Effects of Mendelsohn Maneuver on Measures of Swallowing Duration Post-Stroke

Introduction

The Mendelsohn Maneuver, or voluntary prolongation of hyolaryngeal elevation at the peak of the swallow, has been used to treat patients with pharyngeal dysphagia for many years1–3–sometimes as a compensatory strategy to help the bolus pass more efficiently through the pharynx4–6 and sometimes as part of a rehabilitative exercise program7–10. Early reports on the Mendelsohn maneuver suggested use of the maneuver increases laryngeal elevation and maximal hyoid superior displacement and provides an immediate effect in prolonging the duration of opening of the upper esophageal sphincter (UES) but not the diameter1–6. Since the initial reports, more data have emerged supporting the physiologic effects of the Mendelsohn maneuver on the act of swallowing, but most papers consider only the immediate effects of the maneuver on small numbers of normal participants or patients11–14.

Rehabilitation, like compensation, addresses deficits in swallowing physiology15, but rather than providing an immediate change in the physiology of swallowing, an exercise designed to rehabilitate should provide a lasting effect on swallowing. A few studies provide outcome data on patients with dysphagia who have used the Mendelsohn maneuver as part of a collection of exercises with the goal of rehabilitation, but none have used the maneuver in isolation and reported on change in swallowing physiology as a result7–9. While use of the maneuver shows promise when included as part of a broader regimen of treatment, the specific physiologic effects of the Mendelsohn maneuver on patients with dysphagia cannot be determined without investigation of the maneuver in isolation. The studies reporting positive outcomes incorporating the maneuver also employed techniques, such as head turns, chin tucks, supraglottic swallows, effortful swallows, and the Shaker exercise, amongst others. Moreover, while outcome data from these studies reported improved oral intake in most patients without development of pneumonia or other negative health consequences, specific changes in swallow physiology were not reported, leaving open questions regarding the functional and physiologic changes which may have occurred, as well as the actual cause of those changes (i.e., time, swallowing food and liquid, doing exercises—and which exercises). These studies have clearly demonstrated that dysphagia rehabilitation is possible in certain patients post-stroke; but without specifically examining the use of individual exercises in isolation, the contribution of any particular exercise cannot be clearly defined. In other words, while the Mendelsohn maneuver appears to have an immediate effect on hyolaryngeal movement and duration of UES opening, no data exist to define what, if any, lasting effect use of the Mendelsohn maneuver over time may have on the physiology of swallowing when the Mendelsohn maneuver is no longer employed.

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Based on the reports regarding the immediate effects of the Mendelsohn maneuver on swallowing, we would anticipate that if long term changes result from use of the Mendelsohn as an exercise, they would include duration of hyolaryngeal elevation, anteriorly an/or superiorly, and, consequently, duration of opening of the upper esophageal sphincter.1–6 When swallowing, the hyoid bone and thyroid cartilage begin to rise, then the hyoid bone begins to move superiorly and anteriorly in a quick burst of movement. The path of this movement can vary but is often triangular, moving superiorly, then anteriorly and then back to rest or vice-versa (anteriorly, then superiorly, then back to rest). These durations can be measured as “duration of hyoid maximum anterior excursion” (DOHMAE) and “duration of hyoid maximum elevation” (DOHME)16. These do not measure the duration of hyoid movement from start to finish but rather the duration that the hyoid remains at it’s maximum anterior and superior points. Duration of hyoid movement from start to finish is measured as “pharyngeal response duration” (PRD). Movement of the hyoid, especially the anterior movement, should create a traction pull on the cricoid cartilage which allows for prolonged opening of the UES2, which can be measured as “duration of UES opening” (DOUESO)16.

The purpose of this investigation was to determine if any lasting changes would occur in swallowing physiology as a result of intensive exercise using the Mendelsohn maneuver. Our hypothesis was that measures of the duration of hyoid movement and the duration of UES opening would significantly improve. We also hypothesized that measures of bolus flow—penetration/aspiration and pharyngeal residue—would improve as a result of these changes. In addition, we wanted to obtain some preliminary information regarding dose-response, which could be examined by comparing results after 10 sessions and 20 sessions of treatment. Other measures of oral and pharyngeal swallowing duration were analyzed, as well as outcomes on the Dysphagia Outcome and Severity Scale17.


— Update: 31-12-2022 — cohaitungchi.com found an additional article Combined Effects of NMES and Mendelsohn Maneuver on the Swallowing Function and Swallowing–Quality of Life of Patients with Stroke-Induced Sub-Acute Swallowing Disorders from the website www.mdpi.com for the keyword effects of the mendelson maneuver swallowing post stroke.

1. Introduction

Stroke is very like to have sequelae, even if surgical treatment is successfully conducted and the patient survives. Among various sequelae, the onset rate of swallowing disorders is the highest. Previous studies have reported that the onset rate of swallowing disorders in patients with acute cerebral infarction varies greatly, ranging from 37% to 65% [1,2]. Particularly, special attention should be given to patients with acute cerebral infarction, because they are highly likely to experience aspiration, which means that food passes through the airway. Approximately 20% of patients with cerebral infarction die from aspiration pneumonia within a year from the onset; it was also reported that one in three patients with sub-acute cerebral infarction and aspiration had silent aspiration, which showed no observable symptom [3]. Therefore, active swallowing rehabilitation is needed from the onset of a swallowing disorder, to maintain the life of the patient.On the other hand, the difficulty in swallowing not only causes medical problems but also lowers the quality of life, because swallowing is one of the most fundamental demand of human beings and a complex activity for maintaining social relationships with others. Patients with swallowing disorders experience fear and anger due to aspiration during mealtimes and consequently avoid eating with others, eventually feeling social isolation [4,5]. Moreover, Critchlow et al. [6] showed that extended intubation feeding resulted in a loss of appetite, along with depression. Therefore, it is necessary to identify how to improve the swallowing–quality of life, as well as the swallowing function, in order to evaluate the effect of treatments on swallowing disorders.Traditional treatments to improve the swallowing function include compensatory strategies, such as posture change and maneuver and rehabilitation techniques, that strengthen the muscles associated with swallowing by exercising them repetitively [7,8]. Among these various treatments, the Mendelsohn maneuver, which focuses on submandibular hyolaryngeal muscles, has been used in clinical practice to effectively improve the function of muscles associated with laryngeal elevation [9]. The Mendelsohn maneuver is a method designed to increase the willing movement of the larynx and hyoid bone while pharyngeal swallowing is progressing [9,10]. Moreover, it is a method to voluntarily hold the position after contacting the larynx and raising it to the maximum height, and maintain it for several seconds [9,10]. It has been reported that it is effective in recovering the swallowing of patients with swallowing disorders in the pharyngeal stage [9,10].Recently, neuromuscular electrical stimulation (NMES) has been conducted for rehabilitating the swallowing in the pharyngeal stage, and it has been continuously reported that it has a significant effect on the recovery of the swallowing function [11,12]. Many studies have consistently shown that NMES is effective for compensatory strategies and rehabilitation therapy [11,12]. On the contrary, several studies reported that NMES was not effective [13,14,15,16,17]. Therefore, further studies are needed to verify the effectiveness of NMES. Above all, most of the previous studies compared the treatment effects of NMES and those of an individual traditional therapy, and only a few studies (e.g., Li et al. [14]) have examined the effectiveness of compound interventions, including Li et al. [14].The previous studies comparing the treatment effects of NMES and those of an individual traditional therapy have the following limitations. First, most of them simply confirmed the improvement of the swallowing function owing to an individual intervention. Although it is very rare to conduct an individual intervention for treating a swallowing disorder in the clinical practice, there is not enough evidence for the application of complex swallowing treatment programs to patients. It is very difficult to apply the results of studies that evaluated the effects of an individual treatment on the swallowing disorder to clinical practices as it is. Second, studies that did not find the effectiveness of NMES [18,19] compared NMES with traditional swallowing treatments. However, they are limited in verifying the effectiveness of NMES because they had a small sample size, measured only twice (pre-treatment and after-treatment), and analyzed short-term treatment effects within 4 weeks. Therefore, longitudinal studies are needed to verify the effectiveness by measuring changes over a sufficient period that neurological changes (recovery) owing to a treatment can be expected. Third, most studies analyzed the changes by comparing only physiological indicators related to the swallowing functions, such as aspiration, with the control group. Since swallowing has a very complex mechanism, it is impossible to identify the overall recovery of swallowing just by using physical indicators. Therefore, further verification efforts should be carried out by using various indicators, such as the quality-of-life, to prove the effectiveness of swallowing therapies. Fourth, although the ultimate goal of rehabilitation therapies is to recover functions and improve the quality of life through goal-oriented and comprehensive intervention, only a few studies evaluated the swallowing function and the quality of life at the same time.This study aimed to (1) prove the effects of a compound swallowing intervention (Mendelsohn maneuver + NMES) on the swallowing function and the quality of life by applying the compound swallowing intervention to patients with sub-acute swallowing disorders due to cerebral infarction for eight weeks and (2) provide a basis for applying it to the rehabilitation clinics by comparing the effects of the compound swallowing intervention and an individual swallowing treatment.

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