Effects of Mendelsohn Maneuver

on Measures of Swallowing
Duration Post Stroke
Gary H. McCullough, PhD,1 Erin Kamarunas, MS,1 Giselle C. Mann, PhD,5
James W. Schmidley, MD,2 JoAnne A. Robbins, PhD,3,4 and Michael A. Crary, PhD6
1
Department of Speech-Language Pathology, University of Central Arkansas, Conway, Arkansas; 2Department of Neurology, Virginia
Tech-Carilion School of Medicine, Roanoke, Virginia; 3University of Wisconsin, Madison; 4Geriatric Research Education Clinical Center,
VA Medical Center, Madison, Wisconsin; 5Department of Social and Behavioral Sciences, 6Department of Speech, Language and Hearing
Sciences, University of Florida, Gainesville, Florida

Purpose: The purpose of this pilot study was to determine whether intensive use of the Mendelsohn maneuver in patients
post stroke could alter swallow physiology when used as a rehabilitative exercise. Method: Eighteen outpatients between
6 weeks and 22 months post stroke were enrolled in this prospective study using a crossover design to compare 2 weeks of
treatment with 2 weeks of no treatment. Each participant received an initial videofluoroscopic swallow study (VFSS) and an
additional VFSS at the end of each week for 1 month for a total of 5 studies. During treatment weeks, participants received 2
treatment sessions per day performing Mendelsohn maneuvers with surface electromyography for biofeedback. Measures
of swallowing duration, penetration/aspiration, residue, and dysphagia severity were analyzed from VFSS to compare
treatment and no-treatment weeks. Results: Significant changes occurred for measures of the duration of superior and
anterior hyoid movement after 2 weeks of treatment. Improvements were observed for duration of opening of the upper
esophageal sphincter (UES), but results were not statistically significant. Measures of penetration/aspiration, residue, and
dysphagia severity improved throughout the study, but no differences were observed between treatment and no-treatment
weeks. Conclusions: Intensive use of the Mendselsohn maneuver in isolation altered duration of hyoid movement and UES
opening in this exploratory study. Results can guide future research toward improved selection criteria and exploration of
outcomes. Larger numbers of participants and variations in treatment duration and intensity will be necessary to determine
the true clinical value of this treatment. Key words: deglutition disorders, Mendelsohn maneuver, stroke, treatment

T
he Mendelsohn maneuver, or voluntary Rehabilitation, like compensation, addresses
prolongation of hyolaryngeal elevation at deficits in swallowing physiology.15 However,
the peak of the swallow, has been used to an exercise designed for rehabilitation should
treat patients with pharyngeal dysphagia for many provide a lasting effect on swallowing rather
years1–3 – sometimes as a compensatory strategy than an immediate change in the physiology of
to help the bolus pass more efficiently through swallowing. A few studies have provided outcome
the pharynx4–6 and sometimes as part of a reha- data on patients with dysphagia who have used the
bilitative exercise program.7–10 Early reports on the Mendelsohn maneuver as part of a collection of
Mendelsohn maneuver suggested that use of the exercises with the goal of rehabilitation, but none
maneuver increases laryngeal elevation and maxi- has used the maneuver in isolation and reported
mal hyoid superior displacement and provides on change in swallowing physiology as a result.7–9
an immediate effect in prolonging the duration of Whereas use of the maneuver shows promise
opening of the upper esophageal sphincter (UES) when included as part of a broader regimen of
but not the diameter.1–6 Since the initial reports, treatment, the specific physiologic effects of the
more data have emerged supporting the physi- Mendelsohn maneuver on patients with dysphagia
ologic effects of the Mendelsohn maneuver on
the act of swallowing, but most researchers have
Top Stroke Rehabil 2012;19(3):234–243
considered only the immediate effects of the ma- © 2012 Thomas Land Publishers, Inc.
neuver on small numbers of healthy participants www.thomasland.com

or patients.11–14 doi: 10.1310/tsr1903-234

234
Effects of Mendelsohn Maneuver 235

cannot be determined without investigation of measured as pharyngeal response duration (PRD).

the maneuver in isolation. The studies reporting Movement of the hyoid, especially the anterior
positive outcomes incorporating the maneuver movement, should create a traction pull on the
also used techniques such as head turns, chin cricoid cartilage that allows for prolonged opening
tucks, supraglottic swallows, effortful swallows, of the UES,2 which can be measured as duration of
and the Shaker exercise. Moreover, outcome UES opening (DOUESO).16
data from these studies reported improved oral The purpose of this investigation was to
intake in most patients without development of determine whether any lasting changes would
pneumonia or other negative health consequences, occur in swallowing physiology as a result
but specific changes in swallow physiology were of intensive exercise using the Mendelsohn
not reported, leaving open questions regarding maneuver. Our hypothesis was that measures of
the functional and physiologic changes that may the duration of hyoid movement and the duration
have occurred, as well as the actual cause of those of UES opening would significantly improve.
changes (eg, time, swallowing food and liquid, We also hypothesized that measures of bolus
exercise performance, and type of exercise). These flow – penetration/aspiration and pharyngeal
studies have clearly demonstrated that dysphagia residue – would improve as a result of these
rehabilitation is possible in certain patients post changes. In addition, we wanted to obtain some
stroke; but without specifically examining the use preliminary information regarding dose response,
of individual exercises in isolation, the contribution which could be examined by comparing results
of any particular exercise cannot be clearly after 10 sessions and 20 sessions of treatment.
defined. In other words, whereas the Mendelsohn Other measures of oral and pharyngeal swallowing
maneuver appears to have an immediate effect duration were analyzed, as well as outcomes on the
on hyolaryngeal movement and duration of UES Dysphagia Outcome and Severity Scale (DOSS).17
opening, no data exist to define what, if any,
lasting effect use of the Mendelsohn maneuver may
Methods
have on the physiology of swallowing when the
Mendelsohn maneuver is no longer used.
Participants
Based on the reports regarding the immediate
effects of the Mendelsohn maneuver on swallowing, Participants were recruited through advertising
we would anticipate that if long-term changes and referrals at The University of Arkansas for
result from use of the Mendelsohn as an exercise, Medical Sciences Medical Center, as well as word
they would include duration of hyolaryngeal of mouth by area speech-language pathologists.
elevation, anteriorly and/or superiorly, and, All participants provided written consent, and
consequently, duration of opening of the UES.1–6 all procedures were approved by the hospital’s
When swallowing, the hyoid bone and thyroid Institutional Review Board.
cartilage begin to rise, and then the hyoid bone Eighteen individuals, age 21 and older who
begins to move superiorly and anteriorly in a quick suffered a stroke and were dysphagic, participated
burst of movement. The path of this movement in this investigation (see Table 1). Each was
can vary, but it is often triangular, moving between 6 weeks and 22 months post stroke
superiorly, then anteriorly, and then back to rest (M = 9.5 months) at the time of participation.
or vice versa (anteriorly, then superiorly, and then Because of limited data in the literature and
back to rest). These durations can be measured as numerous potential effects on pharyngeal
duration of hyoid maximum anterior excursion swallowing, we chose to broadly enroll patients
(DOHMAE) and duration of hyoid maximum who were post stroke for this pilot study. Patients
elevation (DOHME).16 These do not measure the who had pharyngeal dysphagia characterized by
duration of hyoid movement from start to finish any apparent reductions in hyolaryngeal elevation
but rather the duration that the hyoid remains or UES opening and evidence of some type of
at its maximum anterior and superior points. residue in the pharynx were invited to participate.
Duration of hyoid movement from start to finish is These were visual judgments made by the principal
236 TOPICS IN STROKE REHABILITATION/MAY-JUNE 2012

Table 1. Participant demographics Each participant underwent an initial VFSS to

ensure a physiologic fit with the study as well as
Participant Age Gender Site of lesion Months post
a baseline of swallowing function. If swallowing
1 70 M L Medulla 18 function appeared to be normal or did not meet
2 42 M R Brainstem 15
3 69 M IC SAH 16
the above inclusion criteria related to swallow
4 58 F L SAH 22 physiology, the participant was withdrawn from the
5 57 F L Brainstem 12 study. Each remaining individual was randomized,
6 88 M B White matter 8 via prestudy blinded number drawing, into 1 of
7 61 M L Brainstem 2
2 groups: Group A received 2 weeks of treatment
8 84 F Nonspecified 1.5
9 73 M R Frontal lobe 2 followed by 2 weeks of no treatment (BBAA), and
10 86 F R Corona radiate 3 Group B received 2 weeks of no treatment followed
11 55 F L IC/pons 8 by 2 weeks of treatment (AABB). VFSSs were
12 70 F R Medulla 12
conducted at the end of each week of the study (A
13 54 F Nonspecified 6
14 73 M Nonspecified 18 or B) to allow for dose-response comparisons of
15 66 M L Basal ganglia 9 baseline measures of swallowing with measures at
16 88 M R Brainstem 15 1 and 2 weeks post treatment and no treatment.
17 86 M R Brainstem 2
18 83 M R Temporal & 4
insula
Measures
Note: B = bilateral; F = female; IC = internal capsule; L = left;
M = male; R = right; SAH = subarachnoid hemorrhage. VFSS
Eighteen participants were recruited to
investigator (PI) during the initial videofluoroscopic participate in this study over nearly 5 years. Even
swallow study (VFSS). Each participant also had though the overall duration of the study was
to be on a restricted diet, defined by the need protracted and some methods of data acquisition
for a nasogastric, jejunostomy, or percutaneous varied between participants, methods were kept
endoscopic gastrostomy tube, or an oral diet that constant for each participant and had no impact
was altered in any way because of swallowing on pre and post measures. The majority of VFSSs
difficulty. Individuals with an absent swallow were (n = 13) were conducted using a Shimadzu
not included in the study. All individuals had to Corporation (Columbia, Maryland) Digital
demonstrate at least a minimal functional swallow Fluoroscope (Model F100–02) and were transferred
with some material passing through the UES. to a KAY Elemetrics Swallow Station (now KAY/
Aspiration was not required for participation. PENTAX, Montvale, New Jersey). Because of
All participants scored 75 or higher on a hospital renovation, a few participants were
the Modified Mini-Mental State Examination. evaluated at another local hospital, and 5 studies
Individuals with current or a history of tracheotomy were recorded directly onto a Sony S-VHS through
or other structural alteration to the swallowing a FOR-A (Fort Lee, New Jersey) 100 ms videotimer
mechanism, history of swallowing problems prior (model VTG 33). Data from the KAY swallow
to the stroke, progressive neurologic disease, or station were also transferred to a JVC (Wayne,
cognitive and/or physical problems that would New Jersey) SVHS/DVD player (model SR-MV40)
have impeded understanding or completion of through the videotimer. No loss of imaging
the therapeutic tasks were excluded. A history occurred during the transfer. This method helped
questionnaire and a cranial nerve/oral motor ensure blinded review of studies. All recordings
screen helped determine the exact nature of the were 30 frames per second but were analyzed to
stroke and further define overall impairment. the 100th of a second using the videotimer.
MRIs or CT scans were obtained when available. Participants swallowed three 3 mL thin liquids
In the absence of neuroimaging information, a (E-Z-HD barium sulfate powder for suspension
neurological examination was performed by the and water/50–50; approximately 14 centipoise)
study physician. and three 3 mL purees (3 parts applesauce to 1
Effects of Mendelsohn Maneuver 237

part barium powder) for each study. The studies (ie, above, on, or below the vocal folds) and the
were brief (6 swallows with less than 1 minute participant’s response to it (ie, coughed but did
fluoro) in comparison to typical clinical studies not clear, coughed and cleared, no cough). A
(12–15 swallows and 4–5 minutes fluoro) to limit rating of 1 is no P/A, 5 is penetration to the vocal
radiation exposure. All swallows were viewed in folds, and 6 and greater are aspiration events. The
the lateral plane with a view of the oropharyngeal DOSS is a 7-point scale where 7 indicates normal
area, including the hard palate superiorly, the swallowing and 1 and 2 indicate severe dysphagia
cricopharyngeal area inferiorly, the lips anteriorly, where nothing is allowed by mouth or only
and the posterior pharyngeal wall posteriorly. therapeutic feedings. Scores in the 3 to 5 range
Patients were instructed to hold the bolus until indicate mild to moderate impairment where
they were asked to swallow and to use subsequent diets are adjusted and compensatory strategies
swallows, if needed, to clear the bolus. are used.
Duration measures, analyzed using the JVC The PI was the primary person responsible
SVHS/DVD player (model SR-MV40) with frame- for data analysis. All measures for data analysis
by-frame viewing, are defined in Table 2. Our were rated from tapes and DVDs by the PI and
primary measures (DOHME, DOHMAE, and not at the time of the study. All SVHS tapes and
DOUESO) were movement durations for specific DVDs were labeled with numbers corresponding
structures and PRD, which is the total duration on to participants. In reviewing individual tapes,
hyoid movement. Duration measures representing there was no way to know whether ratings were
bolus flow (ie, oral transit duration [OTD], being made for swallow studies after periods
pharyngeal transit duration [PTD], total swallow of treatment or no treatment because no marks
duration [TSD]) were also rated. In addition to identified the order for each participant.
measures of swallowing duration, each swallow
was rated on an 8-point penetration-aspiration
Treatment sessions
scale (P/A),18,19 a scale of oropharyngeal residue
(0 = none, 1 = trace coating, 2 = pooling),20 and the During treatment weeks (B weeks), participants
DOSS.17 The 8-point P/A scale rates P/A on the were seen twice a day for sessions lasting between
depth of the misdirected bolus into the airway 45 minutes and 1 hour, with a 2- to 3-hour break

Table 2. Oropharyngeal duration measures

Abbreviation Measure Description

Primary measures
DOHME Duration of hyoid maximum elevation From hyoid first maximum elevation to hyoid last maximum
elevation
DOHMAE Duration of hyoid maximum anterior From first frame showing maximum anterior hyoid movement to
excursion last frame showing maximum anterior hyoid movement
DOUESO Duration of UES opening From the time UES opens to the time UES closes
Other measures analyzed
OTD Oral transit duration Beginning of posterior movement of the bolus to the bolus head
at ramus of mandible
PTD Pharyngeal transit duration From bolus head at ramus of mandible to bolus head entering
cricopharyngeus
TSD Total swallow duration Beginning for posterior movement of the bolus to hyoid return
to rest
STD 1 Stage transition duration From bolus head at ramus of mandible to initiation of maximal
hyoid excursion
STD 2 Stage transition duration 2 From first barium at ramus of mandible to initiation of maximal
hyoid excursion
PRD Pharyngeal response duration From initiation of maximum hyoid excursion to hyoid return to
rest
DTOUES Duration to open UES From beginning of posterior bolus movement to UES opening
238 TOPICS IN STROKE REHABILITATION/MAY-JUNE 2012

in between sessions depending on participants’ mean established from 3 baseline swallows. This
schedules and availability. Each participant was was simply to ensure that the swallows were made
taught the Mendelsohn maneuver, the process with sufficient strength to involve muscles. The
of squeezing and holding the larynx at the peak clinician then asked the participant to face the
of the swallow, using surface electromyography screen and instructed the participant to swallow
(SEMG) biofeedback. SEMG biofeedback was “long and strong” with a squeeze at the peak of the
provided through a 2-channel Pathway MR-20 swallow for 3 to 4 s. The dental swab was delivered
(Prometheus Group, Dover, New Hampshire). The to the participant’s mouth by the clinician, and
electrode pad was placed submentally at midline the participant watched the video monitor and
halfway between the mental symphysis and the tip performed the maneuver. The clinician froze the
of the hyoid bone. Ground and active electrodes video frame after each swallow and provided
are linear on the pad and are not adjustable. visual and verbal feedback regarding the strength
The signal that was derived from muscle activity (amplitude) and duration (seconds) of the swallow.
was rectified and low-pass-filtered to produce a Specifically, the following were pointed out to the
smooth signal. SEMG tracings were used only participant: (a) the onset and offset points and the
for participant biofeedback. Treatment sessions duration of the swallow – including the initial rise
were administered primarily by the PI with of the SEMG tracing, which should appear similar
some assistance from a study clinician as soon as to a straight back chair; (b) the peak amplitude, as
participants were well-trained with the treatment provided by the Prometheus software; and (c) the
protocol. duration of the current swallow as compared to the
Session 1 focused on defining and demonstrating previous swallow.
the procedure, as well as teaching the patient to Forty swallows per session were targeted, but
do the maneuver correctly. The PI demonstrated participants were allowed to stop at a minimum of
the maneuver and provided visual feedback from 30 if they showed signs of uncomfortable fatigue.
the computer as well as tactile feedback through At least 30 Mendelsohn swallows were completed
laryngeal palpation (the participant feeling the during each treatment session. A successful
rise, squeeze, and fall of the PIs larynx). When it Mendelsohn swallow meant that the participant
was difficult to determine whether swallows were was able to swallow and sustain laryngeal elevation
actually occurring, cervical auscultation was used for approximately 2 s or longer. Using SEMG for
along with laryngeal palpation for auditory and biofeedback, all participants were able to swallow
tactile confirmation. Prior to each swallow, dental and sustain some semblance of laryngeal elevation
swabs were dipped in ice water and delivered to for approximately 2 s throughout treatment.
the mouth to provide a small amount of water. It
was not our intent to provide a bolus swallow but Data analysis
simply to moisten the mouth so that swallowing
would be possible throughout the session. After VFSS data were gathered across 5 points,
observing the PI, the participant attempted to including an initial study and 4 more that occurred
replicate the clinician’s swallow, palpating his own after each week of enrollment, treatment, or no
larynx and watching the SEMG tracing on the treatment. Our primary comparison was between
computer screen. ratings of DOHME, DOHMAE, and DOUESO after
Coaching and correcting continued with 2 weeks of treatment and 2 weeks of no treatment;
sessions 2 and 3 (and, to some extent, throughout comparisons were also made after 1 week and
the study). Beginning with session 2 on the first 3 weeks to consider dose response. Because of the
day, each participant began the standard regimen small size of our sample, we did not have enough
of treatment of 30 to 40 swallows per session using power to perform a repeated measures analysis of
the Mendelsohn maneuver. Participants were first variance. Because our objectives were exploratory
baselined (ie, they were asked to swallow hard in nature, we treated the data points as independent
without looking at the computer). An SEMG target measures and used t tests for independent groups
line for amplitude was then set at 5 µV above their (A vs B). A Bonferroni adjustment was used for
Effects of Mendelsohn Maneuver 239

stricter control of family-wise error rate moving the Pretreatment mean durations were compared
acceptable P value from .05 to .017. All other data – with mean durations after 1 week of treatment,
additional duration measures, residue on a 3-point 2 weeks of treatment, 1 week of no treatment,
scale, P/A on an 8-point scale, and swallowing and 2 weeks of no treatment. Treatment weeks
severity on the DOSS 7-point scale – are provided did not always occur after no-treatment weeks.
descriptively. In roughly half the cases, no-treatment periods
Intrajudge reliability was derived by having occurred after treatment periods and could,
the PI re-analyze a random selection of 10% of therefore, have been influenced by the prior
all VFSS measures. Interjudge reliability was 2 weeks of treatment. Results indicate that all
derived by having a second clinician analyze a duration measures improved (increased) during
random selection of 10% of VFSS measures. The treatment weeks and worsened (decreased) during
second clinician was a certified speech-language no-treatment weeks. Results after 2 weeks of
pathologist who had at least 100 hours of treatment were better than results after 1 week of
experience with VFSS and was trained to criterion treatment and results after 2 weeks of no treatment
prior to the initiation of the study. Some interjudge were worse than results after 1 week of no
reliability ratings were made without blinding to treatment, with the exception of DOUESO, which
name, but the reliability clinician was never aware made a nonsignificant improvement in respective
of treatment condition. All measures of reliability no-treatment weeks. Improvements in DOHME
were analyzed using intraclass correlation and DOHMAE were significant (P = .011 and .009,
coefficients (ICC). respectively) at 2 weeks post treatment. No other
Interjudge reliability was high for all measures. results were significant. Results for these measures
ICCs for the primary measures were as follows: are also presented in Figure 1.
DOHME = .749, P = .000; DOHMAE = .775, Table 4 provides means for all other measures
P = .000; DOUESO = .649, P = .002. Intrajudge at study initiation, post 2 weeks of no treatment,
reliability was as follows: DOHME = .787, P = .000; and post 2 weeks of treatment. Results for PRD
DOHMAE = .842, P = .000; DOUESO = .689, (which measures the duration of hyoid movement
P = .002. Intra- and interjudge reliability for all from start to finish) trended with DOHME and
other measures was significant, with ICCs ranging DOHMAE, getting worse during periods of no
from a low of .556 (P = .000) for OTD to a high of treatment and better during periods of treatment.
.998 (P = .000) for PTD. No other measures trended this direction.
Differences between treatment and no-treatment
weeks were minimal, at best, for stage transition
Results
duration 1 (head of bolus), stage transition
Table 3 provides results for the primary duration 2 (first barium in pharynx), pharyngeal
outcome measures of DOHME, DOHMAE, and transit duration, P/A, vallecular residue, pyriform
DOUESO. residue, and dysphagia severity (DOSS) ratings.

Table 3. Primary duration measures at 1 and 2 weeks post treatment and 1 and 2 weeks post no treatment
compared with pre treatment

Mean Mean 2 Mean 1 Mean 2

Duration Mean pre 1 week weeks week no weeks no
measure treatment treatment treatment treatment treatment
DOHME .213 .196 t(192) = .808; .233 t(142) = −.108; .212 t(189) = −1.12; .210 t(180) = −.668;
P = .952 P = .011 P = .918 P = .242
DOHMAE .222 .223 t(188) = −.072; .250 t(148) = −.543; .227 t(183) = −.568; .220 t(174) = .115;
P = .507 P = .009 P = .668 P = .172
DOUESO .592 .606 t(177) = −.607; .614 t(159) = −1.150; .581 t(179) = .578; .589 t(177) = −.724;
P = .351 P = .472 P = .236 P = .550

Note: DOHME = duration of hyoid maximum elevation; DOHMAE = duration of hyoid maximum anterior excursion; DOUESO = duration
of upper esophageal sphincter opening.
240 TOPICS IN STROKE REHABILITATION/MAY-JUNE 2012

0.589
DOUESO
0.614

0.22
DOHMAE
0.25

0.21
DOHME
0.233
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7

Post No Tx Post 2 Weeks Tx

Figure 1. Graph of primary duration measures after

2 weeks of no treatment versus 2 weeks of treatment.
DOUESO = duration of opening of the upper
esophageal sphincter; DOHMAE = duration of hyoid
maximum anterior excursion; DOHME = duration of
hyoid maximum elevation.

Discussion
maximal hyoid movement, as well as duration of
“The fundamental purpose of Phase I research UES opening, would be prolonged. In fact, this
is selecting a therapeutic effect, identifying it if was the case. Data show that DOHME (hyoid
present, and estimating its magnitude.”21 Whereas elevation) and DOHMAE (hyoid anterior excursion)
the Mendelsohn maneuver is not new, no prior significantly improved (were prolonged) during
research has sought to determine the therapeutic VFSS evaluation of swallowing after treatment
effects of the maneuver when administered as an weeks and did not improve after no-treatment
exercise in isolation to patients. Compensatory, or weeks. Research has previously reported that
immediate, effects are only useful in as much as a the duration of hyoid movement anteriorly and
maneuver, or strategy, is used. Data on nonpatients superiorly is reduced post stroke compared to
and case studies performing the Mendelsohn nonpatients.22 Such reductions could affect other
maneuver in isolation during bolus swallows1–6 aspects of swallowing, including duration of UES
have shown improved hyolaryngeal movement opening and bolus flow. DOUESO also improved
and UES opening. For the current investigation, we during treatment weeks compared to no-treatment
hypothesized that duration of superior and anterior weeks, but results were not statistically significant.

Table 4. Means for all other measures at study initiation and after 2 weeks of treatment and 2 weeks of no
treatment

Measure Mean study initiation Mean post no treatment Mean post treatment
Oral transit .569 .693 .604
Stage transition 1 .843 .706 .734
Stage transition 2 .826 .587 .642
Pharyngeal transit .987 .763 .887
Pharyngeal response .895 .833 .911
To UES open 1.88 1.47 1.41
Penetration/Aspiration 3.13 2.30 2.99
Vallecular residue 1.21 .83 1.10
Pyriform residue .90 .65 .73
DOSS 3.92 4.61 4.49

Note: Pharyngeal response duration trended with primary measure of duration of hyoid maximum elevation and duration of hyoid
maximum anterior excursion. DOSS = Dysphagia Outcome Severity Scale; UES = upper esophageal sphincter.
Effects of Mendelsohn Maneuver 241

With a larger sample, it is very possible that this With improvements in the duration of UES
trend would continue and become significant. opening, pyriform sinus residue should logically
We also sought to provide initial data regarding improve more than it did in this study. Our broad
dose response. VFSSs were performed after each inclusion criteria allowed us to consider many
week of enrollment, treatment or no treatment. possible effects of the maneuver on swallowing
Data clearly suggest that whereas improvement physiology but likely affected this measure. Had
was made in all 3 measures after 10 sessions more participants demonstrated moderate to severe
of treatment, effects were much greater after pyriform residue, then results for this rating may
20 sessions. It is very possible that use of the exercise have improved more substantially. Likewise, P/A
over time, possibly with treatment sessions spread might have improved more if only individuals with
out for cycles of work and rest, would continue postswallow aspiration from the pyriform sinuses
to enhance therapeutic effects and provide greater had been included. The current results indicating
impact on additional measures of swallowing improvements in duration of hyoid movements
function, including DOUESO. Prior studies using and UES opening lend support to future studies
the Mendelsohn maneuver have reported success with more specific focus on bolus flow in the
with sessions once or twice daily over a 1- to form of pyriform sinus residue and postswallow
2-week period providing intense neuromuscular aspiration. Such studies should include larger
rehabilitation in an effort to improve both the numbers of participants and examine different
strength and coordination of the swallow.7–9 Part intensities of treatment over varying durations of
of the rationale for this regimen of treatment lies time. Additionally, the effects of the exercise on
in the concepts that swallowing post stroke can swallowing physiology should be examined over
become not only weak but discoordinated9 and periods of time longer than 1 month. Outcome
that more coordinated “patterns” of swallowing measures at 6 and 12 months should be examined.
activity occur with more intensive treatment. Pure
strength training, on the other hand, may benefit Study limitations
from not only “overload” but also periods of rest
scheduled over a longer period of time.23 At the time Our results are derived from a small sample of
this study was initiated, the investigators chose the stroke patients. Our primary measures improved
more intensive approach as outlined in the related in the direction we hypothesized, but only 2
studies, but researchers should examine different of the 3 reached a level of significance. Larger
treatment regimens of duration and intensity. numbers are needed in future investigations, as
are variations in treatment regimens, duration,
and intensity. Moreover, we wanted to examine
Effects on other measures of swallowing
the postacute rehabilitation but not necessarily
As Table 4 indicates, few other measures chronic population, but few individuals met
were affected by exercise with the Mendelsohn the specific criteria and were willing and able to
maneuver in this study. These results are not participate. Data collection took twice as long as
terribly surprising, however. Dysphagia is a expected, and participants were enrolled up to
complex disorder, and we did not expect to find nearly 2 years post stroke. Some of these patients
major reductions in dysphagia severity with could easily be classified as chronic. Comparing
2 weeks of 1 type of exercise. Pharyngeal response results of individuals less than 1 year post stroke to
duration trended the way of DOHME and those 2 years and beyond would provide valuable
DOHMAE. This makes perfect sense in that all information regarding the recovery potential at
3 are different measures of the duration of hyoid different points in the rehabilitation process.
movement. We hypothesized that the hyoid would
be affected by this exercise, and this was the case.
Conclusion
Measures of bolus flow, however, may be affected
by factors other than hyoid movement, such as Our exploratory study indicates that the
pharyngeal muscle strength, epiglottic tilt and seal, Mendelsohn maneuver, used as a rehabilitation
or tongue base strength. exercise, can improve the duration of hyoid
242 TOPICS IN STROKE REHABILITATION/MAY-JUNE 2012

maximum anterior and superior movement Acknowledgments

and impact the duration of UES opening.
This research was funded in whole and in part
These results are consistent with reports on use
by National Institutes of Health (NIH) National
of the maneuver as a compensatory strategy
Institute on Deafness and Other Communication
but present the maneuver as an option for
Disorders grant R03 DC04942–01A2 and NIH
longer lasting changes in the target areas of
NINDS R21 HD055677–01A2.
swallowing physiology. With longer enrollment
We thank Mary Elizabeth Chilcote and Robyn
in treatment and, perhaps, in combination with
Smith for their assistance with data acquisition,
other treatments, it can potentially improve bolus
input, and typing. We also thank the 18 participants
flow and dysphagia severity. More research is
for their time.
needed. Additional measures of biomechanical
Partial data were presented to The Dysphagia
movements – such as the extent of hyolaryngeal
Research Society in New Orleans, March 2009, and
movement and UES opening – are currently being
to the American Speech and Hearing Association
analyzed.
in Boston in November 2007.

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