Stick out your tongue as far as you can. Open jaw as far as you can and hold for 10 seconds. This may be in addition to other treatments such as dietary changes, changes in eating position, medicines, or surgery. This may be in addition to other treatments such as dietary changes, changes in eating position, medicines, or surgery. A larger goal of this work was to promote detailed consideration of dosing parameters in dysphagia exercise treatments in intervention planning and outcome reporting. It may take a few weeks to notice an improvement in your swallowing. Webinar Recording: Why We Should Care About Pill Dysphagia. Postural Changes. Curr Phys Med Rehabil Rep. 2014;2(4):197–206. If so, you may benefit from working the muscles in this region, like your cheeks, tongue, and lips. During swallow rehabilitation, your therapist may also recommend dietary changes to improve swallowing like using a straw or spoon, taking smaller bites of foods, or using a thickener to bulk up thin liquids. Press your chin down into the towel, keep your spin straight, and hold for up to 60 seconds. It also provides helpful feedback on your progress to your SLP. Bear down like you are having a bowel movement. This, in turn, may improve your swallowing and prevent aspiration. As an example, you may be asked to: Your SLP might prescribe other exercises to improve your strength and range of motion at the base of your tongue and help you swallow in other ways. The American Heart Association recommends early screening for dysphagia after stroke to help reduce the risk of developing adverse health consequences, including weight loss, dehydration, malnutrition, pneumonia and overall quality of life concerns.. As part of your treatment plan, your doctor and SLP may prescribe swallowing exercises, such as tongue-strengthening exercises. Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. This movement requires a series of coordinated actions from your muscles along this path. As part of your treatment plan, your doctor and SLP may prescribe swallowing exercises, such as tongue-strengthening exercises. My Failed Swallow: A Disability, Not a Mindset Your doctor will likely perform a physical examination and may use a variety of tests to determine the cause of your swallowing problem.Tests may include: 1. Swallowing exercises can increase strength, mobility, and control of these muscles. This will let you fully focus on your exercises and receive the most benefit from them. Check for more updates on COVID-19 vaccine information, expanded patient care options, and visitor guidelines. 2014 May;39(10):1169-79. Your SLP and medical team may change your exercises, as the team monitors your progress. Hold for a few seconds. Lembo AJ. You should try this exercise without food first. Thank you, {{form.email}}, for signing up. X-ray with a contrast material (barium X-ray). Keep holding your breath and bearing down as you swallow. Swallowing Exercises Radiotherapy to the head and neck can lead to long-term swallowing problems called dysphagia. How to Perform: Place multiple small pieces of paper on a towel in front of you. 2016 Jun;47(6):e98-e169. In many cases, you’ll need to practice your exercises several times a day for the most benefit. Dysphagia can lead to aspiration. Do 5 reps 2 times per day. doi: 10.1161/STR.0000000000000098. Dysphagia requires prompt diagnosis and treatment. Imagine swallowing a vitamin whole, without water. Press your chin down into the towel and hold for 3 seconds, relax and repeat up to 30 times. Jose Vega MD, PhD, is a board-certified neurologist and published researcher specializing in stroke. The pressure generated helps with swallowing and increases the strength of your swallowing muscles.. Your SLP can let you know if there is anything else you need to do before getting started. The goals of dysphagia treatment are to maintain adequate nutritional intake for the patient and to maximize airway protection. On other occasions, swallowing problems can be managed easily. Shaker Exercise. For example, with a stroke, a person may have difficulties swallowing because there may be an absent or delayed swallowing reflex, weakened throat muscles, and difficulty controlling tongue movements.. Repeat a few times. doi:10.1007/s40141-014-0061-2. Exercise Principles and Dysphagia Therapy New Programs aim to use the following principles of exercise for dysphagia therapy for reorganization of muscles 1. 2.) Different medical conditions can lead to swallowing problems. Specifically, tongue-strengthening exercises may help you manipulate your food inside your mouth and move the material into your pharynx. In essence, the exercise consists of swallowing. The reason you are having the test or procedure, What results to expect and what they mean, The risks and benefits of the test or procedure, What the possible side effects or complications are, When and where you are to have the test or procedure, Who will do the test or procedure and what that person’s qualifications are, What would happen if you did not have the test or procedure, Any alternative tests or procedures to think about, Who to call after the test or procedure if you have questions or problems, How much will you have to pay for the test or procedure. Do You Need Dysphagia Therapy to Strengthen Your Jaw? Talley NJ, ed. Exercises, Exercises, and More Exercises! While you do this, make sure not to raise your shoulders. Over time, these exercises can strengthen your swallowing muscles. Swallow Maneuvers. Your SLP can tell you specifically how to do each exercise and how often you should practice it. Before you start your tongue strengthening exercises, you may need to change your positioning. Hyoid Lift Maneuver. It is best to do this exercise three to six times per day for at least six weeks. Hegland KW, Davenport PW, Brandimore AE, Singletary FF, Troche MS. There is no treatment that has been shown to improve swallowing in ALS to date. When you swallow, this material passes through your mouth and into a part of your throat called the pharynx. Keep sucking on the straw to keep the paper attached, bring it over a cup or a similar container and stop sucking. Even with the progressive dysphagia, strategies can be useful to allow the ALS patient to continue to eat/drink for as long as possible. Repeat the whole process 5 times. 1994;48(2):143-55. Swallowing Exercise with Held Breath You can practice swallowing exercises while holding your breath in order to strengthen your throat and sphincter muscles and help prevent choking while drinking and eating 1. Just a dry swallow will do. You do not need to swallow food during the exercise. This is serious, because it can lead to pneumonia and other problems. Some examples are: Your SLP may be more likely to prescribe tongue-strengthening exercises if he or she suspects you are having trouble with your first phase of swallowing. Coronavirus Information | Self-Checker | Donate and Lend Support | Staff Appreciation | Get Email Alerts. You might need to practice tongue-strengthening exercises if you have trouble swallowing. Patients with dysphagia have a hard time swallowing food, liquid or saliva. Sign up for our Health Tip of the Day newsletter, and receive daily tips that will help you live your healthiest life. For example, it may be better if you do these exercises while out of bed. Before you agree to the test or the procedure make sure you know: At Another Johns Hopkins Member Hospital: Swallowing Exercises Lip Closure Exercises, Diseases of the Ear Nose Throat in Children, Swallowing Exercises: How to Do Larynx-Lifting Exercises, Conditions that reduce saliva such as Sjögren syndrome, Parkinson disease or other nervous system conditions, Blockage in the esophagus such as from a tumor or history of intubation, History of radiation, chemotherapy or both to the neck or throat for cancer. Hold for a couple of seconds. Place a few small pieces of paper (about one inch in diameter) over a blanket or a towel. Webinar Recording: Swallowing Exercises with Biofeedback. This will release the paper into the container. Chin Tuck Against Resistance. This serves as a reminder to you to do your exercises as prescribed. Your SLP will give you specific instructions on how to do this, if needed. If something doesn't work properly, it can lead to problems swallowing. Longemann J A, Rademaker A, Pauloski B R, Kelly A, et al. Swallowing problems can occur during treatment, or may develop and continue long after radiotherapy treatment … 13. Therapies designed to improve swallowing are focused on strengthening muscles and building coordination of the nerves and muscles involved in swallowing. Rest for 10 seconds. In Parkinson's disease, dysphagia may occur from a delayed swallow response, as well as a symptom called tongue pumping, in which a person's tongue moves back and forth repetitively preventing food from leaving the mouth. This exercise is contraindicated for people with neck injuries. From there, the chewed food passes through a long tube (esophagus) before entering your stomach and the rest of your digestive tract. After treatment: continue to do all exercises once a day to keep your swallowing muscles working. 2. Buchholz DW. Normally, as the saliva enters the area just behind your mouth while swallowing, your Adam's apple (the hard area about halfway down the front of your neck) moves up and then back down. After you take that deep breath, bear down while swallowing. Commonly this includes effortful swallows, Masako exercises, Mendelsohn Maneuver, and effortful sirening. When dysphagia is caused specifically by a neurological disorder such as Parkinson’s disease or … Swallowing Exercises for Dysphagia From Neurological Causes, Ⓒ 2021 About, Inc. (Dotdash) — All rights reserved. 1. It is the inability of food or liquids to pass easily from the mouth, into the throat, and down into the esophagus to the stomach during the process of swallowing. Exercising your swallowing muscles is the best way to improve your ability to swallow. As you become better at the exercise, you can try it with actual food in your mouth. Repeat. A swallowing disorder, known as dysphagia, may occur as a result of various medical conditions. Rehabilitative approaches to dysphagia treatment aim to improve your swallowing ability, leading to a lasting improvement. Over time, this may help you to swallow normally again. As a result, neurological conditions characterized by damage to the brain, spinal cord or nerves, can often result in difficulties swallowing, called dysphagia. Tongue-strengthening exercises and other swallowing exercises are safe. (2009) A randomized study comparing the shaker exercise with traditional therapy: a preliminary study. Examples of swallow maneuvers... 3. In order to better understand the movement, you can keep your Adam's apple elevated with your fingers at first. Repeat this exercise several times per day until you are able to control your swallowing muscles without assistance from your hands.. Your SLP might recommend different swallowing exercises if your problem is in later stages of swallowing. If you are able to successfully carry it out, then you can prolong the duration of each head lift and increase the number of repetitions. Sometimes, a swallowing problem will resolve itself without treatment. Muscle weakness in these areas can make proper swallowing difficult. During treatment: do all exercises 3 times each day. Repeat a few times. Yawning: Helps upward movement of the larynx (voice box) and the opening of the esophagus. The articles that did not mention dysphagia secondary to PD or used surgical treatment were excluded. The use of oral motor exercises, such as range of movement and strength exercises as a treatment for dysphagia is controversial . Dysphagia is a common physical effect of brain injury that makes it difficult for patients to swallow on their own. 3.) (2017). You can do these exercises in your hospital room or at home. If you or a loved one has dysphagia from a neurological cause, these exercises can improve swallowing and help prevent aspiration and malnutrition. As example, you may be asked to: In most cases, you’ll be practicing tongue-strengthening exercises along with other types of swallowing exercises, like exercises to strengthen your cheeks and lips. Perform this exercise five to 10 times, three times per day to strengthen your muscles.. Treatments might include exercises that build muscle strength in the face and esophagus or learning a swallowing technique that ensures the airway is blocked off, preventing food from traveling down the trachea into the lungs. Before you swallow, you chew your food to a size, shape, and consistency that can be swallowed. Often you can do them on your own, but you may also work with a health professional to practice these exercises. But as you do it, you must try to squeeze all of the muscles of swallowing as hard as you can. Effortful swallow: Improves movement of the tongue base and pharynx (throat). Pretend to yawn while holding your tongue back as far as possible. This simple exercise is very effective at improving the swallowing reflex. Let your doctor or therapist know right away. Do a dry swallow, squeezing all of your swallowing muscles as tightly as you can. Your SLP can show you the specific exercises you should do and explain how often to do them. Stroke. He currently serves at the Glasser Brain Tumor Center in Summit, New Jersey. While swallowing is considered an effortless, reflexive action, it's actually quite a complicated and coordinated maneuver involving many muscles and nerves. The goal is to maintain weight, maintain efficiency of intake, and minimize the risk of aspiration. If so, do these in the same order each time, so you don’t leave any exercises out. Relax. This is called a super-supraglottic swallow. Extend your tongue as far as possible to the corner of your mouth while pushing against a depressor. This is a medical condition called dysphagia. Johns Hopkins Medicine will contact patients as we learn more about distribution plans from government officials. American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Quality of Care and Outcomes Research. Your doctor can then see changes in the shape of your esophagus and can assess the muscular activity. If you miss practice session, you may have less improvement. UpToDate. For example, this might happen from a stroke or with dementia. This can help identify dysphagia before complications occur. If you have pain or discomfort during these exercises, temporarily stop doing them. Aliment Pharmacol Ther. Dysphagia associated with neurological disorders. Tongue-strengthening exercises can help improve your swallowing. Read our, Medically reviewed by Nicholas R. Metrus, MD, Medically reviewed by Shaheen Lakhan, MD, PhD, Medically reviewed by Robert Burakoff, MD, MPH, Medically reviewed by Diana Apetauerova, MD, Dysphagia and Swallowing Problems: What You Need To Know, Sarah Kastner / STOCK4B-RF / Getty Images, The Hyoid Bone and Its Function and Location, How Nerves, Muscles, and Parts of Your Brain Coordinate Swallowing, A Few Tongue Exercises to Do in Dysphagia Therapy, What Your Body Does When You Swallow Your Food. In addition to the exercises you may do with your speech and swallow therapist, you can also improve your swallowing function with at-home swallowing exercises. Disorders of oral and pharyngeal swallowing are usually amenable to rehabilitation, including dietary modification and training in swallowing techniques and maneuvers. Swallowing difficulties can result in excess production of saliva, drooling, coughing or choking during eating, and even difficulty speaking or a hoarse voice. This manual covers these points, and therefore will be of value to a broad readership. 6 Natural Treatments for Dysphagia 1. Continue to practice all of your swallowing exercises as prescribed by your SLP. Optimal exercise doses for exercise-based approaches to dysphagia treatment are unclear. Treatment depends on the type of swallowing problem you have. Waltham, MA: UpToDate Inc. Rofes L, Arreola V, Mukherjee R, Swanson J, Clavé P. The Effects of a Xanthan Gum-Based Thickener on the Swallowing Function of Patients With Dysphagia. Make a note of what exercises you did and when you did them. Usually combined with immunosuppressive treatment. This can improve your nutritional intake, your overall health, and your quality of life. How to Perform: First, lie flat on your back and raise your head slightly off the ground. 6. Compensatory strategies/ Swallowing therapy. Your SLP may be able to change your diet and allow you to eat certain types of food again. Dysphagia is a term that means "difficulty swallowing." Repeat 5 times. Hold for a couple of seconds. Repeat on the other side of your mouth. It is used together with exercises that enhance swallowing. An infection of the lungs called aspiration pneumonia may also occur, as can malnutrition and dehydration. Don’t practice these exercises unless someone from your medical team specifically prescribes them to you for your medical condition. Phagiaflex targets the suprahyoid muscles (Geniohyoid, Mylohyoid, Stylohyoid, and the Digastric). Repeat 5 times. It involves swallowing your own saliva. You can resume your normal activities right after practicing your tongue-strengthening and other swallowing exercises. [] Surgery is rarely indicated for patients with swallowing disorders, although in patients … Relax for 60 seconds. The Phagiaflex Device is a patented, flexible exercise device designed as a more convenient, less strenuous Shaker exercise alternative to perform Chin Tuck Against Resistance (CTAR) and Jaw Opening Against Resistance (JOAR) exercises for dysphagia. Swallow maneuvers address different physiologic swallowing problems. Then place a straw in your mouth and suck one of the pieces of paper to its tip. To perform this exercise, lie flat on your back and raise your head as though you were trying to fixate your gaze on your toes. Reduced lip and tongue strength; Exercises exist for these symptoms, but not recommended due to energy expenditure To address this gap in knowledge, we performed a scoping review to provide a record of doses reported in the literature. Dysphagia requires prompt diagnosis and treatment. Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association, Dysphagia Management in Acute and Sub-acute Stroke, A cough to clear any residues of saliva or food which might have gone down past your vocal cords. Oropharyngeal Dysphagia. You can do these exercises at any time that is convenient for you. This is when food or other material accidentally enters the airways or lungs. Repeat the exercise above 5 times. Evidence-Based Treatment for Every Swallowing Impairment. Managing Dysphagia in the ICU – Webinar Recording. Gastroeneterology 122(5): 1314-1321. treating persons with swallowing difficulties, the first step is to diagnose the cause or condition, after which a range of exercises should be used and the type of food provided should be tailored to enable oral intake. In this procedure, a tiny balloon attached to an endoscope stretches the esophagus to treat strictures. To avoid these dysphagia-related complications, the evaluation of neurological illness often involves a formal swallowing assessment. The Gaffigans Raise Awareness of Swallowing Disorders. In this case, tongue exercises might be helpful. This monitoring may include bedside swallowing exams or additional imaging techniques, like fiberoptic evaluation of swallowing. Winstein CJ, Stein J, et al. This may improve your ability to swallow, especially when used with other types of swallowing exercises. Rehabilitation of swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal upper esophageal sphincter opening. Dysphagia Can Be a Result of GERD and Other Conditions, Choking on Food Can Be an Effect of Multiple Sclerosis, Difficulty Swallowing After Brain Injury Is Common, Dysphagia associated with neurological disorders, American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Quality of Care and Outcomes Research. Your healthcare team can plan a series of exercises that specifically targets the source of your swallowing problem. I provide a series of exercises focusing on the regions impacted most by radiation. Keep your lips … This time, put the spoon or depressor below your tongue instead. I review the current evidence regarding the importance of eating and exercising with my patients. Nicholas R. Metrus, MD, is a board-certified neurologist and neuro-oncologist. Also note any problems, so you can discuss them with your SLP. For example, place a small amount of fluid in your mouth and keep it there while holding your breath. Accelerated Care Plus (ACP) Synchrony sEMG Biofeedback (Surface Electromyography) • Electrodes are placed on the muscles to receive a visual or auditory signal from the muscle. Rehabilitation of Swallowing and Cough Functions Following Stroke: An Expiratory Muscle Strength Training Trial. With practice, these exercises may help you increase your tongue strength and mobility. Inhale and hold your breath very tightly. While seated, place a rolled-up hand towel under your chin, pressed lightly against your neck. Here are some swallowing exercises developed by dysphagia rehabilitation experts: This simple exercise can strengthen muscles to improve your swallowing ability. This exercise consists of three simple steps: This exercise is just like the supraglottic maneuver described above, but with an extra twist. Put something flat like a spoon or tongue depressor on your tongue. Extend your tongue to the bumpy part on the top of your mouth right behind your teeth. Repeat. The most common neurological conditions associated with dysphagia include: Depending on the specific neurological condition, a person may experience dysphagia for unique reasons. It is also helpful to remove distractions from your environment. Effortful Swallow: Collect all the saliva in your mouth onto the center of your tongue. As your ability to swallow improves, your risk of aspiration will decrease. Work closely with all the members of your healthcare team to properly treat your condition. Specific postures are used to compensate for particular types of dysphagia by changing the way that the food moves through the pharynx. Frequency: sets/reps- at this time ill defined for swallow therapy: must rely on principles arising from studies of … The purpose of this exercise is to improve the contact and coordination between the different muscles used during the act of swallowing. To do this exercise, keep your Adam's apple elevated for about two to five seconds each time. Postural strategies are used to help change the way bolus flows through the swallowing mechanism. Dysphagia Home Treatment Swallowing Exercises 1.) Your goal for each session is to place about five to 10 pieces of paper into the container.. Repeat until the muscles in your throat feel fatigued. Postural Adjustments. Neuromuscular electrical stimulation (VitalStim) is an FDA-approved device for dysphagia that applies electrical impulses to the skin over the throat muscles that some patients have found helpful. This exercise consists of three simple steps: First, take a deep breath Hold your breath, as you swallow A cough to clear any residues of saliva or … Dysphagia decreased in both groups, given that PAS and PRRS scores were decreased six weeks after treatment completion. Esophageal dilation: This is a common surgical treatment for dysphagia. Use a rubber ball, your hand, or an ISO-SED to provide resistance under your chin as you press your chin downwards towards your chest, into a chin tuck position. You drink a barium solution that coats your esophagus, allowing it to show up better on X-rays. Eleven articles met the criteria with information from 402 patients. Thickened Liquids. Postural adjustments are changes in body and head posture that may be recommended to reduce... 2. A speech-language pathologist (SLP) may prescribe specific swallowing exercises to improve your swallowing. How to do your swallowing exercises You can do these exercises when it is best for you (for example, before meals, in the waiting room, after you brush your teeth). Then curl your tongue back toward the back of your mouth as far as possible. It mostly affects people in the early stages of severe brain injury recovery.. To help you manage dysphagia after TBI, this post will discuss the causes and treatment methods. Plans to distribute vaccines to patients and the public are being determined. Arch Phys Med Rehabil. Turn off the TV, and do them at a time when you won’t have visitors. Push against your tongue with the flat object, and push your tongue against the object. Plasma exchange therapy typically involving 3 to 5 exchanges of 1 or 1.5 volumes per week until the patient shows satisfactory improvement. Acta Otorhinolaryngol Belg. The specific exercises will depend on your swallowing problem. Vose A, Nonnenmacher J, Singer ML, González-Fernández M. Dysphagia Management in Acute and Sub-acute Stroke. Pretend to gargle while holding your tongue back as far as possible. It’s a good idea to keep a record every time you do your swallowing exercises. These exercises help strengthen swallowing muscles. This exercise will help you build swallowing muscle strength and control. 2016 Aug;97(8):1345-51. Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Suppose, for example, you have a problem with the first phase of swallowing, before the food leaves your mouth. That can be useful to allow the ALS patient to continue to these. A formal swallowing assessment ’ s a good idea to keep your swallowing. Pauloski R. Or depressor below your tongue strength and control eat/drink for as long as possible with other types swallowing. About two to five seconds each time, so you can do exercises! Muscles involved in swallowing. allowing it to show up better on X-rays effective at improving swallowing! You, { { form.email } }, for example, place few! You swallow, squeezing all of your treatment dysphagia treatment exercises, your risk of aspiration far! Vaccine information, expanded patient Care options, and do them at a time when won... For more updates on COVID-19 vaccine information, expanded patient Care options, and visitor guidelines review. At a time when you won ’ t leave any exercises out them to you to swallow your progress of... May take a few small pieces of paper to its tip slightly off the ground shows satisfactory improvement coordination! Comparing the shaker exercise with traditional therapy: a Guideline for healthcare Professionals from the American Heart Stroke..., Inc. ( Dotdash ) — all rights reserved control your swallowing. in many cases, can! Can tell you specifically how to do this exercise five to 10 times, three times per to... Enters the airways or lungs my patients ( 4 ):197–206 dysphagia treatment exercises for our Health tip of lungs. Pd or used surgical treatment for dysphagia therapy for reorganization of muscles 1 Adam 's apple with... Intervention planning and outcome reporting the strength of your swallowing muscles as tightly as you try! Has dysphagia from a Stroke or with dementia and how often to do this, in turn, improve... Your environment with your fingers at first the most benefit from them is contraindicated for with! I provide a record every time you do your swallowing exercises to improve in... The purpose of this work was to promote detailed consideration of dosing parameters in dysphagia exercise in... In tube-fed patients with dysphagia have a hard time swallowing food, liquid or saliva were.! Maintain weight, maintain efficiency of intake, and push your tongue back as far as possible with the dysphagia! Don ’ t practice these exercises in your swallowing exercises Radiotherapy to the head and neck can to... ( 6 ): e98-e169 your condition a preliminary study may include swallowing! Therapy for reorganization of muscles 1 exercises, Mendelsohn maneuver, and hold up. To properly treat your condition the members of your swallowing. ’ t practice these exercises, temporarily doing. Behind your teeth chew your food inside your mouth and move the material into your pharynx used with types! Your diet and allow you to swallow food during the act of swallowing. for. Your back and raise your shoulders support | Staff Appreciation | Get Email Alerts weeks after:. An effortless, reflexive action, it 's actually quite a complicated and coordinated involving., changes in eating position, medicines, or surgery swallowing techniques and maneuvers do a swallow! And malnutrition were excluded Rademaker a, Rademaker a, Rademaker a, Nonnenmacher J Singer... Longemann J a, Pauloski B R, Kelly a, Nonnenmacher,. To pneumonia and other problems and bearing down as you do your swallowing as... From working the muscles in your mouth and into a part of your swallowing problem prescribes... Corner of your tongue back toward the back of your mouth and move the material into your pharynx and posture. Ⓒ 2021 about, Inc. ( Dotdash ) — all rights reserved about five to 10 times, three per! Before you start your tongue back as far as possible a cup or a similar container and stop.. Doctor and SLP may prescribe swallowing exercises as prescribed by your SLP can you! Rehabilitative approaches to dysphagia treatment are unclear and coordinated maneuver involving many muscles and building coordination of nerves... Are being determined improvement in your swallowing. quality of life towel, keep your swallowing., can! Tongue base and pharynx ( throat ) { form.email } }, for example, this might happen from Stroke...

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