. Speech Path.,
3:15-26, 1995.
Stierwalt, JAG, and Youmans, SR. Tongue measures in
individuals with normal and impaired swallowing. Amer. J.
Speech-Lang. Path., 16: 148-156, 2007.
Theodoros, DG; Murdoch, BE, and Stokes, P. A
physiological analysis of articulatory dysfunction in
dysarthric speakers following severe closed-head injury.
Brain Injury, 9:237-254, 1995.
Youman, SR, Youmans, GL, and Stierwalt, JAG. Differences
in tongue strength across age and gender: Is there a
diminished strength reserve? Dysphagia, 24:57-65, 2009.
Youmans, SR, and Stierwalt, JAG. Measures of tongue
function related to swallowing. Dysphagia, 21: 102-111,
2006.
Group
Young
Middle
Old
Age range (years) Number of
subjects
20-39
226
40-60
159
>60
155
Fig 2 Clark & Solomon 2011
Fig 3 Clark & Solomon 2011
A clinician would be correct 95% of the time if they concluded that the following
people have abnormally low tongue strength:
• A young person whose maximum tongue pressure is less than 44 kPa.
• A middle-aged person whose maximum tongue pressure is less than 43 kPa.
• An old person whose maximum tongue pressure is less than 37 kPa.
Studies of tongue exercise
Speculation:
1. Most normal-functioning people have a
tongue that is pretty “physically fit”.
 Mastication
 Swallowing
 Speaking
2. If that is the case, then lack of mastication
and/or swallowing may cause, by disuse
atrophy, tongue weakness.
Robbins et al. Table 2, Ref. List 1 #15
Robbins et al.: stroke patient/tongue exercise
Summary Conclusions
Tongue exercise can increase strength,
but the increase will probably be small
unless the patient’s tongue is relatively
weak to start with. At least 8 weeks of
exercise is necessary to produce
optimal effects.
Summary: Exercise help?
Some evidence shows that increases
in strength resulting from tongue
exercise are associated with
improved swallowing. More
research to document the efficacy of
tongue exercise is needed, however.
 HOW does exercise increase strength??
 Increases the strength of muscle cells.
Right?
 Eventually, but short-term strength
increases because:
 We can drive our motor neurons better:
 We’re exercising our NEURONS too!!
Motor Units
CNS
Maximum
Effort
Synaptic
Input
Moderate
Effort
Synaptic
Input
Low
Effort
Synaptic
Input
Motor Neurons
plus
Muscle Units
Many big muscle cells
High force output
Fast contracting
Fatigable
Anaerobic metabolism
Medium # muscle cells
Medium/ low force output
Reasonably fast
Fatigue resistant
Mixed anaerobic and aerobic
Small # muscle cells
Low force output
Slow contracting
Non-fatigable
Aerobic metabolim
What muscles are exercised during tongue
elevation? during tongue elevation?
 Study by Palmer et al.: JSLHR, 51:828-835, 2008
 Hooked wire EMG electrodes in intrinsic and
submental muscles during tongue elevation task with
IOPI.
 Intrinsic tongue
 Geniohyoid (GH)
 Mylohyoid (MH)
 Medial pterygoid(MP)
 Anterior belly of digastric (ABD)
Normalized EMG of intrinsic and extrinsic muscles vs normalized pressure : Palmer et al.
For References:
 www.IOPImedical.com
 Published References (menu)
 [email protected]