REHABILITATIVE MANOEUVRES FOR DYSPHAGIA

INTRODUCTION (2 marks)

CLASSIFICATION OF REHABILITATIVE APPROACHES (1 mark)

1. Swallowing manoeuvres - performed during a swallow (direct techniques)
2. Strengthening/exercise-based techniques - performed without a swallow (indirect techniques)
3. Compensatory postural strategies - modify swallow mechanics without altering physiology (adjuncts)
4. Stimulation techniques - thermal-tactile and electrical stimulation

I. SWALLOWING MANOEUVRES (DIRECT TECHNIQUES) (6 marks)

1. Mendelsohn Manoeuvre

• Physiological target: Reduced/incoordinated laryngeal elevation; cricopharyngeal dysfunction
• Indication: Failure of laryngeal elevation with residue in pyriform sinuses and tongue base; failure of UES/cricopharyngeal (CP) opening on MBS/FEES
• Mechanism: The patient is instructed to feel the thyroid prominence (Adam's apple), perform a dry swallow, and then - at the peak of laryngeal elevation - consciously hold the larynx as high as possible for 1-2 seconds before relaxing. This extends the duration and height of laryngeal elevation, thereby prolonging the duration and widening the aperture of cricopharyngeal (UES) opening
• Effect: Increases extent and duration of hyolaryngeal excursion → widens and prolongs CP opening → better bolus clearance through the pharyngoesophageal segment
• Biofeedback: EMG biofeedback is commonly used to enhance efficacy
• Patients: Those with poor laryngeal excursion, discoordinate swallow, or cricopharyngeal dysfunction (- KJ Lee's Essential Otolaryngology, p.673-674; Murray & Nadel's, p.949)

2. Supraglottic Swallow

• Physiological target: Inadequate laryngeal/glottic closure during swallow
• Indication: Vocal fold paresis/paralysis, laryngeal sensory deficits, aspiration during the swallow
• Mechanism (5 steps):
  1. Inhale and hold breath firmly before placing bolus
  2. Hold breath while bearing down (increases intralaryngeal pressure)
  3. Swallow hard while holding breath
  4. Immediately cough voluntarily after the swallow to expel any penetrated material
  5. Swallow again to clear residue
• Effect: Voluntary airway closure technique - closes the glottis before and during the swallow, protecting the airway; the post-swallow cough clears any laryngeal residue
• Indication in practice: Vocal fold weakness, post-laryngeal surgery, aspiration during the swallow (- KJ Lee's, p.943)

3. Super-Supraglottic Swallow

• Physiological target: Aspiration at the level of the laryngeal vestibule
• Mechanism: Same as supraglottic swallow but with increased effort and deliberate bearing down before and during the swallow
• Effect: Closes the entrance to the larynx (arytenoid-to-epiglottis approximation) even before the swallow, providing added protection at the vestibular/supraglottic level
• Indication: Post-supraglottic laryngectomy; patients with reduced aryepiglottic fold closure

4. Effortful Swallow (Hard Swallow)

• Physiological target: Reduced tongue base retraction; poor posterior bolus propulsion
• Indication: Tongue base weakness with vallecular residue on MBS/FEES
• Mechanism: Patient is instructed to "squeeze hard with all the throat and neck muscles" during each swallow, generating maximum muscular effort
• Effect: Increases posterior movement of the tongue base → improves contact between tongue base and posterior pharyngeal wall → increases pharyngeal pressures → better bolus propulsion and clearance from oropharynx; reduces vallecular residue
• Caution: Should be used carefully in patients with oropharyngeal weakness or poor vocal fold closure (- KJ Lee's, p.943-944; EBRSR Chapter 15)

5. Masako Manoeuvre (Tongue-Hold Manoeuvre)

• Physiological target: Reduced tongue base strength and contact with posterior pharyngeal wall
• Indication: Reduced posterior tongue base movement
• Mechanism: Patient protrudes the tongue and gently bites/holds it between the front teeth, and then swallows in this position. By holding the tongue forward, the posterior pharyngeal wall is forced to bulge anteriorly to compensate during the pharyngeal swallow
• Effect: Strengthens the propulsive ability of the tongue base and improves tongue base-posterior pharyngeal wall contact (- Murray & Nadel's Respiratory Medicine, p.949)

II. STRENGTHENING / INDIRECT (NON-SWALLOW) EXERCISES (5 marks)

1. Shaker Exercise (Head Raise / Head Lift Exercise)

• Target muscles: Suprahyoid muscles (geniohyoid, thyrohyoid, digastric anterior belly)
• Indication: Reduced UES opening; failure of laryngeal elevation
• Mechanism:
  • Patient lies flat on back with shoulders on the floor/bed
  • Lifts head high enough to see their toes (without lifting shoulders)
  • Isometric (static) phase: Hold head lift for 60 seconds, rest 60 seconds - repeat 3 times
  • Isokinetic (dynamic) phase: Lift and lower head 30 consecutive times rapidly without holding
• Effect: Strengthens suprahyoid muscles → increases the anterior traction force on the hyolaryngeal complex during swallowing → increases UES opening aperture → decreases hypopharyngeal bolus pressure → reduces pharyngeal residue post-swallow
• Evidence: RCT (Choi et al., 2017) showed benefit in stroke-related dysphagia (- KJ Lee's, p.944)

2. Lingual Strengthening Exercises

• Target: Tongue musculature (CN XII - hypoglossal nerve)
• Indication: Oral dysfunction, poor bolus handling and propulsion; tongue weakness post-surgical resection or stroke
• Mechanism: Tongue resistance exercises (pressing tongue against palate, lip, or Iowa Oral Performance Instrument); articulation exercises
• Effect: Improves oral bolus control, transmission, and initiation of the pharyngeal swallow; improves handling of bolus and transmission through the oral cavity
• Devices: IOPI (Iowa Oral Performance Instrument) is commonly used for quantified tongue pressure training (- KJ Lee's, p.944; Cummings Otolaryngology, p.1861)

3. Chin Tuck Against Resistance (CTAR)

• Target: Suprahyoid and submental muscles
• Indication: Reduced hyolaryngeal elevation; comparable indication to Shaker exercise
• Mechanism: Patient tucks chin against a resistance ball (or their own chest) and holds
• Effect: Strengthens suprahyoid muscles with greater EMG activation than the Shaker exercise in preliminary studies; improves hyolaryngeal elevation (- EBRSR Chapter 15)

4. Expiratory Muscle Strength Training (EMST)

• Target: Expiratory and suprahyoid muscles
• Mechanism: Patient breathes out against a calibrated pressure threshold device
• Effect: Strengthens expiratory muscles - which have anatomical overlap with suprahyoid muscles - thereby increasing hyolaryngeal movement, improving airway clearance, and augmenting the post-swallow cough reflex
• Evidence: Three RCTs support its use compared to conventional care (- KJ Lee's, p.944; EBRSR)

III. COMPENSATORY POSTURAL STRATEGIES (3 marks)

IV. STIMULATION TECHNIQUES (2 marks)

1. Thermal-Tactile Stimulation (TTS)

• Technique: Rubbing a chilled laryngeal mirror or probe against the anterior faucial pillars / tonsillar pillars before the swallow
• Effect: Heightens pharyngeal sensory awareness → reduces delay in triggering the pharyngeal swallow reflex (reduces pharyngeal transit delay); increases sensitivity, minimizing pharyngeal delay
• Indication: Neurologically impaired patients with delayed pharyngeal trigger (- KJ Lee's, p.944)

2. Neuromuscular Electrical Stimulation (NMES)

• Types:
  • Percutaneous: Hook-wire electrodes placed directly into target muscles
  • Transcutaneous (VitalStim): Surface electrodes applied to the anterior neck to stimulate sensory fibres and underlying muscles
• Effect: Stimulates and re-educates the neuromuscular unit; aids laryngeal elevation
• Evidence: Widely used but evidence of efficacy remains limited (- KJ Lee's, p.944)

V. SELECTION CRITERIA AND PRINCIPLES (1 mark)

1. Instrumental swallowing assessment - MBS or FEES to identify the precise physiological deficit
2. Phase of dysphagia - oral, pharyngeal (most manoeuvres target this), or esophageal
3. Patient's cognitive and physical capacity - complex manoeuvres like Mendelsohn require adequate comprehension and motor control
4. Cause - post-stroke, head and neck cancer, neurodegenerative disease, post-surgical
5. Stage of recovery - acute stage may require compensatory strategies first; exercise-based rehabilitation later

SUMMARY TABLE (Quick Revision)

KEY EXAM POINTS

• Mendelsohn manoeuvre is the single most commonly tested manoeuvre - know the mechanism (prolonged laryngeal elevation → prolonged/widened UES opening) and its indication (cricopharyngeal dysfunction)
• Shaker exercise = head-raise exercise in supine position; strengthens suprahyoid muscles specifically
• Supraglottic swallow = voluntary airway closure; 5-step sequence; for glottic incompetence
• Masako = tongue-hold manoeuvre; strengthens tongue base - posterior pharyngeal wall contact
• Effortful swallow = increases tongue base retraction and pharyngeal pressures
• Manoeuvres are rehabilitative (change physiology); postures are compensatory (redirect bolus without changing physiology)
• All manoeuvres should be selected based on FEES or MBS findings, not empirically