Cecile Buker peered at the computer screen as a therapist prepared to feed her a teaspoon of water from a clear plastic cup. An animated kangaroo on the screen hopped toward a gold coin suspended in the air.
"Get ready to swallow now," said the speech therapist Inoka Tennakoon. "A nice strong swallow."
Buker took a gulp and the kangaroo jumped, capturing the coin.
For more than a year now, therapists at the Lorien Health assisted-nursing facility in Columbia have been using virtual reality technology and video games to help treat people with swallowing disorders.
They say the video games being used at the 205-bed facility keep people engaged in their treatment. Therapists have also seen patients recover more quickly because they get instant feedback on how they're doing. If they don't swallow enough, they don't succeed at the game.
Buker, 60, suffered a stroke at her Frederick home in April and could not swallow any solid or liquid foods when she first arrived at Lorien for therapy. She had to use breathing and feeding tubes. With therapy, including the video games, she slowly recovered and learned to swallow again.
On this day, Buker was practicing typical swallowing. On other days, she and other patients might perform exercises such as sucking through a straw, lip pressing, effortful swallowing and jaw grading — learning to judge how wide to open their mouths. Sensors placed on Buker's neck feed data on her swallowing technique to a computer. Typically, the patient does the exercise in sets of 25 repetitions, Tennakoon said.
Buker said the games don't fool her into thinking she's not getting therapy. But they help ease the monotony and boredom, and the games do help, she said.
"It gives me something to do," said Buker, who speaks in a whisper because of lingering effects from the stroke.
Conservative estimates are that nearly one in 25 U.S. adults will experience a swallowing problem each year, though it is more common in older people, according to the American Speech-Language-Hearing Association.
Swallowing problems are often the result of neurological conditions such as stroke, traumatic brain injury, cerebral palsy or Parkinson's disease. Either the muscles are damaged because of the illness or they become weakened because patients are on ventilators and feeding tubes for long periods of time.
Swallowing disorders can make it hard for people to ingest sufficient nutrition and can lead to life-threatening conditions such as aspiration pneumonia, a serious type of lung infection. About 60,000 people die each year because of complications from problems swallowing.
Doctors said that technology to treat swallowing disorders is steadily improving and has the potential to help doctors better treat patients. For instance, devices called expiratory muscle strength trainers help exercise key muscles used in swallowing, said Dr. Luis F. Riquelme, chair of the American Board of Swallowing and Swallowing Disorders.
Another device, an accelerometer sensor, measures how a patients' muscles move when swallowing. This can help a doctor determine what kind of physical therapy will best benefit the patient.
Even technology as common as an iPad helps doctors because it can be used to show patients 3-D images of swallowing disorders, so they better understand what is going on with their bodies, said Riquelme.
"When you tell a patient they're aspirating, they don't really understand until you show it to them," Riquelme said.
Lorien, where one out of three patients has a swallowing problem, uses a computer system called Synchrony that includes several games that test different swallowing functions. Synchrony was created by the Nevada company Accelerated Care Plus Corp., which specializes in rehabilitation technology.
One of the Synchrony games, called "Divers," tests isometric and oral motor skills by requiring the patient to swallow in order to move an animated diver up or down to collect pearls from clams that are distributed across the computer screen.
The Synchrony system also comes with a second component called a stimulator. With this device, electrodes are placed on the cheek to stimulate nerves that connect to the brain stem, which controls swallowing. Patients then play the video games in hopes that the stimulated nerves will improve results.
Another game, "Bow & Arrow," works on swallowing time and coordination. The patient must swallow hard enough to draw back a bow. Then the patient has to time the swallow to release the arrow to shoot down balloons at the top of the screen.
The data from each patient's gaming session is stored for a starting point the next time.
Tennakoon said the virtual therapy helps therapists better determine how patients perform their exercises.
"With traditional therapy, we said, 'Swallow really, really hard,' but we couldn't really measure how much effort the patient was using," Tennakoon said. "Now I can look on the screen and see how hard they swallowed."
Tennakoon said she thinks the technology has made a huge difference in the treatment of some patients.
"When you have tried everything for a patient and you can't do anything more, this works," she said.