(sEMG) biofeedback training during the Mendelsohn maneuver vs

Effects of Surface Electromyographic (sEMG) Biofeedback Training During the Mendelsohn Maneuver vs. the Mendelsohn Maneuver C
arly P
engelly, B
.S. &
A
bbie O
lszewski, P
h.D., C
CC-­‐SLP •Introduction•
U
niversity o
f N
evada, R
eno Swallowing is a biochemical process characterized quan=ta=vely by, • 
“ displacement of oropharyngeal structures and associated =ming and dura=on of movement during a swallow” (Wheeler-­‐Hegland, Rosenbeck, Sapienza, 2008). • 
Problems with swallowing is known as Dysphagia, which can be a result of a TBI, stroke, cancer, or other neurologic diseases. • 
Surface electromyographic (sEMG) feedback provides biofeedback on the =ming of selected muscle contrac=on paSerns during swallowing on the amplitude of electric ac=vity of the muscles. • 
•Methods•
•  Search Terms:: Dysphagia, Mendelsohn Maneuver, surface electromyographic feedback, swallowing disorders, aspira;on, swallowing therapy, swallowing rehabilita;on, neurogenic dysphagia. •  Databases: PubMed and ASHA (40 ar=cles). •  RaRng System: Cri=cal Appraisal of Treatment Evidence (CATE form) was used to appraise validity and clinical significance with interrater reliability; 15 point ra=ng scale; 10 ar=cles appraised. •  Reliability: Interater reliability for 8 ar=cles with 85% accuracy. Four selected for EBP decision. Authors Date Research Design Purpose of InvesRgaRon Number and DescripRon of ParRcipants Coyle (2008) Quasi-­‐Experimental To evaluate whether supplemen=ng surface electromyographic biofeedback with the Mendelsohn maneuver, creates las=ng effects to the ini=al efficacy of voli=onal prolonga=on of muscle ac=vity responsible for upper esophageal sphincter opening(UES) during the swallow. N = 27 • 25-­‐39 years old • No medical condi=ons containing swallowing disorders or preexis=ng medical condi=ons. •DuraRon •Peak amplitude •Average amplitude •Minimum amplitude **during Mendelsohn with blinded sEMG (TradiRonal Training) and Mendelsohn with sEMG.(Biofeedback-­‐Mediated Training). Crary, Carnaby, Groher, & Helseth (2004) Retrospec=ve, Observa=onal Describe the func=onal outcomes, cost per unit of func=onal change, and =me in therapy who used sEMG Biofeedback for pharyngeal dysphagia therapy. N = 45 • Age range not specified • Pa=ents with dysphagia secondary to stroke, or head and neck cancer. •Change in FuncRonal Oral intake score(FOIS) (7 point ra=ng scale). •Number of therapy sessions to discharge (NS) •EsRmated cost per unit of funcRonal change. (Cost) • FOIS: Overall, 87% of pa=ents increased FOI by at least one scale; 92% of stroke pa=ents and 80% of head and neck cancer pa=ents. The difference was trending sta=s=cally significant (p = 0.079). • NS: Average sessions for stroke: 12.32, Average for head and neck cancer: 9.3., sta=s=cally significant (p = 0.0043). • Cost: Stroke: $949, H/N Cancer: $716 per unit of func=onal change. This trended toward sta=s=cal significance (p = .0079). McCullough, Kamarunas, Mann, Schmidley, Robbins, & Crary (2012) Quasi-­‐Experimental Determine if any las=ng changes would occur in swallowing physiology and efficiency as a result of intensive exercise using the Mendelsohn maneuver as measured by Videofluoroscopic swallowing studies. N = 18 • 21 years old and older • Suffered a stroke and were dysphagic; each between 6-­‐22 months post stroke. (9.5 months on average. • DOHMAE Dura=on of Hyoid Maximum Anterior Excursion •DOHME Dura=on of Hyoid Maximum Eleva=on •DOUESO Dura=on of Upper Esophageal Sphincter •DOHMAE: Mean treatment for week 1: 0.196t(192); p = .952, Mean treatment for week 2: 0233t(189) p = .011 • DOHME: Mean treatment for week 1: .223t(188); p = .507, Mean treatment for week 2: .250 t(148); p = .009. •DOUESO: Mean treatment for week 1: .606 t(177); p =.351, Mean treatment for week 2: .614 t(159); p = .472. N = 25 • 18-­‐35 years old • None had a history of dysphagia, neurologic disease, vascular disease, or hypertension. Healthy adults. sEMG of Mendelsohn: • Avg EMG: mean amplitude of onset/ offset. • Max EMG: peak amplitude onset/offset. • Hstart EMG: ac=vity of onset of task • Hmax EMG: ac=vity at the point of max hyoid movement. Hyoid Trajectory of Mendelsohn: • A1: angel associated with maximum hyoid displacement. • D1: maximum hyoid displacement • A2: maximum hyoid angle • D2: hyoid displacement associated with maximum hyoid angel • A3: Hyoid angle at end of task • D3: hyoid displacement at end of task sEMG of Mendelsohn: expressed as a raRo of the hyoids posiRon • Avg EMG: 0.35 • Max EMG: 0.88 • Hstart EMG: 0.49 • Hmax EMG: 0.59 •Clinical Scenario•
•Purpose•
PICO (patient, intervention, comparison, and outcome) framework (Gillam &
Gillam, 2008) was used to develop the following clinical question:
To determine if sEMG biofeedback with a Mendelsohn Maneuver compared with only a Mendelsohn Maneuver in adults with neurogenic dysphagia improves swallowing as measured by larynx elevaRon and quanRty of residue post swallow? P— Adults with neurogenic dysphagia I— sEMG biofeedback with a Mendelsohn Maneuver C—only a Mendelsohn maneuver O— improve swallowing as measured by larynx eleva=on and quan=ty of residue post swallow •References•
Coyle, J. & Univeristy PiSsburgh. (2009). Mi=ga=on of oropharyngeal swallowing impairments and health sequel: Two meta-­‐analyses and an experiment using surface electromyographic biofeedback. Disserta;on Abstracts Interna;onal, 69(7-­‐B), 4130. doi: 978-­‐0-­‐549-­‐74717-­‐8 Crary, M., Carnably, G., Groher, M., & Helseth, E. (2004). Func=onal benefits of dysphagia therapy using adjunc=ve sEMG biofeedback. Dysphagia, 19:160-­‐164. DOI: 10.1007/s00455-­‐004-­‐0003-­‐8 Gillam, S., Gillam, R. (2008). Teaching graduate students to make evidence-­‐based interven=on decisions: Applica=on of a seven step Process Within an Authen=c Learning Context. Topics in Language Disorders, 28(3), 212-­‐228. doi:10.1097/01.TLD.0000333597.45715.57 McCullough, G., Kamarunas, E., Mann, G., Schmidley, J., Robbins, J., & Crary, M. (2012). Effects of the Mendelsohn maneuver on measures of swallowing dura=on post stroke. Topics in Stroke Rehabilita;on. 19(3): 234-­‐243. doi:10.1310/tsr1903-­‐234 Wheeler-­‐Hegland, K., Rosenbeck, C., Sapienza, C. (2008). Submental sEMG and hyoid movement during Mendelsohn maneuver, efformul swallow, and expiratory strength training. Journal of Speech Language, and Hearing Research, 51,1072-­‐1087. doi: 1092-­‐4388/08/5105-­‐1072. External evidence: • Results indicate that both the Mendelsohn maneuver with seMG and Mendelsohn alone demonstrate increased swallowing efficiency, but Mendelsohn with sEMG produced greater effect. • sEMG can not only be used as a screening measure, but as a strength training treatment for the submental muscles. •sEMG and the Mendelsohn maneuver increased efficiency of hyoid movement (these results were significant) but opening of esophageal sphincter for bolus flow, (although trending to sta=s=cal significance) was not significant. Internal evidence to clinical pracRce: • Results indicate neurogenic dysphagia pa=ents have greater efficiency outcomes results than cancer pa=ents with dysphagia when using Mendelsohn maneuver. • sEMG may not be accessible in all facili=es; whereas the Mendelsohn Maneuver can be trained in all seWngs. • Cogni=ve abili=es need to be accounted for when making compensatory behavior strategies that require learning. Summary: If accessible, using sEMG with Mendelsohn maneuver results in more effec=ve swallowing efficiency than Mendelsohn alone. •Results•
The Mendelsohn maneuver is a type of behavioral treatment that requires the pa=ent to learn to swallow by voluntarily prolonging the hyolaryngeal eleva=on at the peak of the swallow. It is designed to prolong the dura=on of muscular forces during swallowing •  I am new graduate student of Speech Language Pathology at the University of Nevada, Reno and am interested in working in a acute care or rehabilita=on seWng with adults with dysphagia. •  AXer observing diagnos=c evalua=ons and therapy at the University of Nevada, Reno, I have learned different compensatory techniques for swallowing to reduce residue and aspira=on by eleva=ng the larynx. •  In the different evalua=ons observed, different techniques were used to minimize residue and aspira=on yielding different amounts depending on the technique or mul=ple techniques used. •Discussion•
Wheeler-­‐Hegland, Rosenbeck, & Sapienza (2008) Quasi-­‐Experimental Measure the biochemical and electromyographic elements of 2 swallow tasks (including Mendelsohn maneuver) and 1 nonspecific swallow task to determine differen=al effects of hyoid movement and submental ac=va=on. Dependent Variable Results Pre-­‐Training Post-­‐Training Mean (SD) Mean (SD) Mendelsohn only (TradiRonal Training) • Dura=on (s) 2.03 (0.45) 4.58 (2.32) • Peak Amplitude (μV*sec) 3.16 (1.75)
4.33 (3.53) • Average Amplitude (μV*sec) 1.10 (0.48)
1.51 (0.94) • Minimum Amplitude (μV*sec) 0.20 (0.05)
0.19 (0.07) Mendelsohn with Biofeedback-­‐Mediated Training
• Dura=on (s) 2.09 (0.46)
4.21 (1.65) • Peak Amplitude (μV*sec) 3.88 (2.09)
4.41 (2.32) • Average Amplitude (μV*sec) 1.33 (0.65)
1.64 (0.87) • Minimum Amplitude (μV*sec) 0.18 (0.07)
0.19 (0.06) **Mendelsohn training produced significant overall increases in dura=on and amplitude with tradi=onal training and sEMG training, though greater effect was caused by use of sEMG. **Results indicate all dura=on measures improved during treatment weeks. All measures were significant and were significant according to interrater reliability. Hyoid Trajectory of Mendelsohn: (Means) • A1: 10.30 • D1: 1.43 • A2: 16.71 • D2: 1.23 • A3: -­‐3.51 • D3: 1.06 ** Results indicated that the Mendelsohn Maneuver modified hyoid bone movement and increased the ac=va=on of submental muscles. Results not significant. Efformul swallow achieved higher sEMG scores than the Mendelsohn.